Volume II, Number 4 - April 1997 (This is another 6-page special issue--the print version has more information than the online version due to my lack of knowledge of formatting online in chart form - Editor)

Doctor's Column can be seen: Here

Methadone in Australia - Dr. Andrew Byrne

Big Differences: Methadone Clinics in England - John Lystad

Switzerland

Check Out Your HMO Before Signing Up

Rights Advisor/DONT Meeting - Beth Francisco, Editor

Briefly Speaking

Did You Know?

As in America, the history of methadone treatment in Australia is long and bumpy. It was first used in 1969 in Sydney within a couple of years of the introduction of recreational heroin to our country by servicemen on leave from the Vietnam war. With the help of a couple of devoted people and a few hundred initial patients, the word slowly spread that methadone had advantages for addicts as well as society generally. It was used in a haphazard manner in some states during the 1970s (but that is better than no methadone in the other states!).

In 1985 there was a Special Premiers' (= State Governors) Conference to discuss a strategy for the looming HIV epidemic. Already Australia had initial cases, and people were dying. Methadone treatment was recommended as a way of reducing needle sharing. Hence, a vast expansion of the numbers in treatment commenced in different ways in the various states.

New South Wales used generalist doctors like myself to prescribe methadone, whereas previously only psychiatrists were permitted to do so. Other states mostly used large centralized clinics, most of which have since closed down. For the past ten years, methadone has been available from a variety of sources in New South Wales (population 5.5 million; capital, Sydney)--private and public hospitals, local community pharmacies, traditional clinics, most prisons, (some) emergency rooms and even (exceptionally) doctors' offices.

All Australian methadone for addiction treatment is given as a foul-tasting liquid which is paid for directly by the federal government. Note this is the drug itself, which costs about 50 cents per dose (average 65mg). The dispensing, however, costs from $3 to $7 daily, depending on the setting (pharmacies the cheapest and private clinics the most expensive).

If patients are hospitalized for any reason, the Health Department requires that they be given their normal dose by the hospital on telephone confirmation of the last dose from the patient's normal dispensary. This usually works well, although a few hospital staff members are still methadone 'skeptics'.

We now have strict rules (which are usually adhered to) that if methadone patients are taken into police custody, they must be permitted their medication within 24 hours, even if that means the police taking the patient to their clinic. Usually, in practice, it is simpler since they are released sooner, or else there is an obliging clinic nearby with a reciprocal arrangement to dose the patient on receipt of a confirmatory fax. All prisons are now obliged to maintain patients on methadone on the inside if they were on treatment on the outside.

Police and prison officers were initially resistant to these moves, but they have since mostly come on side for the simple reason that it is humane and very practical. Patients who are given their normal daily medicine are cooperative and appreciative, whereas those denied treatment can understandably become rather stroppy (angry). These innovations have been successful in New South Wales but, like condoms in prisons, the policies have yet to be used widely in other states or territories.

All things considered, the story has been quite the reverse of what I read of the American experience of methadone treatment delivery. We still have some waiting lists, it can be quite expensive and take-home doses can be hard to obtain. But generally, most Australian addicts who want to get methadone can access it one way or another.

We still have a large heroin problem, and overdose deaths are increasing. But, we now have over 35,000 patients who have been on methadone (15,000 currently). They all used to be unstable heroin users but most now lead relatively normal lives. Indeed, amongst them are physicians, nurses, legal workers, airline staff and others from virtually every walk of life.

Our most notable achievement has been the very low rate of HIV amongst drug users. With needle exchanges widely available, methadone treatment, as well as education campaigns, the incidence of HIV has remained less than 2%. In spite of this good fortune, we have over 90% positive for hepatitis C.

There are lessons for Australia in the US experience, but the reverse may also be true. In a future paper, I will outline the nuts and bolts of what treatment entails in this country. I would also like to address the brave new world of methadone maintenance alternatives, buprenorphine, Kapanol, Pallium and even heroin itself. While we have limited experience, these drugs are being used in various parts of the world. Results are awaited with interest.

Written by Dr. Andrew Byrne, General Practice Physician in Sydney, Australia. Dr. Byrne has also written 2 books on the subject: "Methadone in the Treatment of Narcotic Addiction" and "Addict in the Family". $US14 and $9 respectively, including postage. Contact Tel: (612) 9319 5524 Fax: (612) 9318 0631 E-mail: ajbyrne@ozemail.com.au

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I recently had the good fortune to visit England. Since I am on methadone maintenance, and the FDA refused to allow me any take home methadone, it was necessary for me to dose at a London clinic during my stay.

For an American in my situation, this proved easier said than done. First off, dosing status must be arranged by the clinic, not the guest, and apparently my clinic had a rather difficult time doing whatever had to be done in order for me to guest dose in London. I received no word on my guest-dosing status for months.

This was an extremely stressful time for me because I had planned, saved, and dreamed about this trip for a long time. If I were denied access to methadone, it would mean horrible withdrawals, or possibly worse. Actually, it probably would have meant that all of my dreams, planning, and the non-refundable airline ticket I purchased all went for nothing because I would be too scared to go. But, just days before my flight, confirmation of dosing status was granted, and a London clinic address was given to me.

There are some major differences between methadone clinics in England compared with those in the US. One big difference is that no one in England can be refused treatment because of inability to pay; they are free to everyone including non-citizens. Imagine that! The doctors there focus more on harm reduction and medicine rather than making a profit. There was no bullet-proof glass, no mandatory drug testing (except for gaining initial admittance to the program), no strong boxes were necessary, they do not picture I.D. you every single visit (no matter how well they know you) like they do in America (Editor's note: This is a clinic, not a government, regulation). Counseling sessions are available but not required. I also could not help but notice that there was no "You got a problem with that?" attitude from anyone in the whole place.

As an American, I was pleased to be given the dignity of take home medication. Everyone gets take home medication in English clinics, even me. Here, in my own country, I am denied take home medication.

It was also nice to see truly helpful and useful information available and distributed--things like where to find shelter, a hot meal, a shower, clothes, medical attention, etc., as well as guides on transportation, nutrition, parenting, medical emergencies and health bulletins. They made me feel like a regular person, not a morally deficient inconvenience and of no consequence.

In many ways, the British treat methadone patients with far more dignity and concern than the US does. The British medical community does not punish methadone patients because of the nature of their illness, and doctors are given much more freedom to treat patients as individuals. Under English law, doctors are allowed a wider range of possible treatments in order to better address the differing needs of their patients. This is tremendously beneficial because what works for one person may not be effective for another.

English physicians will sometimes prescribe an addict's drug or drugs of choice when the life of the patient is clearly in danger from use of impure street drugs. The people who are maintained on pharmaceutically pure, abusable drugs are prescribed those drugs because it was determined to be the most effective way of reducing the harm of addiction and improving the quality of life for those people. These therapies mean nothing less than survival for some people in the throes of addiction.

Although America does not allow an addict dignity, equal medical treatment or rights, and it has not been effective in curbing drug use, the English approach has proved promising. After years of medically-supervised drug maintenance, many addicts have actually gotten over the "thrill" of using drugs and gradually began to see it as more of a waste of time. A good portion of the people who are prescribed their drugs of choice quit using on their own after a time. It is through the purity of their prescribed drugs and the hygienic, medically-informed conditions that legal drug maintenance allows them that many patients survive the most self-destructive years of their addictions.

Unlike America, England never really had a "War on Drugs" (which actually translates into a "War on Personal Rights", or more basically, a "War on People"). America has had the same old tired anti-drug campaign for almost a hundred years now. Most Americans have been spoon-fed anti-drug ads, commercials, political campaigns, TV shows, etc. since birth, thus hating and blaming drugs and drugs users comes easy. Heck, it's almost politically correct; it's certainly common, and there are more drugs and drug money around than ever.

Propaganda has not warped the English sense of objectivity about drugs as much as it has here in America--that's why the English are more tolerant, realistic, less hysterical and more effective in dealing with the matter. It is interesting that in a country where many abusable drugs can prescribed legally to maintain addicts that the addiction level is among the lowest in the world, and the recovery rate is one of the highest.

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One advantage of being online is the wealth of information available about methadone from all countries. The Swiss Methadone Report: Narcotic Substitution in the Treatment of Heroin Addicts in Switzerland (3rd ed.) was offered to me through one of the lists I subscribe to.

This report states that the Swiss policy demands an "age restriction of 20 years for initiation to methadone substitution treatment", and "two unsuccessful in-patient withdrawal treatment attempts" are usually required before methadone maintenance is allowed.

In Switzerland, "people already receiving methadone substitution treatment can continue to be treated in nearly all district or regional prisons. In 89.66% of such institutions it is possible to continue treatment for an unlimited amount of time. In another 5.17% treatment is limited for a time period, which varies between one and twelve months."

For those inmates already incarcerated, methadone treatment is not allowed to be initiated in approximately half the cases. "When asked to briefly describe those situations that enabled a new indication for methadone treatment, 26 institutions indicated that they did so to prevent relapses. This is particularly true for those persons going on vacation or preparing for dismissal."

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The necessity of switching to HMOs is a sad, but true, reality. Soon, there will be no other choice, but before you sign up for one, you can call the National Committee for Quality Assurance (NCQA). The NCQA rates HMOs on their medical care, doctors' qualifications, and several other factors. One out of every eight HMOs fail this test. Most of the big ones, which care for about half the people enrolled across the country, have been rated, though the committee is still reviewing others.

For a copy of the Free Accreditation Status List, call toll free (800) 839-6487 between 9 a.m. and 5 p.m.

Also, Methadone Today and DONT have been advised that the HMOs are either not paying for methadone treatment or are slow paying. Many of them have been referring methadone patients to non-methadone treatment centers--in other words, abstinence-oriented treatment.

Although we have been stressing the inadequacies of and problems with HMOs over the past year and a half, we cannot repeat enough that you emphasize to the HMO BEFORE you sign up with them that you are on methadone maintenance. Also underscore to them that only licensed clinics are able to dispense methadone, your treatment choice. Insist that you be given referral to a methadone clinic before signing.

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DETROIT - On March 5, 1997, DONT officers met with Kristy Reed, Recipient Rights Advisor for Parkview/NPL. At that time, Kristy explained the complaint process to us. If you have a problem but do not want to file a formal complaint, call her at 7-Mile Parkview/NPL (810) 532-8015 and tell her what the problem is. She can arrange for you and the offending person to meet to talk through the problem with her as mediator.

If, however, you wish to file a formal complaint, you can get a complaint form at any of the Parkview/NPL clinics. Fill out the form and mail it to Ms. Reed. She has 14 days in which to investigate the complaint and get back to you. If you do not hear from her or if you are dissatisfied with her ruling, you can then file the complaint with the Regional Rights Advisor.

Also, if you would like to take a DONT officer along with you, we have made arrangements for that possibility. You will need to notify us and fill out a release of information form for the session. If you do not know your DONT patient advocate, write to Methadone Today, and we will tell you who your advocate is.

This is a process that should be used if you experience problems. All too often, we complain about treatment from certain staff persons but do not do anything about it. This is a formal, legal process; once it is started, do not worry about repercussions from filing it.

Although this was explained by the Recipient Rights Advisor at Parkview/NPL, the procedure should be the same at other clinics, minus the DONT officer.

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4th Century - St. John Chrysostom (345-407), Bishop of Constantinople: "I hear man cry, ‘Would there be no wine! O folly! O madness!' Is it wine that causes this abuse? No, for if you say, ‘Would there were no light!' because of the informers, and would there were no women because of adultery" (Quoted in Berton Roueche, The Neutral Spirit, pp. 150-151).

1985 - Pentagon spends $40 million on interdiction.

More tax dollars are spent on the "Drug War" than on the space program. Shame on us!

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"Methadone Anonymous" is confusing and only adds to the misconceptions and myths about methadone. NAMA conducted a "man in the street" survey, interviewing about 100 people from all walks of life. We asked people: "What do you think Methadone Anonymous is?"

Most of the answers were, "It's a detox group; it's for people wanting to get off methadone", or "It's a group for people who have detoxed from methadone." Very few answered correctly, less than 18%, that Methadone Anonymous is a 12-step group for methadone patients. In other words, no one understood what Methadone Anonymous was for!

We then explained what Methadone Anonymous was, and asked them if they thought the name was a misnomer. Everyone said yes! (100%) This made it clear to NAMA--as we had suspected--that the name Methadone Anonymous was confusing to people. I am certain you understand the myths, misconceptions and confusions that abound regarding methadone maintenance treatment. So why add to it! And in fact, isn't the name Methadone Anonymous an oxymoron!

Would not "Heroin Anonymous" be more correct? Are not all the anonymous groups struggling against the preceding word, and are not methadone patients struggling against heroin, not methadone!

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