TIP/TAP Series: Urine Testing/Dirty Urines - Nancy Rose (DONT Secretary)
Americans With Disabilities Act Applies to Prisons/Jails
- Robin Robinette (TMAC)
My Takehomes and A Negligent Program - Name withheld by request
Letter from the Editor - Beth Francisco
NAMA Column #5 - Joycelyn Woods
Doctor's Column - Patient wants to know what to tell a prospective employer.
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TIP 1, for example, states that CSAT, along with the American Methadone Treatment Association and the American Society of Addiction Medicine's Committee on Methadone Treatment, have "developed these practical treatment guidelines. . .[to] serve as a blueprint for state policy officials and methadone maintenance treatment providers." The CSAT Director goes on to say, ". . . this nation's [MMT] programs must incorporate what the scientific community has demonstrated to be effective treatment practices.... based on lessons learned from relevant science-based research."
TIP 1, "State Methadone Treatment Guidelines," has an entire chapter (Ch. 6) on "Urinalysis as a Clinical Tool" (p. 59). It says, "Methadone maintenance programs should offer treatment. . .where a sense of trust and safety exists....If a patient must provide a urine specimen in an atmosphere that suggests punishment and power, trust and patient growth cannot thrive. There is an inevitable tension that exists [when] programs...use urine screening...in conferring take-home privileges....Falsification [of urines] is best minimized if patients do not feel that the urine results will be used to punish them" (p. 61).
"Some patients will adamantly deny substance use despite positive results... .[MMT] providers should take adamant denial seriously and not discount the patient as a manipulator or a liar....Whenever possible, the positive screen...should be retested and confirmed by another method" (p. 62). Clinic staff should consider the patient's history and previous urine results when deciding whether or not to believe the patient.
TAP 7, "Treatment of Opiate Addiction with Methadone, A Counselor Manual", says testing can help counselors determine whether a patient is diverting his/her methadone or taking illicit drugs but need to understand that there can be errors in test results. Occasionally, a test will show "low specific gravity" which means the urine is "watery." TAP 7 states, "This can indicate that the patient had drunk a lot of fluid just prior to the urine test OR that the specimen was diluted with water. Eating poppy seeds, even as little as a teaspoon, can result in a morphine-positive test" (p. 26). Counselors, as well as patients, should be aware of medications, including over-the-counter and other substances that may possibly affect urine test results. This topic was covered in a previous issue of Methadone Today (Vol. II, no. 6, June 1997).
Counselors are advised of various ways to approach the patient regarding positive--"dirty"--urine test results. "Punishment" such as lowering methadone dose or discharging from the program are NOT advised. TIP 10, "Assessment and Treatment of Cocaine-Abusing Methadone-Maintained Patients" states, "It is clinically appropriate to treat patients with concurrent dependencies within methadone programs. . . .Lowering methadone doses as part of a contingency management protocol [for urine tests showing cocaine] does NOT appear to be effective in managing cocaine use and may increase heroin use" (p. 2).
Regarding retention in the program versus discharge for "dirty" urines, TIP 10 "agrees that patients should be given every chance to continue in and try to benefit from treatment...Staff should make every effort to rework treatment plans and provide help and counseling for continued use of other drugs. A policy of administrative discharge. . .for continued addict behavior [i.e., dirty urines], may sometimes be self-defeating.
If a patient continues to use heroin, the physician should look carefully at dosage and blood plasma levels to see if there is a problem with metabolism [or] absorption. . .that might influence adequacy of dosage" (p. 55) to see whether an increase in dose may help. As TAP 7, p. 5, states, "Methadone is not a treatment for cocaine...or alcoholism....[but] the majority of patients on methadone substantially reduce their overall use of drugs and alcohol."
TIP 10, pages 55 & 56 state, "There will, nevertheless, be situations when an administrative or disciplinary discharge is necessary" such as when a patient is violent toward staff or other patients or for "criminal behavior", or when a private clinic has to discharge for nonpayment. BUT, they recommend an "ethical criteria for withdrawal from methadone and a readmit procedure...", and they say "blind withdrawal is unethical unless requested by the patient.
Withdrawal [or] discharge should be a LAST RESORT in light of the strong probability of relapse and the subsequent dangers of infectious disease that jeopardize the patient's health..."Additionally, regarding pregnant patients, "It is...essential to retain pregnant patients in treatment where they may benefit from supportive and medical services."
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The Supreme Court ruled unanimously that the Americans with Disabilities Act (ADA) applies to prisons and jails. The issue in the case that was heard related to a prisoner request for assignment to boot camp to reduce his sentence but was refused because he had high blood pressure. Pennsylvania (and 36 other states) had claimed that prisons were outside the requirements of the ADA, but the justices confirmed that they are a "public entity" and that any programs or services must comply. Some of the references included (directly quoted from the brief):
"Disabled prisoners have a right, if the [ADA] is given its natural meaning, not to be treated even worse than those more fortunate [able-bodied] inmates." Crawford v. Indiana Department of Corrections, 115 F.3d 481, 486 (7th Cir. 1997) (Posner, C.J.). Seeking equal access, not better treatment than others, disabled prisoners have raised substantial claims of discriminatory treatment in seeking relief under the Rehabilitation Act and the ADA."
Reasonable accommodation is required to be made, so be sure that
any request will not present more of a problem than might be granted to
another person needing a prescribed medication for a chronic illness. This
might mean that your program would need to cooperate in some way.
Enlist the local or state chapter of the ACLU for assistance, as many systems
may still refute the challenge, and time may be critical for many patients.
Advocates may want to write letters to ask for assistance BEFORE the issue
arises, so that a response from ACLU could be "in hand" should it be needed.
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I see the frustration and agony we face every day in our quest to be normal citizens. A little true story that may drive the point home of how programs can control and affect our lives. The program director in a certain state had promised me over the phone many weeks in advance of moving my family from New York to there that he would secure a once-a-week methadone pickup for me. He did tell me a few times on the many calls that there should be no problem.
With that verbal promise, I moved to Florida. Mind you, I was getting twice-a-month take outs from the NYC clinic before I moved. They were approved by federal, New York State and New York City authorities. It was well documented and in my file when I started on the new program.
When I arrived for my first pick up, to my surprise, the program director had done nothing. So, he called the State Methadone Agency (SMA) without any look at the facts or preparation for his conversation to see if they would approve a once-a-week pickup schedule. The person on the other end of the phone either got up on the wrong side of the bed or did not get his the night before and denied all but a twice-a-week pickup.
I then asked the Director about what he had told me and said that I was in deep trouble as I counted on him and his word. I travel for work all the time at a moment's notice--like midnight the night before pickup day.
So we were off to a bad start. For the next few months, I had three counselors in three months; they were not helpful. I arranged not to travel. This did not give me good status at work. The fourth counselor was able to help me secure emergency bottles to keep my job.
Then she left, and I got the "counselor from hell." She had a chippy all the time. I needed the emergency takeouts almost every week now. By the way, I substantiated my travel in triplicate, so there was no doubt where I was and for what purpose. However, she started to question me and said that the doctor could get in trouble for all the special takeouts I needed.
The new director, who was married, and my counselor were caught in the car around back of the clinic doing their nasty deed. Well, they decided to try and get me a special exemption to allow me six take outs at a time again. The dynamic duo decided I knew too much and only got me five bottles at a time, which still made me come to the clinic two times a week. It was easier for them to get me an exemption than ask the doctor for the special take outs. State law usually allows as many bottles as needed up to two weeks at a time or more, depending upon the situation as long as it can be substantiated. I had checked this out before I went on the Florida program.
The company I was employed with spun off from the main company, and I had only a company name change on the check (we have to substantiate employment every month). On a Sunday, with my plans to travel to Atlanta in my pocket, the counselor from hell and her director lover said that the Special Exemption was no longer good and took my bottles. I pleaded to show that this was not true and that only the name changed, not the company. The same person signed the check, my employee number was the same, and all my other information did not change. Their decision was that I had to pick up two times a week.
Again, I had to put my job in jeopardy because of not being able to travel and meet my promised job responsibility. So I got a letter from my boss after telling him another story as to why I needed it. This was the third letter I had asked for. They lost the first, and I had to get another one as the date needed to be different by the time they procrastinated. I asked every other pickup day as to the status of the request and was told a lie by the duo. This added great amounts of stress, and I almost lost my job, as I had no way of arranging a guest pickup at another clinic due to not having advanced warning and notification most of the time.
So I had to do what was necessary to cope (if you get my drift). I tried very hard not to relapse, but that even came close after 20 plus years of being clean. I have been stalled in airports, and bad weather interrupted my being able to return on time on many occasions.
So, finally, I called the Senior VP of all the clinics, and he was appalled at their behavior, plus the fact I had spoken to the head of the State Methadone Authority to try and see if I could get a sane resolution to this matter. The SMA Director called the senior VP of the clinics. The end was at hand for the duo, as they were both fired for immoral behavior and endangering my safety, health, anonymity, and well being. Their negligent behavior and lack of judgment was negatively affecting many other patients as well. Many a warning and threat was issued to the clinic; the DEA, FDA, and other state authorities were after them, and the clinic was threatened with closure.
That is when I was assigned a new counselor (The angel Head Nurse) for many apparent reasons, and my health was not good (Hep C and Cirrhosis). She had a special meeting with the State Methadone Administrator as he has the authority to grant special exemptions. She drove all the way to the state capitol to meet with him, as face to face is the best way, and she secured a once-a-week take home exemption for me which is still in force.
Note: Old "counselor from hell" had added
many incorrect lies to my file which I did not know about, and it was signed
by both the old counselor and director. I had that stricken from
the file and corrected.
The moral is that sometimes counselors and directors make up restrictions on the fly. You need to know what your rights are and how you can protect yourself from this happening. If I had this information either at the clinic or on hand, I would have been much wiser. A knowledgeable patient is a wise patient. Information rules. This is one of the reasons that others in our position need to have availability to the real truth and not a made up set of rules that change to meet the counselor's or clinic's needs. Our right to anonymity and safety of our health is not to be compromised.
This is a true story, and it could have been avoided by having
the information nearby and being told the truth by people who (in some
cases) are out only out to burn certain people. We are entitled
to be treated like human beings and not subjected to endangering our health
and well being by a bad counselor whose ambition for power over you can
affect you to your very human core.
Regards, and I hope some others will learn by the injustice done to me by the people who run our daily lives.
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Some of you know that DONT/Methadone Today helps patients to figure out where to go with problems and to get help. We will still do this, but patients must pay expenses such as phone calls, photocopying, and postage. If you need literature, this also applies.
If you know of anyplace we may be able to get funding for the newsletter, please let us know as soon as possible. Or, if you have done well since becoming a MMT patient, perhaps you could make us your favorite charity!
From the letters I have received, I know that you realize how important Methadone Today is, and hopefully, you can afford $12 per year to subscribe to the newsletter to find out about methadone maintenance treatment (MMT) issues, such as federal, state, and local regulations; information about diseases such as HIV/AIDS and Hepatitis C; treatments such as UROD/RAAD (Rapid Detox), LAAM, Ibogaine, and Buprenorphine, etc.; the U.S. Department of Health and Human Services' guidelines and protocols through the TIP/TAP series, which included but was not limited to proper dosing, serum levels, and length of treatment; treating pain and hospitalization; treatment of MMT patients in jail/prison; treating pregnant patients with methadone; issues regarding legislation that affect MMT patients; the fight for medical maintenance for long-time patients, etc. These are very important issues for the MMT patient, but often the patient is not informed about his or her treatment and the issues surrounding it.
We can also use your help in ways other than financial. Pick an area related to methadone maintenance that interests you and needs correction, and help us out. There is so much to do and too few people to do it. No one will do it for us.
To donate or subscribe, please use form below:
If you want to help out, call us at:
Methadone Today/DONT (810) 658-9064
or E-mail us at: email@example.com
See snail mail address below
Please make checks payable to: DONT/Methadone Today and
send to PO Box 164, Davison, MI 48423-0164. Phone:
(810) 658-9064 Visit our web site* at http://www.tir.com/~yourtype
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As a network, we are going to have to reevaluate how we operate and particularly how to support the work of advocacy groups. NAMA is already planning to meet with our chapters during the National Methadone Conference and a few weeks later at the Harm Reduction Conference in Cleveland. It will only cost about $200,000 to fund NAMA and all of our affiliates, and in the scheme of things, that is not much.
One thing is certain--we cannot depend upon one source for funding. While the DPF helped to "jump start" NAMA and our growth, we have to consider our options. Because of the stigma we have to overcome, it will have to be a creative solution. These next years will be a transition to more stability, and we are not going to go away. All of NAMA's chapters are in it for the long haul.
We welcome our first chapter in Texas--TEXNAMA. The group is being sponsored by one of our Advisors, Dr. Tom Payte, of Drug Dependence Associates. John and Barbara Fingers are the organizers of TEXNAMA, which they intend to expand statewide.
Positive Health Project, the sponsor of one of NAMA's chapters, the Midtown Methadone and Advocacy Group, will be the first needle exchange program to put public ads in New York's subway system. At a press conference held in Times Square early in July, Jason Farrell announced that throughout July, 1140 ads will appear in subway cars to promote New York City's needle exchange programs.
Appearing in the Journal of the American College of Physicians,
is an editorial by Dr. Sox who criticizes the medical profession for their
passive acceptance of our nation's drug policy and the treatment of addiction.
In particular, the editorial gives an excellent explanation of methadone
maintenance and continues with:
"Probably the most important action is to rethink our attitudes toward addiction to illicit drugs and to recognize it as a chronic disease rather than a manifestation of psychological impairment." As one expert has said, "Drug use is a choice, addiction is not." We need to open our minds to methadone maintenance, which is a pharmacologically sound approach to minimizing the harm from addiction." (Sox, H.C. The national war on drugs: Build clinics, not prisons [President's Column] ACP Observer 1998, June).
Matthew Southwell of the Respect Users' Union London also contacted
me this month to ask NAMA to be the North American representative for the
International Users' Groups' Meeting which takes place during the International
Conference on Harm Reduction.
No one will do it for us. Very often, it is just not to their benefit. And we can do it; we would not have methadone treatment at all today if it was not for the perseverance of a few dedicated professionals and the early patients who were facing far more difficult odds than we are today. They started it, and we have to finish it. You can start by writing this month, and don't forget to drop NAMA a short note telling us who you wrote to. We are tracking all of this and will follow it up. And don't forget to check our website (www.methadone.org) for any other information.
National Alliance of Methadone Advocates
435 Second Avenue
New York, NY 10010
Attn: The National Letter Writing Campaign
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