Category Archives: Prescription Monitoring

New York City’s Black Market for Painkillers

pain-pill-scheme-new-yorkA Reuter’s story was just released highlighting a large drug bust in New York City in which 25 people were indicted on drug charges including two physicians. The charges stem from evidence that a healthcare clinic called Astramed dumped $500 million in prescription opioids into New York City’s black market from 2011 through 2014. It is reported that a total of 5.5 million oxycodone pills were sold to local drug dealers via phony prescriptions. The Reuter’s article reports a federal indictment was issued in which 24 defendants were charged with conspiracy to distribute narcotics.

This story is especially disturbing and comes on the heels of other recent stories in the news like the overdose death of Philip Seymour Hoffman and the death of 17 people in Pennsylvania who had used the deadly heroin and fentanyl mixture only weeks ago.

The opioid abuse problem in the United States is reaching unprecedented levels and is causing concern in segments of society that had previously never thought much about addiction-related issues.

As addicted individuals come to grips with the reality of their illness, it will be imperative that they have ready access to detoxification and treatment services.

As a clinician of 25 years in North Carolina, I have witnessed a gradual and steady reduction in both substance abuse and mental health funding over the last decade. When rehabilitation services become no longer available to help people, the vast majority of them either remain in active addiction and die prematurely, or wind up incarcerated for committing crimes in desperation.

Stiff penalties for drug dealers are obviously merited. But treatment is the answer for those with addictive disease. We must also do something about our culture which far too often glorifies drug abuse and partying among the younger generation in our society. Opiates are seriously powerful and potentially dangerous medications. America needs to revisit the necessity of increasing funding for drug education & prevention as well as evidenced-based treatment for opioid addiction. That includes life saving medications like methadone and suboxone administered professionally, ethically, and responsibly.

Safety and Security With Methadone

methadone-safetyIf you are currently a client in a methadone clinic, then you have most likely heard treatment staff emphasize the importance of safety with methadone and the necessity of carefully securing take home methadone doses. Methadone is a powerful medication that is tremendously helpful to recovering individuals. It is also potentially lethal in the wrong hands and consequently must be deliberately safeguarded.

There is a recently published article on Bloomberg regarding methadone being diverted and then taken by someone who later died from an overdose. This turn of events has led to newly proposed legislation in five states (Maine, Indiana, Minnesota, West Virginia, and Pennsylvania) that would further tighten regulations regarding the operation of methadone clinics and their award of methadone take home medication to their clients.

The reported misuse of methadone, and associated deaths, was allegedly tied to several private, for-profit clinics that operate in these states. One of the criticisms of the private, for-profit clinics was that they are not providing "enough services". This is intended to mean that the clinics in question were not providing sufficient education & counseling support or adequate monitoring of those who receive take home methadone.

It is critically important that all methadone clinics (both private and publicly supported) implement thorough measures to educate clients on methadone safety concerns as well as institute monitoring protocols like 24 hour callbacks and random drug testing. 24 hour callbacks require take home recipients to return to their home clinic within 24 hours and to produce their methadone take home doses for count and inspection by the clinic's medical staff.

It is also important that methadone clinics only award take home medication privileges to those clients who have achieved certain progress milestones such as successive months of clean urinalysis, attendance to required counseling sessions, the absence of criminal charges, and demonstrated appropriate behaviors & attitude toward staff and peers at the clinic.

When individuals intentionally divert methadone doses or mishandle methadone through lax practices (such as leaving it sitting out in plain view), they put others at risk and ultimately undermine the delivery of methadone services in the community. In other words, the mistakes of a few can negatively affect everyone. This also erodes the community's confidence in methadone as a life-saving medical treatment.

In the end, it is the shared responsibility of all methadone clinics and their clients to insure that methadone is taken as prescribed, and safeguarded from diversion. When proper precautions are not honored, tragedies will occur. This will lead to state legislators taking matters into their own hands with additional laws & regulations that may keep worthy individuals from receiving a valuable privilege. Take home medication is so very beneficial to honest, hard-working individuals in recovery. It frees them to seek employment, hold a job, care for family, and to more easily meet many other important responsibilities in their lives.

Prescriptions for Opiates

opiatesThere are many legitimate and appropriate uses for opioid medications. Opioids are excellent at managing acute or chronic pain for back injuries, post-surgical recovery, dental work, and other medical conditions that generate unbearable pain.

For those who may become physically dependent upon opioids, their difficult journey often does not begin with a chase for euphoria or a “drug high”, but with a short-term prescription from their physician for a pain killer … in order to minimize the pain and discomfort from a recent surgery or injury.

How the brain & body respond to opiates varies from one person to the next. Some individuals have a very high tolerance for pain and may need relatively less pain relief medication than someone who possesses a high sensitivity to pain.

If an individual takes pain medication for a long enough period of time, they may run the risk of developing a tolerance to the medication such that only higher doses of it are effective at reducing pain. As the person begins to increase their use of the pain medication, a physical dependency begins to set in resulting in withdrawal symptoms when the opioid relief wears off. The only thing that will eliminate the uncomfortable withdrawal symptoms is taking more of the pain medication. And thus, a vicious cycle sets in.

It is important to consider than no one starts out intending to become addicted. Unfortunately, many prescribing physicians do not explain to their patient the potential for developing an addiction to opioids. In fact, there is general consensus emerging that pain prescriptions are too readily given out. Many admissions to methadone clinics include individuals whose opioid dependency began with a legitimate prescription for pain medication. It is important that both doctors and patients share responsibility in addressing the potential for addiction with opioid medications. We do not want to discourage the appropriate use of pain medications. They are extremely effective at helping people manage their pain and be able to function. But education is critical if we are to help individuals adopt the proper caution & awareness in regard to potential opioid dependency.

Methadone and the Importance of Safety

safety1Methadone is so very beneficial when used properly and judiciously (as prescribed). However, in the wrong hands, methadone can lead to tragic consequences. Here is a cautionary tale.

Making the news in Gaston County, North Carolina was the recent death of a young man who was a member of his school’s football team. His name was Harry Cohen, and he was 17 years old.

Harry had played in an extraordinary football game on August 26, just days before his death. He is reported to have rushed for 241 yards and passed for 107 yards. A very impressive performance. He is also reported to have taken some hard hits in the game. His family indicated that he was sore from the highly physical contact.

While visiting with his grandmother later (who had a legitimate methadone prescription for pain management), Harry decided to take some of the medication to ease his physical pain. His mother found him the next morning in bed. He had died from a methadone overdose as a result of not having developed a tolerance to the medication.

This story reinforces how important it is that methadone (and all potentially high risk medications) be carefully safeguarded. The Gaston County article had a number of comments and opinions posted by local community members expressing their sorrow over Harry’s death. Fortunately, no one blamed “methadone”.  Most commenters emphasized the importance of treating prescription meds with caution. This is exactly the right sentiment, and a message that bears repeating over and over.

Often, children & teens assume that a medication must be “safe” if it is prescribed by a doctor and sitting out in plain view. Of course, this is not the case in many instances. It is imperative that adults think twice about securing medications, and also educate themselves on the associated safety concerns that come with various medications.

It saddens all people when something tragic like this hits a family and a community. Hopefully, we can draw from this loss an important lesson … that will help to prevent future losses.

Methadone Take Home Medication

methadone78Methadone take homes (or carry outs) are awarded to clients that have demonstrated treatment progress, stability, and personal responsibility. A take home dose of methadone may be earned once a client has met a number of criteria set by each methadone clinic. Each state has its own methadone authority that provides additional guidelines regulating take home award. Consequently, take home medication awards may differ from one clinic to the next, and from one state to the next.

Some clinics provide an automatic take home for Sunday (often because the clinic is closed on Sunday), although a number of treatment programs have discontinued the “automatic” Sunday take home and are now open every day of the week for medication dispensing . This change resulted from a move to increase patient safety and to help ensure that take home medication was provided only to those with a good track record of program success & compliance.

It should be noted that pain management clinics and addiction treatment clinics, both of which provide their patients with methadone, are very different programs and operate with significantly different standards and oversight. Opioid addiction treatment programs are subject to much tighter regulation and require that new participants be seen face-to face everyday in order to be evaluated before they receive their methadone dose.

This is not required of pain management clinics who are able to dispense opioid pain medication (including methadone) without the same level of oversight. Consequently, much of the methadone diversion concerns making the news (including related overdoses) are the result of diversion of methadone provided by the less regulated pain management clinics.

Unfortunately, the general public have often wrongly assumed that addiction treatment clinics were at fault. While diversion of methadone does occur on occasion in both settings, methadone treatment clinics offer much more comprehensive accountability & monitoring measures than do most pain management clinics.

A majority of methadone take home recipients are very responsible with their medication. They take it exactly as prescribed, and store it safely & securely. Many patients have properly utilized their take home medication for years without incident or problems of any kind.

A number of clinics allow their patients to receive up to 13 take home doses requiring an in-person visit to the clinic on the 14th day. Some clinics provide up to a month of take home medication for patients showing long-term stability and responsible handling of their take home medication. Take homes are earned one-at-a-time at specific time intervals as clients move through phases (or levels) in the opioid treatment program.

It is important to note that take home medication is a privilege, and not a right. The award of take home medication is usually a team consensus decision based on a patient’s excellent urinalysis results, consistent attendance to & participation in treatment sessions, and evidence of psychiatric stability and good decision-making ability. If a client relapses or is having a particular problem coping, then take home medication is suspended for the client’s safety, and until the treatment team determines that the client is doing well enough to resume take homes.

Prescription Monitoring Helps Suboxone and Methadone Treatment

methadone40Dr. Jana Burson, in her opioid treatment blog, has written two important and interesting entries on the value of prescription monitoring programs (entry 1, entry 2). Prescription monitoring allows approved physicians to review a database listing controlled substances a patient receives (like opioids or benzodiazepines), the prescribing physician, and the pharmacy that filled the prescription.

This information is extremely useful for monitoring patient behavior in opioid treatment and helping to provide a measure of patient accountability. Some patients have a pattern of doctor shopping and abusing prescription medications even after entering opioid treatment. This monitoring program allows doctors to identify doctor shopping activities and to intervene with their patients who may be abusing prescription meds or selling them.

Dr. Burson writes that 42 states have approved a prescription monitoring program, and a majority of them already have the program up and running in their state. One notable exception is the state of Florida. Dr. Burson writes that Florida’s Governor Scott has blocked the implementation of the prescription monitoring program. This is detrimental to identifying & managing prescription abuses across the state. It is reported that Governor Scott has been contacted by other State Governors urging him to reconsider.

Methadone and suboxone treatment programs aim to help their clients change their lifestyle & behavior, and to make choices rooted in healthy recovery. Prescription monitoring enables treatment professionals to assist their clients in examining negative behaviors and correcting them.

Some individuals who doctor shop find themselves in legal trouble and facing possible incarceration. This can derail a client’s opioid treatment, as well as compromise the integrity and reputation of the methadone treatment program trying to serve addicted people. It is much better to identify prescription abuses early on and to intervene quickly.

Prescription monitoring programs are ideal for the safety and security of clients and the welfare of communities. The over-prescribing of opioids and benzodiazepines has become a major problem in the United States, and prescription monitoring is a huge forward step in rectifying this troubling issue.