Methadone Today

Methadone Success Stories: Going Public - "Gina C."

Inmates on MMT - Aaron Rolnick

Dear Readers - Denise, Montevallo, Alabama

TIP/TAP Series - MMT in Jails & Prisons - Nancy Rose (DONT Secretary)

NAMA Column - Joycelyn Woods

Doctor's Column - Addiction/Dependence: there is a difference

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I found a copy of a newspaper article from the New York Times written by Christopher S. Wren floating around our clinic. The title was cut off, but the sub-heading read: "Greatest Success Stories Go Untold Because of Stigma."

The article is about a musician, Jimmie Maxwell, a veteran jazz trumpeter, who has played with Benny Goodman, Lionel Hampton, Duke Ellington, and Gerry Mulligan. He also worked as a studio musician on the Perry Como show and Johnny Carson's Tonight Show.

The main point of the article is that Mr. Maxwell finally went public with the fact that he has been a methadone patient for 32 years! He is presently 80 years old. Mr. Maxwell tells how heroin addiction nearly killed him 32 years ago, but he has stayed "clean" for the past 32 years by staying on the medication methadone (He had joined Dr. Marie Nyswander's original program back in 1965!) He hid it for years from his employers and fellow band members because of the stigma attached to a treatment for heroin addiction.

Mr. Wren estimates that over 115,000 Americans take methadone daily. He also explains there is "...an insidious social stigma that equates methadone with illicit drugs, forcing users to hide the achievement of taking back their lives."

Mr. Wren quotes several physicians in the article. Dr. Edwin Salsitz (director of the methadone medical maintenance program of Beth Israel Medical Center in New York City) said, "Successful methadone users are invisible; methadone is always judged by the failures." Dr. Salsitz equates methadone for opiate addicts as insulin is for diabetics (in other words, the medication corrects faulty brain and/or body chemistry). Dr. Robert Newman (president of Beth Israel Medical Center) said, "The safety and efficacy of methadone in the treatment of narcotic addiction have been documented more extensively than any other medication in the pharmacopeia." Dr. Mary Jeanne Kreek (an early colleague of Dr. Nyswander) said that when the very first patients were given...methadone daily, "...they began turning away from [illicit] drug administration and getting on with their lives".

Many of us methadone patients today are still afraid to let employers, friends, or others know we are on methadone. Some are even reluctant to let family members know. But, we should be PROUD that we chose to recover from our addiction, that we are able to live "clean" because of this life-saving medication! Hopefully, with all the advocacy groups sprouting up locally, nationally, and internationally, more famous people or professionals (doctors, nurses, teachers, lawyers, etc.) will go public with the fact they are methadone patients. Then, maybe the rest of us patients will feel we can "go public".

So please, any of you methadone patients who can "risk" educating people, please do so! Yes, it can be embarrassing to tell people we were once a using-addict. It's certainly understandable if you feel you don't want to offer this bit of personal history, since many people can be judgmental. But, we can start with the people who did know us as addicts; let them know (and see for their own eyes!) how much you have improved your life by seeking treatment and taking this life-saving medication. If you see a TV program or read an article that is biased against methadone, write a letter (anonymously, if necessary) to tell them the truth! Most of the media only tell about the small percentage of methadone patients who aren't doing well. (Christopher Wren is an apparent exception, along with Rolling Stone Magazine; both have written honest articles about methadone and methadone patients. Additionally, Rolling Stone has written about harm reduction and other drug policy issues.)

All of us thousands of methadone patients who have turned our lives around and presently are working, going to school, raising families, voting, and paying taxes are invisible to the general public. If we don't educate the rest of the world, who will?

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Jails and prisons often will not provide methadone to inmates (on MMT prior to incarceration), yet such jail/prison actions are rarely challenged in court. In the August 1996 issue of Methadone Today, "Sad Tales From Nassau County Jail" by Donna Schoen compiled a set of stories by several inmates of the cruelty they were forced to suffer as a result of the jail refusing to provide methadone to them or rapidly detoxing them despite being maintained on methadone prior to incarceration. Although all the stories came from the same jail in Nassau County, New York, the editor of Methadone Today made sure to point out that, "Any city, Anywhere, USA could be substituted." Unless a particular state has legislation requiring jail and/or prisons to dose inmates on methadone or even setting standards for detoxing inmates on methadone, jails and prisons with a few exceptions have a great deal of leeway in detoxing/dosing inmates on methadone.

Anyone who has suffered the debilitating symptoms of withdrawal syndrome knows that enduring the pain and suffering of it is like being tortured. Jails and prisons that withhold an inmate's dose technically are not directly inflicting pain and suffering, but withholding necessary medication makes the jail/prison as responsible for the pain and suffering as if a jail/prison employee had beaten an inmate. Furthermore, a jail or prison withholding necessary medication resulting in severe withdrawal syndrome is just as cruel as any direct act of torture. Not even considering the possibility of relapse, depression, and even suicide, cold turkey withdrawal or even a 6 day detox from a very common dosage of 100 mg. of methadone would result in severe physical withdrawal symptoms that would probably be more painful than, for example, a flogging, a practice that would not be allowed in a U.S. jail or prison. Thus, jails and prisons should be prohibited from forcing an inmate to go through cold turkey withdrawal, detox at an untherapeutic rate, or even involuntary detox at all.

Contrary to the notion that withholding medical care from inmates is, or at least should be, considered unconstitutional "cruel and unusual punishment" pursuant to the 8th amendment to the U.S. Constitution, the courts have only recognized a limited right of an inmate to medical care. The courts have used two different standards to determine the rights of inmates: one standard for "pretrial detainees" (those held in jail or prison awaiting trial) and another less stringent standard for those already convicted and serving time.

The U.S. Supreme Court addressed the rights of convicts to medical care in Estelle v Gamble (1976). In Estelle, the Court ruled that failing to provide a convict with medical care only violates the 8th amendment if: 1. The denial or delay of medical care is deliberate. 2. The medical needs that are not tended to are serious (failure to address medical needs will result in sufficient harm to the convict). Unfortunately, these standards are very stringent and quite difficult to prove. Obviously, most jails and prisons are going to do just enough to demonstrate that any inadequacy in a prisoner's medical care will not be found to be "deliberate"; in Estelle, the Court explains that, "an inadvertent failure to provide adequate medical care" would not violate the 8th amendment (if it's not "deliberate," then it must be "inadvertent" and permissible). Thus, even medical malpractice would be allowable, as long as the inadequacies were not intentional.

Given the above standard for determining whether denial of medical care constitutes a violation of the 8th amendment, the likelihood of a jail or prison withholding methadone from a convict being ruled unconstitutional is very low. As long as the inmate is examined by a doctor at some point, the jail or prison is probably under no obligation to provide methadone, and at very most, may be required to provide minimal medication to ease withdrawal symptoms.

The degree/standard of medical care that jails and prisons are constitutionally required to provide pretrial detainees has not been clearly established by court decisions. Unless a court case has already established that a medical treatment (or lack thereof) is cruel and unusual punishment, the court must decide whether the treatment/denial of treatment should be considered a punishment. In Allegheny County Jail v Pierce (1979), the Court declared that absent an expressed intent to punish, if a restriction of pretrial detention is reasonably related to insuring jail security or making sure the prisoner attends trial, it is not unconstitutional "punishment". On the other hand, if the restriction of pretrial detention is "arbitrary or purposeless," then the action is considered unconstitutional punishment and may not be inflicted upon the prisoner.

The Federal Courts have made different and sometimes conflicting determinations of whether or under what circumstances jails and prisons may rapidly detox or simply refuse to dose a pretrial detainee who was on methadone maintenance before being incarcerated. In Cudnik v Kreiger, the (District) Court determined that jails and prisons do not have a legitimate reason to withhold methadone from methadone maintenance patients and therefore, it is unconstitutional for them to detox a pretrial detainee at all. In Norris v Frame, the Court (of Appeals) reasoned that there could be a legitimate reason to withhold/limit methadone, but whether there is depends on the circumstances--if a jail or prison had dosed inmates in the past, the Court doubted that the jail or prison all of a sudden needed to withhold methadone for security or other legitimate reasons. On the other hand, many courts have ruled that jails and prisons have a legitimate security interest (albeit weak) in withholding methadone from pretrial detainees and have allowed detox or even a complete withholding of methadone (at least if tranquilizers and/or other medications are used to somewhat ease withdrawal): Allegheny County Jail v Pierce, Owens-El v Robinson.

The courts have virtually eliminated the rights of convicts and have limited the rights of pretrial detainees who are methadone patients to maintain on methadone. The preponderance of Federal Appeals Court decisions have permitted jails and prisons (at least under certain circumstances) to a minimum, limit a pretrial detainee's access to a short (6 day) detox. Fortunately, the courts have not yet set this in stone, and since the U.S. Supreme Court has not ruled on this issue, pretrial detainees may still be able to obtain a fair hearing. Thus, if a medical expert could convince the court that given the relapse rate and severity of physical withdrawal symptoms that a jail or prison forcing a detainee to detox is not reasonable, it would indeed constitute punishment.

One Final Note:
The US Supreme Court has not taken any such methadone cases, so until/unless they do, the lower federal courts are left to determine whether jails/prisons are allowed to withhold methadone from pretrial detainees. In the US Sixth Circuit, which includes Michigan, no such methadone case has reached the Court of Appeals. The only such case within the Sixth Circuit reached a US District Court in Ohio: Cudnik v Kreiger. A District Court is inferior to a Court of Appeals and therefore not binding on a Court of Appeals. However, the courts generally prefer to remain consistent with other courts and court decisions within their circuit. Therefore, other district courts within the Sixth Circuit, as well as the Sixth Circuit Court of Appeals, may be persuaded to follow the decision of the Court in Cudnik v Kreiger. Fortunately, in that case, the Court ruled in favor of the pretrial detainee, agreeing with them that jail/prison security is not advanced by withholding methadone from inmates and, therefore, was punishment and in violation of the detainee's constitutional rights. Thus, pretrial detainees in Michigan and the Sixth Circuit may be able to successfully sue to obtain methadone maintenance by persuading the courts to follow Cudnik v Kreiger.

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Dear Readers: I am a fifth-year methadone patient. I am also an addict with a 20-year history of drug abuse. There's not much I haven't been through relating to addiction. I did, however, manage to hold onto my home, job of 15 yrs. and child. Methadone saved my life.

Last year, I was really put to the test. After four years of successful methadone maintenance, I "fell," so to speak. During a time of extreme stress, I reached back into my old habits and took several Valium. My mother had a stroke, and my father is terminally ill with cancer. Being the total caregiver for both, I was reaching for some relief. Did I ever look in the wrong place.

To make a long story short, I was arrested. I do not take Valium on a regular basis; this was the second time I had taken them in five years. I do have a previous arrest for possession for which I received 15 years probation. I made almost four years before I was caught for DUI, Valium (2), and pot (2 joints). I paid a lawyer $10,000, for which he said I was lucky to receive a split sentence--2 years in jail and 10 on probation.

I don't feel "lucky." Now I am faced with coming off methadone immediately; this is my eighth day without any medication. My thoughts are, "If I have to detox immediately, I'd prefer to do it at home."

Anyhow, my reason for writing is to let you know it only takes one slip to put you where you do not want to be. Every month when I receive the newsletter, I thank God above that there is someone out there who feels as I do. This is my assurance that I am not alone. Many, many times I've wanted to tell Beth Francisco what her work and dedication has meant to me "hands across the miles" so to speak. Nevertheless, I never got around to just saying, "Thanks, Beth."
When my problems arose, I immediately thought of Beth--if anyone would know how I could be helped, it was she. When I called her, it was quite early. She took a deep breath and listened quietly to what I had to say. She also offered encouragement, helpful information, and basically friendship.

So, here I sit wondering why I waited to tell her how very much she is appreciated. I've never met her, but the kind concern she has shown to me is something that is all too rare in this world in which we live. Not only did she listen quietly while I sobbed--after an hour or so of encouraging words, she spent the rest of the day preparing detailed information that would be helpful to me. This, to me, is the caring attitude that I wish more people in the world would exhibit. Now not another day shall pass before I must say, "Thanks, Beth. Your kind and gentle concern does not go unnoticed. - Denise; Montevallo, AL

Editor's Note: Denise wishes there were more caring people--there are many, and they are working long, hard hours to put an end to the insanity. The names are endless: Aaron, who researched "Inmates on MMT"; Nancy, who is writing the TIP & TAP Series; Ken, who has been ill but keeps on taking complaint calls; the great doctors in the Doctor's Column; Liz M, Bill R, Jimmie P, Jessica D, Katherine B, Joycelyn, Diane S, Judith O, Maia, Odus, Rokki, Magic, Nick M, Floyd L--the list goes on...

My heart aches for Denise. She is no criminal, but she does put a human face to addiction and the addict in prison.

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This is a new column that will run for several months and will bring you information straight from the U.S. government's TIP & TAP Series. Both the TIP and TAP series of books are put out by the U.S. Department of Health and Human Services. TIP stands for "Treatment Improvement Protocol" series, and TAP for "Technical Assistance Publication" series. There are about 25 books in each series--available free by calling 800 SAY NOTO and asking for them.

Each book begins by explaining that it contains the "state-of-the-art protocols and guidelines for the treatment of alcohol and other drug abuse" for the nation's substance abuse treatment programs. The TIP & TAP books are written by a number of professionals, including "acknowledged clinical, research, and administrative experts" and other experts in the field. CSAT puts together a Federal Resource panel to review each book after it is written, which then has to be approved by several different groups of professionals, including a non-federal consensus panel and a group of "expert field reviewers" before being finalized and accepted as the government's official guidelines.

Several of the TIP & TAP books are specifically on Methadone Maintenance Treatment (MMT); some of their titles, for example, include: "Treatment of Opiate Addiction with Methadone - A Counselor's Manual" (TAP #7); "State Methadone Treatment Guidelines" (TIP #1); and "Matching Treatment to Patient Needs in Opioid Substitution (Methadone) Therapy" (TIP #20). Topics of some of the other books include LAAM and treating pregnant women, adolescents, and drug-exposed newborns.

For today's topic, I have searched through the TIP & TAP books for the federal government's recommended guidelines regarding methadone treatment for patients who are incarcerated in jail or prison. TIP #19 ("Detoxification from Alcohol & Other Drugs"), page 37, states: "Persons who are incarcerated or detained in holding cells or elsewhere should be assessed for physical dependence on alcohol, sedatives-hypnotics, and/or heroin. Untreated withdrawal from alcohol or other sedatives/hypnotics can be life threatening. Heroin withdrawal is not life threatening to an individual who is healthy (emphasis mine); however, it may be difficult for the patient. Individuals who are on methadone maintenance may experience severe withdrawal symptoms if the medication is abruptly stopped. Persons who have been on (methadone) maintenance therapy before being incarcerated should continue to receive their usual dosage of medication (emphasis mine) if the expected period of incarceration is less than two weeks. If incarceration is longer, the maintenance therapy should be gradually discontinued....There may, however, be restrictions on the use of methadone...in a prison setting. In such cases, staff may need to create linkages with local methadone...programs."

Now, there are some people who believe that if an addict gets locked up (guilty until proven innocent?), he or she "deserves" to suffer from withdrawal. But, any one of us--and this includes all law-abiding citizens, be they MMT patients, clinic staff, or others--could unexpectedly find ourselves locked up and charged with a crime even if innocent. It happens every day, folks--mistaken identity, police raiding the wrong address, being in the wrong place at the wrong time, etc. ALL of us should be concerned about our rights if we should happen to get locked up. Every citizen has a right to their medication, whether it's methadone, insulin, or whatever. Even the federal government recommends this in their guidelines and protocols in the TIP & TAP books.

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Perhaps the one important event this past month was the Moyers Special, "Close to Home" that aired on PBS. On the down side was the emphasis on groups and the one researcher who made a statement that inferred morality and the need for spirituality to recover. The young boy was perhaps the best thing about the entire show for methadone when he looked directly at the camera and said that he wished his father would get on the methadone program (because his mother had made so much improvement since beginning MMT). "Close To Home" is the first step in destigmatizing addiction and correcting the public's belief that it is a behavioral problem. It will be up to us to use the momentum from "Close To Home" to educate the public, policy makers, social workers, health professionals---everyone! A big task, and now we have some help.

Monthly Tasks
Each month we will ask all of our members (this includes you, the reader) to write a letter to a specific politician or policy maker. It can be the same letter each month because different individuals will receive it. So once you write your letter, you can use it over and over again. And you don't have to worry about typing it; in fact, if you do it in your own handwriting, the letter will be taken far more seriously because they know you took the time to write it. So the target group for April is your two Senators in Washington. Last month, it was the House, so this month we will complete the federal part of this letter writing campaign, at least for now. When you write, be sure to drop Methadone Today a note saying "I wrote to my senator this month." We will forward the information to NAMA. This is the way we will keep tally of the number of letters. Nothing like this has ever been done before, and if each senator receives even a few letters, it will make a tremendous impact. Editor's Note: Thanks to everyone who sent the letters which were in the February 1998 Methadone Today (although we sent "thank you" letters to those who informed us that they participated, some did not give us their address, so we thank you now). If you did not send the letter, you can use it now or at least get some ideas from it. Please do your part, and send one this month.

April 22nd was the First Annual Syringe Exchange Lobby Day. Thousands of activists went to Washington to talk with their representatives. It is not too late to do your part--you should call, write a letter or send a fax to your representative and senator--yes both--and if you have the time, you might write to Health and Human Services Secretary, Donna Shalala, and President Clinton asking them to lift the federal funding ban on needle exchange. Of course, you can add that Methadone Maintenance Treatment needs to be made available to every addict and American citizen who needs it, NOW. Addicts and their loved ones should not be abandoned because the public does not understand addiction.

About Employment Discrimination
I am consistently getting phone calls, letters and messages on the Internet from patients who do not realize that they are protected by the Americans With Disabilities Act (ADA). They are frightened and feel trapped. Just recently I received a call from a patient who was told by staff that they had better withdraw from methadone treatment before getting a teacher's license. Clearly this so-called methadone professional is ignorant about the consequences of withdrawing from treatment. A patient should never, never withdraw from methadone because of a job or family or any reason that does not come from you--you do it because you and you alone want to.

Patients who withdraw from methadone usually relapse, no matter their stability or what they have achieved. So when such an idea is presented to a patient who is obviously not ready, it suggests to me a severe lack of education and misunderstanding about addiction. Yes, these people are dangerous to us, and there is no excuse for their lack of education with the wealth of information about methadone that is available--and most is free! Obviously this staff person does not realize that former addicts and methadone patients are considered disabled and thus protected by the ADA. Now I realize that many do not like the idea of being disabled, however when one considers the prejudice directed towards methadone patients because of our disorder, our primary disability has become the stigma we endure. And that is a good reason for the ADA to protect us!

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