TIP/TAP Series: Treating Pregnant MMT Patients - Nancy Rose (DONT Secretary)
Medical Maintenance - The Holy Grail &
the Con Man - Bao Dai
NAMA Column #6 - Joycelyn Woods
Doctor's Column - Naltrexone-Related Deaths
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TIP 2 states, "Methadone substitution is the standard treatment
for heroin addiction. Methadone treatment alternatives consist of
(1) high-dose blockade, (2) low-dose maintenance, and (3) medical withdrawal.
Medical withdrawal of the woman is NOT recommended in pregnancy because
of the increased risk to the fetus of intrauterine death" (p. 19).
Page 20 warns: "NARCAN (or any narcotic antagonist) should NEVER be given
to a pregnant, substance-using woman except as a last resort to reverse
severe narcotic overdose."
"Methadone maintenance is strongly encouraged for all pregnant, opioid-dependent women. It provides the following advantages:
Additionally, "An increased methadone dosage may be needed in later stages of pregnancy to prevent withdrawal (The greater plasma volume and renal blood flow of pregnancy can contribute to a reduced level of methadone in the blood)" (p. 20). TIP 1, State Methadone Treatment Guidelines, also covers MMT in pregnancy, stating (emphasis theirs): "It is extremely important to understand the increases in blood volume and metabolic changes specific to pregnancy, as methadone-maintained women frequently develop increasing signs and symptoms of withdrawal as pregnancy progresses and need elevations of their oral dose in order to maintain the same plasma level and remain withdrawal free" (page 87). TIP 1 states that even women on high doses prior to becoming pregnant should not be forced into withdrawal, as "withdrawal is not recommended during gestation, since the risks of withdrawal and recidivism associated with withdrawal are HIGHER than any that might theoretically be associated with a high dose of a licit medication such as methadone" (page 87).
TAP 7, Treatment of Opiate Addiction with Methadone: A Counselor Manual says, "Pregnant users who are in treatment with methadone deliver healthy babies. It is true that babies born to women on methadone sometimes experience some withdrawal symptoms. . . [but] symptoms are routinely treated by the baby's pediatrician and do not result in any long-term damage. . . . The most important comparison, however, is not how these babies compare with nonaddicted [babies] but rather how they compare with babies of mothers addicted to heroin. Studies have demonstrated tremendous benefits from methadone" (p. 6).
During labor and delivery, physicians are advised to "Provide pain management as appropriate. Analgesia and anesthesia administered during labor may include the same range of options available to all patients. Pain medication and attempts at adequate pain relief should NEVER be withheld simply because the patient has a history of alcohol and other drug use...Due to tolerance, patients may require higher than usual doses of short-acting intramuscular/injection narcotics. . ." (TIP 2, p. 39).
For postpartum care, health care workers are advised to "Encourage continuation of. . . drug treatment" (TIP 2, p. 42). Also, "Permit breast feeding in methadone-maintained women. . . Breast feeding is NOT contraindicated in a methadone-maintained patient if she is known to be free of other drug use and is known to be HIV-seronegative" (TIP 2, p. 42).
There is much more information about treating pregnant MMT women,
but it is beyond the scope of this article. If interested, order
a set of TIP/TAP books (or at least TIP 2, Pregnant, Substance-Using Women)
by calling (800) SAY-NOTO (729-6686).
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There have been "experiments" involving .1% or less of MMT patients which have been conducted (primarily at Beth Israel in New York City) literally for years, but recently there has been a growing cry coming not only from patients but from the public health sector and even the Drug Czar to radically change the face of the Methadone Bureaucracy to make it more patient friendly and accessible to those who could benefit from it.
The availability of "Medical Maintenance" - primarily for patients who do not have active drug abuse issues or other problems which might require more frequent clinic contact - is one of the things which would change the present system. To that end, the State of Connecticut enacted a law allowing for the establishment of programs which would allow selected patients to pick up a 30 day supply of methadone at a time. The law will apparently go into effect sometime later this year.
In 1997 a person calling himself "Laurence Alderman, M.D."* began posting on an Internet "mailing list" devoted to the discussion of methadone treatment. An "Internet Mailing List" is essentially a free system by which subscribers send communications to a single address which is then distributed to all subscribers. The "Methadone List" was subscribed to mainly by patients, although a handful of providers have also been an active part of it (notably Dr. Marc Shinderman of the Center for Addictive Problems in Chicago).
"Larry, as he became known, participated in the List intermittently (frequently unsubscribing after people attacked him for holding such views as "all patients are cons") claimed to have been a methadone patient himself while in medical school and also claimed he owned a clinic in New Haven. When the law passed, Larry's clinic soon included the "only (seriously operating) medical maintenance program outside of New York City" for a lucky three hundred. Dr. Shinderman and a host of patients took him at face value.
And why not believe him? It isn't as if MMT patients are known for holding doctors in terribly high regard, and Larry's general attitude toward patients was fairly apparent from the start (e.g. his subjecting patients with take homes to random demands that they return to the clinic with their bottles to demonstrate none had been diverted) and it didn't exactly illicit general affection for the man, or benefit the general reputation of providers. It wasn't like saying "I own a clinic" was going to make him Joe Popular.
To patients, the existence of an increase in the number of Medical Maintenance programs anywhere in the United States is akin to proof that there really is a heaven in the sense such programs are tangible illustrations that maybe, just maybe, if you play your cards right in a few years you won't *still* have to arrange your life so that you can spend a minute (or as long as the staff wants) each day, or at least each week, at the clinic.
Well, as things turned out, Larry, who had the habit of popping up elsewhere on the World Wide Web like some sort of bad cyber penny, allegedly doing all sorts of dastardly deeds which aren't here relevant, wasn't a doctor and never had anything to do with a clinic (except perhaps as a patient of a counselor who had a very short career).
Still, Larry could be having whatever fun he was having pretending to a bunch of recovering addicts that he was one of their own who was, so to speak, giving back to the community by operating a clinic and championing Medical Maintenance like some brave pioneer, except he got greedy.
Now, this greed had nothing to do with money--like a drooling pedophile, Larry needed a victim of flesh and blood, and he found one in the person of "Nancy," a nurse who had recently left New Hampshire because she left her husband who had relapsed into active heroin addiction.**
Nancy moved to Massachusetts to live near her daughter and grandchildren. She enrolled in the only viable clinic for her; one which might have been called "The Eighth Circle of Hell" if its owners had a sense of humor, but they had no sense, let alone humor. The clinic didn't "recognize" her documented years of clean tox screens--it made her start earning take homes from scratch. And, of course, to earn a take home, a patient had to be employed, and to earn a take home (indeed, not to be threatened with a detox), a patient had to attend group therapy and other counseling sessions. And, of course, the clinic held such sessions during regular business hours. And so, of course, Nancy could not very easily hold onto her job if she was to get the counseling the clinic felt she needed to stop taking the drugs she hadn't taken for over five years (if you suspect that perhaps the clinic may have gotten more money if patients didn't get take homes and even more if they were unemployed, STOP BEING PARANOID!).
Larry hears of Nancy's woes and, like a blood-starved vampire, descended upon her with promises that she could get on his Medical Maintenance program just as soon as a spot opened up. . .she was always next on the waiting list, and there was going to be a spot open soon.
By making such promises, Larry encouraged and got Nancy to release all of her medical records to him. Perhaps this bit of voyeurism is what got Larry off--a third-rate scam around the laws which protect individuals' privacy--a mental and emotional kind of rape--it can only be speculated, since Larry isn't talking (he has been asked to give his side many times and has refused comment).
Not only that, but he had Nancy a bus ticket away from relapse. Driven to the brink of insanity by her clinic's 7-day dosing regime, missed group therapy sessions, and threats of discharge, Larry became Nancy's only hope, as can be seen by their correspondence and her telephone bill.
But there were always problems. . .The State of Connecticut wasn't sure the precious slot should go to a nonresident. There was this problem and that problem. She was often packed and ready to go when Larry would call to say "Sorry, but. . ." Much like that junky "friend" you may have had who took your money to score on Tuesday but never showed after you waited and waited, there was always some excuse. . .
. . . and Larry managed to string Nancy along for about half a year. . . . Finally, things at her clinic got so Nancy couldn't take it anymore. She was packed and ready to leave--even if it meant accepting his offer to be a patient on his regular program for however long it took to get on the Medical Maintenance program--even if she had to accept his offer to live at his house and work as a secretary in his clinic for a month.
Larry may have sensed the hounds of suspicion sniffing his trail.
Nancy wasn't too happy about being continually put off and was making sounds
like she might just call the State of Connecticut herself to learn the
nature of their alleged objections
As she was about to call and say her goodbyes, hoping she'd be back in a month, Nancy got the following E-mail from Larry:
Subject: Ok. . . you didn't call AGAIN. . .! [suggests he's replying to a letter wherein she complained about how he was stringing her along].
"I was just sitting down to write you and I got your message. I had a meeting yesterday morning w/ H & as and there is no more Med Maint in the State of Ct. I got so pissed off I handed over the clinic to my partner and new TOTAL owner of both clinics this afternoon. They met w/ me and then jerked me around for a day, then @ 4 pm today I got this wonderful news. They say it's because of the suit the FDA has pending against them for unilaterally putting in Med Maint w/o Federal perm. It def. has nothing to do w/ you as all med. Maint patients lose their once a month p/ups as of Mon. March 16. I have had enough and am very sorry this had to happen to you also. Your best bet at this juncture is to go back to the other clinic you were on up there before ["The Eighth Circle of Hell"]; now that winter is over you won't have Rt 128 to contend w/ anymore.
"I'm done w/ Methadone Maint., no money, too many problems, too
many lies, including the state and fed officials. This has dragged on so
long now I feel obligated in some way to you. However there is nothing
I can do. Please accept my apologies and I wish you the best of luck in
this absurd system. Your Friend always, Larry."
Who wants a long-term house guest who is expecting there to be a job waiting for her at a clinic, especially when the clinic doesn't exist? It could have proven a rather tense situation.
"So what?' you ask. "I have to drive 90 minutes 7 or 6 or 5 or 4 or 3 or 2 or at least one time a week."
Well, some little psycho doesn't have your entire medical and social history with which to blackmail you or post on the Internet or use for masturbatory purposes. You didn't almost quit your clinic and head off to end up puking your guts out all over some sleazy motel room and then go out and find a fix and a point just to be in some form of human condition in which you could figure out exactly what the point of it all could have been. No one played upon your desperation just to have a good time.
The point is that under the present Methadone Bureaucracy, we are all desperate people. They call narcotic addiction a disease, but they refuse, by and large, through regulations and rules on reams of paper made from the trees which have died for our "sins", to treat a very treatable condition as a simple medical one, requiring that patients maintain, if only to humble themselves before the Bureaucracy and some Providers, just a touch of that certain something which differentiates an addict from someone who needs a drug to simply function normally, perhaps to punish patients, as the average methadone clinic seems part penal in inspiration.
It isn't good form to exploit anyone, especially not the already exploited by playing on their hopes and dreams and need to believe. And exploitation for its own sake is sick--it's a sickness which is chronic, and I'd bet my last dollar that this person who called himself Laurence D. Alderman, M.D. pulled the wings off flies as a youngster, stuck firecrackers in the orifices of small pets as a teenager, and hides bed pans at hospices in his spare time will show up somewhere, someplace, pulling another stupid, pointless, yet terribly cruel hoax. . .
. . . perhaps in prison--as several sources indicate that authorities and Yale University, with which he claimed affiliation, are interested in his fraudulent misrepresentations. Well, at least in prison, I understand justice for such things is terribly swift--if a tad harsh and lacking in due process.
*It's uncertain, but a review of governmental records resulted in the conclusion that this was "probably not his real name" - there clearly is no physician in Connecticut involved in MMT or affiliated with Yale University with that name.
**While NH allows no clinics within its pristine borders and, thus, Nancy had to regularly skid through the pre-dawn snow to get to a clinic in another state to maintain her recovery, it obviously must have heroin, but that's another story.
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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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The Mayor could harass methadone programs through the things over which he does have control. The primary strategy that he has used in the past, and will probably continue to use, is Medicaid. During the past two years, methadone patients have been assigned to workfare programs.
Another problematic area is toxicology reports. The later is a breach of confidentiality; however, over the past two years, Medicaid has been requiring toxicology reports with the insistence that they are not going to use them for anything. Then why request them? NAMA has believed that from the beginning this has been a way to get at the most vulnerable patients in methadone treatment and that eventually toxicology reports will be used against patients. So far they have not.
The Mayor's remarks have had a positive impact. The reality is that it was a bizarre thing for the Mayor to say from the city with one of the largest addict populations in the world and also a significant HIV prevalence rate. His words were so far out on a limb that even policy makers who do not normally defend methadone found themselves doing so. All the major agencies, institutions, organizations and societies have made statements defending methadone treatment.
The most important message comes from the patients, many of whom wrote handwritten notes to the Mayor saying that methadone has saved their lives and that without it, they most certainly would be either dead or a drain on society. The letter writing campaign to the Mayor continues, and I would estimate that several thousand letters have already been received from all over the United States and continue to be sent.
If you do not live in New York City, do not think this has nothing to do with you. Other mayors and governors, encouraged by New York City's Mayor's comments, could get a similar idea. These elected officials could have control over methadone treatment. In essence, this has been a warning that we need to organize more and develop connections. But most importantly, we need to educate the public and our elected officials that methadone does work.
Send it to: Mayor Rudolph W. Guiliani, City Hall, New York, NY 10007
NAMA needs copies of your letter so that we can show several federal agencies, including General McCaffery of the Office of National Drug Control Policy and Donna Shalala of Health and Human Services how the Mayor's callous remarks have impacted the lives of patients.
NAMA is working with a committee of organizations to make sure that your letters will make the greatest impact. We need to have an idea as to the number of letters that have been sent to the Mayor's office to show that methadone patients are concerned. Send a copy of your letter to: National Alliance of Methadone Advocates, 435 Second Avenue, New York, NY 10010 Attn.: Letter to NYC Mayor Project
NAMA of Northern California (NAMA NorCal), Khalil Abdus-Samad
P.O. Box 425264, San Francisco, CA 94112
Haverhill Associated Methadone Advocates (HAMA), Daniel LaProva
P.O. Box 1471, Haverhill, MA 01830
Minnesota Chapter of NAMA (MN NAMA), Becky Duarte
Hennepin County Treatment Program, 1800 Chicago, Minneapolis MN 55404
I can not emphasize the importance of this letter writing campaign. If we want to change methadone treatment, it is imperative that we become habitual letter writers. Methadone treatment has been over regulated and politicized, and if we are to ever rid ourselves of this serfdom, we must become sophisticated medical consumers. Finally, if we are to grow in numbers, each of us must undertake to recruit at least one other patient.
Patient issues have already become realized as important aspects of methadone treatment, and patients need to be involved in policy making. This has occurred because of NAMA and other groups and individuals who have come to realize that something is wrong with methadone maintenance treatment. This is the first step in really changing it to the caring program that Drs. Dole and Nyswander envisioned when they developed methadone treatment.
It is our responsibility to ensure that methadone maintenance treatment lives up to the covenant that it once promised. No one will do it for us. 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 web site (www.methadone.org) where you can find information and links to our chapters and other important methadone web sites.
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