Treatment trials

Every morning more than 1,000 people across Central Florida take a daily dose of a medication that lets them function; because of it, they hold down jobs, support families, live the delicate, perplexing thing we call life. But the people who need this medicine are not allowed to swallow it in the bathroom after a morning shower; each day they must get into their cars and drive to a building where they line up with other patients like them.

The needed medicine is methadone, an opiate that blocks the craving for heroin and reduces withdrawal symptoms. It also, on the most basic level, keeps people from dying; after all, on average in Central Florida in 1998 and 1999 one person died every week from a heroin overdose. Who were those casualties? Everyone from first-time experimenters to long-time addicts, the young to the middle-aged, students to degreed professionals. Heroin users these days come from every Central Florida zip code, and the next addict desperate for treatment might be the Express-dressed girl next to you at the suburban multiplex's early show of "Keeping the Faith."

The effectiveness of methadone treatment is supported by more than 40 years of research, but as soon as the words "heroin" and "addict" enter the conversation, people think that the issue is moral, not medical. Private-practice doctors are forbidden to treat opiate addiction. Federal law stipulates that only registered programs can dispense methadone, and the requirements for running a methadone clinic are longer than a 1040 tax form's instructions.

But what if that changed?

Think of this scenario: At the corner Walgreen's, people loll around on plastic chairs waiting for the pharmacist to fill prescriptions for antibiotics, birth-control pills, Prozac, insulin and ... methadone.

Currently a few programs across the nation are experimenting with offering methadone in private medical settings. You might think this isn't such a big deal, but you'd change your mind after talking to Mark Parrino, president of the American Methadone Treatment Association. He considers it a "major tectonic shift" in the attitude toward narcotics treatment in this country.

Making methadone available outside of clinics is more than just a matter of convenience to an addict who, instead of traveling every day to a clinic, could make weekly or monthly appointments with a doctor. It could mean that the increasing need for methadone could be met without starting new clinics, which consistently meet with opposition from people who don't want a stream of addicts in their neighborhood.

And, on its most immediate level, prescription methadone could mean that Central Florida's next heroin addict could get access to treatment that right now is clogged up. Here's the problem: Orlando's three methadone clinics are filled to the brim, and a lawsuit has held up a fourth. And the tight federal regulations mean there's nowhere else for a heroin addict to turn.

Ask Joan Ballard, director of community relations for the Center for Drug-Free Living, whether local facilities are meeting the need for methadone treatment, and she'll tell you: The demand is "barely" getting met.

Or better yet, ask Alan, the white, nearing-50 Disney worker who, when talking about his efforts to get into the Center's methadone clinic on West Columbia Street, still conveys the palpable fear and unexpected grace of the lucky survivor.

"When I last came here, I had a difficult time getting in," says Alan, which naturally isn't his real name. Alan has been an addict since his teens, going through heroin, downers and alcohol, as well as several treatment programs, near-ruin financially, personal traumas and job-loss risks. In January he showed up at the Center: "This last time I was devastated emotionally," he says, "more than I've ever been in my life. The financial [difficulty], that played a part, but I was so devastated. I didn't even speak without crying. I surely felt that I would die."

Not wanting to jeopardize his job by checking in to a weeklong detox program, Alan waited for a methadone slot for about two weeks -- not excessively long, in the grand scheme, but an agonizing delay in this kind of situation. "When you decide you need help, you want it right away," Alan emphasizes. "I had to wait. And waiting means $100 a day."

The Center currently has about 140 methadone clients, and "We're waiting to get more staff so we can take in more patients," Ballard notes. Federal law sets staffing requirements for clinics, for two reasons: Enough counselors need to be available to clients, who in turn must be carefully watched to make sure they're following the rules. For about $70 a week at the Center for Drug-Free Living, a patient not only gets a daily dose of methadone and counseling, but also random urine testing and the distribution of their photograph to other area clinics, to ensure that they're not scamming another dose from a different program.

Colonial Management Group runs the Orlando Methadone Treatment Center. Located on South Semoran Boulevard, it's the largest clinic in Florida, with more than 600 clients. Last year Bill Sheridan, vice president of Colonial Management, told the Orlando Business Journal, "All the local methadone programs are swamped." Is that still the case? "Very much so," he answers without hesitation.

The need for methadone treatment is assessed yearly by the state Department of Children and Family Services, which keeps strict tabs on the number of methadone-treatment slots in Florida. Last fall, Central Florida received approval for one of only two new methadone programs in the state. That planned Kissimmee clinic, however, hasn't opened; Colonial Management and the Central Florida Substance Abuse Treatment Center, a clinic located on West Colonial Drive, have been fighting in court over the right to run the new operation. "When there's a license available, the person who gets the license is determined by competitive bid," explains James Sawyer, a lawyer with the Department of Children and Families. "They both felt they were entitled to the license." While Sawyer has never previously dealt with a methadone-clinic case, "My suspicion is that this is fairly normal," he says. "The only time that any `company` can attempt to grow is when one of these licenses becomes available."

And even then, the proposed clinic often finds itself battling the surrounding community. In the past year, Colonial Management, which runs about two dozen clinics in seven states, faced opposition to programs in Alabama and Louisiana. In the month of April, existing or proposed clinics in Boston, the San Francisco Bay Area, Maine and Rhode Island have faced stay-away tactics ranging from special zoning ordinances to court battles to petition drives. "Everybody acknowledges the need for more treatment facilities, but it's NIMBY -- not in my back yard," notes Sheridan. "Methadone is still not largely understood by the general public."

When a client starts a methadone program, the clinic's doctor determines that person's dosage range -- say, between 40 and 75 milligrams -- and then patient and the staff work together to determine the most effective amount within that range. Thus, within the structured environment, the client has a certain amount of control and input, being able to request, for example, a slight decrease over time.

"I drink it in the morning," says Alan of his 50-milligram dose, "and I feel like `myself`. I'm not sedated. It completely eliminates the craving for any other opiate."

So Orlando's three clinics are packed, and a fourth is stalled in litigation. When Joseph Merrill, a University of Washington medical researcher, looks at the tight reins on methadone treatment and the hesitations people have over making it available, he's indignant. "Can you imagine doing this for any other disease?" he asks. "Why is there a conflict about providing something that's so obviously effective?"

Merrill is the director of a hospital-based methadone clinic in Seattle -- the first in the nation. Like Orlando, Seattle is swamped with heroin; the local government there recently increased the number of client slots at the existing methadone clinics. But what Merrill's program does is integrate stable patients into a traditional medical practice. "These are people who have been successful in a structured program," says Merrill of the 30 patients in the program.

Private-practice treatment might become increasingly possible if the federal government follows through with talk about loosening regulations. Last year a bill was introduced and Congress held hearings on allowing specially trained physicians to prescribe narcotics that treat opiate addiction.

"If you look at it from the patient's perspective, then this kind of program makes a lot of sense," insists Merrill. "People are doing it because their lives are complicated." But, more important, "This is a way of mainstreaming their care, destigmatizing their care."

A program such as this also does an end run around the opposition that clinics face from the community. A proposed clinic causes people to have visions of a hoard of addicts congregating in one spot right down the street. As a result, the words "crime" and "bad influence" start getting used a lot. "The main issue from a policy perspective is that opening a program with 300 to 600 patients is likely to encounter some local opposition," says Merrill. "By getting physicians involved, we would hope to decentralize treatment" -- thereby diffusing the community's cause for alarm.

Parrino, of the American Methadone Treatment Association, is constantly frustrated by the resistance to treatment centers. "Often there's a community," he says, "that basically takes the position, 'We do not want programs in our area. We want them somewhere else.' Where is the ‘somewhere else'? The question for the community to ask is, 'Where are these people going to be treated?'"

Additionally, rotating people into private medical settings would let stable patients erase the "recovering addict" stamp they're branded with every time they walk into a drug clinic. And then that person's slot would be freed up, and the clinic could accept a new patient.

At this point there's little organized resistance to the idea of this change in policy, although hesitations and questions arise from several quarters. When asked about the practicality of private treatment, the Center for Drug-Free Living's Ballard responds, "I think a lot of it comes back to the dollar" -- meaning that private treatment would probably be even more expensive than a clinic. Ballard also wonders if patients would take advantage of any decrease in monitoring, and she questions how much attention the patients would get from doctors: "Given insurance companies' requirements, doctors barely have time to say hello. Would they have time to do counseling? You have to do counseling."

The American Methadone Treatment Association's Parrino notes that often the resistance that's voiced is based on the need for surveillance: People wonder how patients will be tracked once they disappear behind the doors of a private doctor's office. But Parrino emphasizes that doctors dispensing methadone would work in connection with existing treatment programs, and that the qualifying patients would be screened. The Seattle program continues to conduct regular urinalysis, and the clients are randomly required to bring in their remaining methadone supply for verification. Of the 180,000 people currently in methadone treatment in the U.S., Parrino estimates that 7 to 8 percent could move into private programs or hybrid models -- not a huge number, but enough to make a significant shift in the attitude toward those who need methadone.

While a private setting for methadone would be a welcome option for any recovering addict, it's noteworthy that the profile of the heroin user has changed in recent years. These days heroin comes relatively cheap, and it's so pure that people can snort the stuff instead of shooting up. In some people's minds that makes the whole experience seem a little less like a hardcore, groveling "Sid and Nancy" scene. At least until they're hooked. Snorting heroin gets you addicted, no question -- and addiction makes you flat-out, uncontrollably desperate, every joint aching. Parrino notes that heroin has become more of a "white, suburban, middle-class problem," which means that different types of people now have to concern themselves with things like where to go if they're addicted.

"Federal policy is 'let's incarcerate them,'" says Parrino. "But parents of these 18-, 19-year-old kids don't want them in jail. Now it's a matter of access `to treatment`."

Parrino has come across some resistance to medical-office methadone from the people who run clinics. He relates how, when he's at a conference or giving a talk, a clinic staff member "inevitably comes up to me and says, 'We understand your point, but you're also taking our best patients, our most stable patients.'" His response? "This is in the interest of the patient. That should seem obvious. If it works for the patient, let's do it. What works for the program is a consideration, but that should be secondary."

Merrill, from the Seattle hospital, says the staff at their affiliated clinic, the Evergreen Treatment Services, had no reservations about the experimental program: "It may be that the leadership at Evergreen strongly supported this." Evergreen's counselors did the screenings to determine who was eligible.

Did any of the potential patients have reservations? "I think there was one patient that said, 'Well, things are going well. Why rock the boat?'" says Merrill.

It's not hard to imagine some methadone patients being wary of losing the reassurance and motivation of being carefully watched on a daily basis. "I like a strict program," says Alan. "That's comforting to an addict." Nonetheless, the Center for Drug-Free Living's program already allows Alan to bring home a "takeout" dose, so that once a week he doesn't need to show up at the clinic, although he often does, anyway, for a group counseling session. Overall, the treatment attitude strikes a balance that he praises: "You have a hand in it. But if I'm irresponsible in my judgment, it's going to be seen. Therein lies the safety."

When he looks down the road, what does Alan see in his future? "This is a sickness, and it's not going away," he knows. And as for his participation in the methadone program? "I am in no way in any hurry to leave. I'm going to take my time." Still, when considering his progress, he says, "I don't see myself being here forever." What will give him the confidence to take another step toward recovery? "Time, knowledge, growth, confidence," he sighs.

And there are those people who are at just such a point, who have attained the confidence over time, who want to regain some measure of control over their lives. For those people, the possibility of a private-based program such as the one in Seattle is important: As Merrill explains simply, "People see it as an acknowledgment of their recovery."

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