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PostPosted: Fri Apr 14, 2017 7:58 am 
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It's a long read, and grimly depressing. But it's worth at least a skim. It's all here, all the perfectly predictable harmful consequences of forgetting that the the distinction between alcohol and drugs is merely an arbitrary legal fiction. Prohibition failed utterly, and so of course has the war on drugs.

As far as I can tell, Donald Trump is planning to continue on in the same vein. In fact he's made noises about "doubling down."

http://assets.realclear.com/files/2017/ ... pdated.pdf


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PostPosted: Fri Apr 14, 2017 8:15 am 
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Depressing indeed.
The War on Drugs flat out employs to many people to be given up. Sadly.
Johann Hari "Chasing the Screem" is also a good read on this too.
Such good information in this book.
The artical coves many of the same issues...


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PostPosted: Fri Apr 14, 2017 1:16 pm 
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I was just talking with a patient about the heroin problem, and what could be done about it. Everyone has his/her own perception and opinion, but even if we had endless resources it is hard to think of a 'solution' for the heroin crisis.

Legalization plus education isn't going to help with a drug like heroin; the effects of the opioids are so powerful, and so appealing, that there will always be a direct correlation between access and death.

Abstinence programs have been shown to be ineffective, with programs shorter than 60 days having no value at all.

Medication-assisted programs work for people who are motivated to use them. But from what I see, most people who come for medication-assisted treatments are only PARTIALLY motivated. Drop-out and relapse rates for all treatments are high.

I see people do well when they are FORCED to do well. My success, for example, came from six years of drug testing twice per week, with my medical license on the line the whole time. But there is no way to set up programs like that in people who are not on probation or parole. Society would never allow for programs that lock people up, or pull out fingernails, because of relapse!

So if not the 'war' on drugs, what is the solution to the heroin problem? If there IS an answer, let's put it here! What would YOU do to reduce or fix the heroin crisis? Anyone?


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PostPosted: Fri Apr 14, 2017 4:26 pm 
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The positive is that those who do have access to buprenorphine, whether or not they are super motivated, are receiving the harm reduction benefits from it. Buprenorphine is preventing overdose and death even for people who are ambivalent about being in recovery.

I think that locking people up for possession is counterproductive and expensive. I don't know if legalizing and regulating drugs is the best thing to do, but what we are doing is absolutely not working. In general, I think that natural consequences (besides death) are the best teachers.

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PostPosted: Fri Apr 14, 2017 4:43 pm 
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Completely change course. I didn't finish the article so I apologize if I repeat anything said there. I agree with Razor, "Chasing the Scream" is a great book. It doesn't give a solution but does give a blueprint of a different direction. People are dying- we have to use harm reduction techniques first. Living a meaningful life without addiction is the ideal, and the goal. But we are way too far away from that right now.

In Hari's book he describes medically supervised heroin clinics. Addicts ( people who have been unsuccessful with numerous treatments) come to the clinic, ask for a specific amount of heroin, they are given supplies needed and they are required to stay and be monitored by nurses for a certain amount of time. Addiction counselors are on site advising and ready to get the addict into treatment if they want. They are encouraged but not bullied or forced into treatment.

There are or have been trials of this type of program in Canada and some other countries, and per this book the results have been pretty successful (I don't have all the details because I don't have the book with me). By successful I mean people are dying less and decreasing on their own the amount of heroin they use. Some of these addicts have been able to turn their lives around- get housing, jobs etc. that's a huge deal. I'm sure a big part of the success is due to the quality control of heroin. No more fentanyl, you know the exact dosage you are getting, etc.

People also know they can come in tomorrow- they don't have to worry about the next fix. Not knowing where your next fix is coming from, or if you will get it is part of what makes addicts do crazy and illegal and immoral stuff. That anxiety is almost worse than withdrawal. Not worrying about that frees up a lot of time and money-changes lives as we all know. Lying, stealing, and illegal stuff goes away.

I'm sure there are conflicting opinions on this type of treatment, problems to be ironed out, more evidence to support success, and I have lots of questions about it too, as well as some skepticism, but even if we are only able to decrease deaths, that's a huge success. We got to keep people from dying, that has to be priority in my mind.

I think as a society we have to stop demonizing drugs. I'm not saying we should legalize everything, but we have to change how we view drugs. Sometimes drugs are helpful, sometimes they are harmful. They are not evil predators in and of themselves, and addicts are not bad people for choosing to use them. We have all made bad choices but it doesn't make us criminals.

First we need decriminalization- like it's not legal but if you do it you get a traffic ticket instead of 10 years in prison, that sort of thing. We've created criminals, and it's not necessary or helpful.

Drugs need to be monitored, but our government's war on drugs and Prohibitionism has created all of the crime, has created a thriving underground business, created international problems. We created it , we should be able to repair it. I'm sure that is not all coincidental. I don't know how all the pieces fit together but I'm sure entities are benefiting from keeping the war on drugs going.

Sorry to go on a rant. This is actually a passion of mine. I hate the way we approach drugs as a society. Drug use, abuse, and addiction belong in the realm of biology, psychology, medicine, and cultural studies, not in the legal arena. People have always used drugs, we are never going to extinguish that need in humans. We can only try to keep it from doing as little harm as possible. Best


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PostPosted: Fri Apr 14, 2017 5:17 pm 
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No need to be sorry! Let's have the discussion.
The concept you suggested for heroin clinics sounds a lot like methadone treatment. I've been working in a program for a couple years now, and I become more and more of a fan, the longer I'm there. Buprenorphine is a better drug-- no doubt about that. But methadone remains the gold standard for preserving life-- in part because buprenorphine isn't used as much, or for so long.

The problem from my perspective with decriminalization is that the term is so large, and ambiguous. I presume you don't mean decriminalization for drug dealers-- a concept I could never get behind, given the death that dealing heroin causes (I'm trying to stick to heroin, because I think everyone recognizes the different addictiveness, deadliness, and costs to society of THC vs. heroin).

Likewise I have a hard time getting my head around 'reversing course', because there are so many different courses taken by society right now-- ranging from incarceration for possession, which is still uncommon in most of the country unless repeated many times, or part of a plea bargain to drop other, more serious charges-- to methadone programs that have very strict privacy protections and are covered, entirely, by US taxpayors. Then there is the stuff in-between--e.g. drug courts, where people are coerced into Vivitrol treatment under threat of incarceration, or a range of treatments that are private and confidential for 'nonoffenders'.

There are also practical limits on the options. Some limitations are legal-- for example opening heroin clinics would require eventual cases before the Supreme Court to overturn how schedule I substances are handled. Other limitations are financial, since there is a finite amount of money that any government gets to spend. And finally, public opinion is a realistic limitation, because any changes by a politician will require more than a couple years in office to see through. If you're tossed out in 2 -3 years, your efforts will be replaced by the next guy (even after 8 years, as we're seeing now, if the changes aren't established through actual laws passed by Congress).

Let's discuss what could ACTUALLY be done-- let's say by Trump, since Godfrey mentioned him (or let's say by a US President, just to keep politics off the forum).

You just got a phone call from the US President. He/she says he wants someone who has been in the real world to guide policy to reduce the heroin problem. The President reminds you that you will need to have enough support from the US Senate and House of Representatives in order to enact any laws-- but you do have the power of executive order to make changes at least during the rest of the current Presidency.

What would you do now?


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PostPosted: Fri Apr 14, 2017 6:00 pm 
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I'm on the run but immediate thoughts are:
Rejig or exempt parts of the Harrison act and data 2000 act.
Remove the X waiver designation required
Remove all patient caps
All Drs can treat addiction w any MAT product. ?? methadone too??
ACA/US healthcare policy continues to cover MAT
Require 3rd party surveys of rehabs/abstinence based programs to show their results or lack of.
Require rehabs/abstinence based to follow evidence based medicine unless patient opts out of MAT.
Prohibit Insurers from requiring PAs for MAT scripts.
Allow generic plain buprenorhine as most of the EU does.
Ok back to real life..

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PostPosted: Fri Apr 14, 2017 7:04 pm 
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Hi, great points and questions Dr J! I unfortunately don't have a well thought out plan as much as a philosophy/ criticism. I said I was passionate, so you would think I'd have more details to how to change, but I'm much more of an idealist than a practical person. I am not sure how to pass legislation , especially since Congress can't seem to pass much of anything, even if it seems really simple. Hopefully someone more versed in the law, or more practical than me has some ideas!

I know it's way easier to sit on the sidelines and criticize than getting your hands dirty and actually changing things. i like to think change starts with changing our perceptions, vocabulary and education, but again I know that is idealistic. It doesn't stop the immediate issue. I like this topic and I will think very hard about what we can do. I hope others have ideas!

Oh, and to clarify, I don't also I don't condone illegally selling drugs. The point is in my world the dealers would decrease and become less of a problem because of a decrease in demand. So, no I wouldn't necessarily decriminalize selling, but some desperate drug addicts do end up selling in order to buy, and I would rather they got treatment and stop selling than to jail.

I'm no expert, I really just wanted to share my thoughts because no one I talk to is very interested in the subject. So I guess I just got excited to "talk" to someone but don't have any concrete answers.
Best!


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PostPosted: Fri Apr 14, 2017 8:05 pm 
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As usual, Dr. Junig's thoughts are very much on track. This is all so complicated. I agree that the war on drugs has been very much a failure. That said, many people do not get and stay sober until forced. Those with the most to lose tend to do the best. I've been doing a little public speaking with a physician who went through the same program for medical professionals that dr. j did. The stats for success on that program are amazing. Near 80% of those who enter are successful at the 5 year mark. What are they doing different? Not a darn thing! That program works because the docs have so much to lose. Now it may also be due to the personality involved. Docs tend to be well educated, high IQ, driven individuals. That could be a part of it but as Dr. J points out, they have so much to lose and don't want to lose it! Things get very serious very fast when facing the loss of a medical license that it took between 8 and 13 years to get! Losing the salary that comes with it also factors in.

The same happens with drug courts or even just charges. A friend could not get sober until she was arrested breaking into a neighbors house in search of oxy she knew was in there. She's coming up on one year using 12-step since she now has a felony conviction that goes away if she makes three years. Even for me, being drug tested and facing charges was a huge motivator. If we take that away, how many more will relapse? I'm past all of that now but the sober behaviors are instilled in me and together with bup, Kees me sober.

Then we have all of the actions states have been taking. All but one state now has a prescription database. The amount it of CII opiates prescribed last year went down by 10%. The USA will allow less CII to be manufactured this year. Narcan is carried by nearly every police department and fire department in addition to ambulances who have long had it. It's available without prescription now in many states. The cap on bup patients has been nearly tripled. In the state Dr. J and I are both from, there were more new docs who got the Data2000 waiver in 2016 than did in the last three years combined.

So look at all that has been done in the past five years! And the result? Well, the result is more people have died of an opiate overdose than ever before. Three people died during the time it took me to type this post! Over 90 people now die each day! What in the hell is the answer? It appears we still don't have an answer. The war on drugs has been a huge failure and if asked to start it today, I'd say no way. Thing is,if asked should we have no drug laws I'd say no way to that too! I don't have the answer. Obviously no one does. Clearly incarcerating users is wrong. Dealers is another story. And then what about someone who shares their H with a buddy in deep withdrawals and that buddy dies? What then?

It's almost like the question with our boarders - it's two-fold. We have to first deal with all of the current addicts (or illegals) then we have to stop new people from becoming addicted (or crossing the boarder) Sadly we can't build a wall high enough to stop either.


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PostPosted: Fri Apr 14, 2017 8:39 pm 
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Quote:
So if not the 'war' on drugs, what is the solution to the heroin problem? If there IS an answer, let's put it here! What would YOU do to reduce or fix the heroin crisis? Anyone?


How about a thought experiment? Let's imagine a world in which heroin were regulated, uniform as to dosages, free from contaminants, cheap, and legal.

When we talk about the heroin problem I don't think we'r chiefly talking about addiction per se. Or we shouldn't be in my opinion. So where's the harm we all attribute to chronic usage. Let's list them. Addicts are thrown in jail because they're forced to steal. Or deal. Addicts die of overdoses all the time. Why? Often because they never know what they're getting. Because heroin is not pure, Because it's cut with fentanyl, or half a dozen other nasty unpredictable contaminants. At the very least, overdose deaths could be cut signifantly.

I can attest from my person experience as an addict for a twelve year span, that I was perfectly capable of working, never got sick from my drug, never had to steal. Never got thrown in jail. Why? Because I was buying it legally or at least "semi-legally" and because I had the means to pay for it.

Is legalization a perfect solution? NO of course not. But I believe passionately that by far the greatest harm
associate with opiate addictions are a direct result of the laws against.

Look at Mexico in the ten years so since their President decided to fight the cartels? 85,000 dead. My God. Think about that for a second? If you want to fight the cartels, legalize the drugs, tax and regulate. The cartel s would be gone over night!!!

I think this is pretty damn near self evident.

And let's not forget the issue of personal freedom. I can't stand that the government thinks it has the right
to control what I do with my own body. I have not given them that right personally, and I don't understand
why we allow it as a society.


Sorry for my passion. I"m just writing this and submitting this. . No internal censor. and no editing. Just my thoughts and opinions.


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PostPosted: Fri Apr 14, 2017 9:01 pm 
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Love it Godfrey!


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PostPosted: Sat Apr 15, 2017 12:39 am 
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Don, that's not who I think it is, is it? I wish I had advised her to get on buprenorphine then! She wouldn't have gotten into trouble for stealing at least!

I have to make a case for those of us who didn't get forced into treatment and did it anyway before the consequences became too bad! I'm sure many people only start recovery when they are forced into it, but not all of us. If a treatment as good as buprenorphine was readily available and easy to obtain, maybe more low level addicts would get treatment before getting into real trouble! And if there was more support for being on buprenorphine for long periods of time, instead of all of this ambivalence about getting back off as soon as possible, then maybe overdose death rates would fall.

We need to have a comprehensive public health campaign educating about the almost inevitable progression of addiction, especially opioid addiction, and the evidence based treatments (MAT) that has shown the most success in stopping opioid addiction in its tracks.

It is also incumbent upon the treatment industry to stop pretending that 12 step programs should be the basis of treatment, when there is little to no evidence supporting it. We can't afford to let 12 steppers frame the argument and bully those of us who know better that opioid addicts are better off attempting abstinence based programs while they continue to relapse and get worse!

In one of my classes we were talking about relapse prevention. I proposed that the 12 step focus on sober time could backfire, turning a lapse into a relapse because, screw it!, I lost all my clean time anyway. She responded by writing, "Your proposal is wrong." She claimed that when someone relapsed it was the best cautionary tale for other addicts, so that they wouldn't do that themselves. And that people were welcomed back some warmly after a relapse, that they were practically celebrated for lapsing. All of which sounded like BS to me!

This divide in the treatment industry needs to be met with facts about treatment outcomes.

Amy

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PostPosted: Sat Apr 15, 2017 6:43 pm 
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Yes Amy, it actually is who you thought it might be. She went to the "world famous" Hazeldon treatment center where they didn't think she needed bup (which is exactly what she wanted to hear) so she is trying 12-step. At this point, she is doing well but with an 80% relapse rate within two years, she still has about 15 months to go. I sadly have my doubts. Clearly, however, with the police at her door ready to arrest her, going into Hazeldon looked rather good. Had that not happened, she likely would not have gone in.

In my case I at least tried a bit to get into a Suboxone program several years prior to my legal challenges. Of course the few that I called were all full with long waiting lists. I reached a couple methadone facilities as well, but that just didn't seem for me. Without a bigger push or facing any real consequence if I didn't get into treatment, I just kept treating myself with what I came to call the poor man's Suboxone - tramadol. However, once, I was outed it was a whole different situation and I ended up going into a short-term inpatient. I never would have done it that way, knowing what I know now as the care was average at best and nearly $10,000 for less than a week. I was then handed a script by the doctor for 30 days and told "find someone to refill it." When I asked him how in the hell I was supposed to do that he looked at me in semi-shock as if to say, "I don't know, what are you asking me for?" LOL The nurses found me a provider with openings. Again, I am positive that had my motivation not been so high due to the consequences I was facing, I may have went back to using. I'm betting it's the same for my friend right now. She's tested and checks in for her 120 day home confinement sentence. Once that goes away, and life returns to "normal" I'm afraid what might happen.

I'm out the door here but as to regulating heroin and dispensing it - what is the difference between that and Methadone? right????? It's pretty much the same thing, it's just a difference molecule hitting the same receptors. Rather than regulate H I'd stick with the replacements we now have.


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PostPosted: Sun Apr 16, 2017 1:25 am 
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That was my thought too, about replacement programs. There is one heroin replacement program in Canada, in Vancouver. But heroin is not a good replacement drug. The half-life is too short, so addicts would have to come back several times per day to avoid withdrawal and the desire to use. The 3 doses essentially triples the cost of the program.

Methadone has some features that help with treatment. These days, most of the patients who start on methadone have a host of addictions. They are smoking crack and shooting IV cocaine; they are shooting heroin, they are taking benzos, and amphetamine (or smoking crystal meth). We cannot punish people by putting them into withdrawal, but we can reduce the dose of a person is taking other drugs. So people are left with a choice- get their withdrawal symptoms under control by stopping other substances, or keep using cocaine and stay on a sub-optimal dose of methadone.

I've seen patients in that system decide to stop cocaine, and even stop smoking pot.

Another cool thing about metadone treatment is that the consequences occur very quickly. Patients are drug-tested often, and if a test is positive for illicit substance, a counselor meets with the person that same day to discuss whatever happened.

BUT-- while methadone is one of the most effective treatments at preventing death, why is it viewed so negatively?


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PostPosted: Sun Apr 16, 2017 7:40 am 
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Quote:
BUT-- while methadone is one of the most effective treatments at preventing death, why is it viewed so negatively
?

Do you mean by addicts or society at large? When I was trying to decided which MAT I wanted to undergo, I took a long look at methadone because of the potential complications around treating pain when on bupe. It ended up being an easy call because of the traveling difficulties, and because I hated the idea of going to a skeevy clinic in the early morning every day, or most days, or even a bunch of days. Since I've not been through that I can only imagine how it might feel to be reminded so often that I'm a sick addict among other sick addicts.

Bupe is so, so easy! I still did not like going to a clinic even once a month with all the reminders of being in that life, and ceding all that power to a single doctor who could cut me off...or just make my life harder because he happened to be in abad mood that day.

So I found an addiction psychiatrist with a pretty liberal approach. He's even letting me travel out of state for months at a time, while keeping monthly half hour telephone appointments. I'm not even required to do urine tests. I think one of the most important benefits of bupe is that one has the sense of living a normal life. I'll take that any day.

As to society at large concerning methadone clinics, there's remains a stigma attached to addicts, similar i think to the mentally ill. I think Amy mentioned this in the past. There's a puritan streak still, in this country,
whereby pleasure seekers are viewed as somehow shameful. Just doling out powerful narcotics to junkies strikes middle america as making things too easy for people who don't really deserve to be treated with kindness.

I think that' slowly changing though as even those on the political right are beginning to wake up to the colossal failure of the war on drugs.


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PostPosted: Sun Apr 16, 2017 9:00 am 
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I think if everyone who has had some type of drug arrest or probation, were to somehow be required to start a treatment like suboxone or methadone, there'd be a lot less second offenses. That's just me speaking on my past and what I know would have worked for myself.

I went to jail about 5 times, all drug related, and put on misdemeanor probation. I was required drug tests and I just didn't show up because I knew I was going to fail. So it became a vicious circle of not showing up then getting arrested and then a newly issued warrant for violating my probation. I wanted to stop, for yrs I wanted nothing more, but every time I tried, the cravings and depression got me. So facing drug tests in fear of jail time didn't change my outcome, it just made me run and last as long as I could that way. Yes I feared jail, but using didn't stop.

I went to rehab thinking 12 steps and inpatient would help me and if they had offered buprenorphine or methadone treatment it would have imo, but they didn't. NA meetings and learning the steps didn't help me or my cravings. I wasn't forced to go to rehab but I wanted help.

I don't know why I never considered buprenorphine an option before all that time passed but if I had things would have been very different (for the better). I think I was listening to society in recovery has to be abstinence. I truly believed that and knew it wasn't going to happen that way for me. I think there's a lot of ppl who believe that because they don't know any different.

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PostPosted: Sun Apr 16, 2017 10:02 am 
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Dr J, can you help me better understand?

This part I get:
"Methadone has some features that help with treatment. These days, most of the patients who start on methadone have a host of addictions. They are smoking crack and shooting IV cocaine; they are shooting heroin, they are taking benzos, and amphetamine (or smoking crystal meth)."

Can you elaborate on the following? I'm not grasping and would like to, brackets are mine:
"We cannot punish [because they continue to use?] people by putting them into withdrawal but we can reduce the dose [of methadone?] of a person is taking other drugs [I assume its the clinic drug tests that show this?]. So people are left with a choice- get their withdrawal symptoms [by taking methadone? this helps the other substances WDs? or is it that it stops the heroin/other opiate WDs which is the most important to first address] under control by stopping other substances or keep using cocaine and stay on a sub-optimal dose of methadone. [how do they get a suboptimal dose of methadone? so folks aren't kicked out? ]" Sorry for my confusion! P

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Last edited by Pelican on Sun Apr 16, 2017 10:16 am, edited 1 time in total.

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PostPosted: Sun Apr 16, 2017 10:09 am 
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Pelican, thanks for asking as I'm unclear as well.

Jennifer,
Great post. I think you like so many others were abused my the legal system for what is essentially a medical problem. It simply seems crazy to me to lock a person up for having a disease, which by definition means having something he or she can't help.


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PostPosted: Sun Apr 16, 2017 10:10 am 
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jennjenn, Agree so much w your post. great post. Thank you. My particulars are different but had MAT been presented, I'm convinced I'd have few to no losses. I had to swim thru a sea of sharks to get on bup. No way should it have been so difficult.

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PostPosted: Sun Apr 16, 2017 1:22 pm 
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Thanks for helping me clarify.

Understand, I believe buprenorphine is the ideal treatment for this crisis. I’m not about to change the title of my blog!

I was wary when I started in the methadone program, but I’ve learned that many of the hard parts of methadone treatment are actually beneficial, and many different aspects of treatment come together nicely for some patients. Patients are sicker than they were ten years ago, and methadone is a good option if buprenorphine has repeatedly failed.

The daily attendance, for example, provides structure for people who have none. I sometimes think we are almost ‘family’ for some patients, who come from backgrounds where parents were never there. The mixing that occurs in the wait area has a downside, but the upsides are the familiar faces that people see, of others who (mostly) are trying to leave heroin behind. I’m aware of the comments out there about meeting dealers at methadone clinics, but we really try to keep the environment clear of those behaviors, including the parking area and even the streets near the program. Police have a presence in the areas near the clinic, for example.

The rules seem rigid to new patients, but again, they provide a lesson about life in general. The law says that if bottles are defaced, take-home privileges are removed. So it doesn’t matter whether the person has a million excuses, as everybody does. The rule is the rule, and there is no ability to talk one’s way out of it. That is what I faced with the Medical Board, and it was a valuable lesson.

I should point out too that methadone is used to treat withdrawal symptoms… so that the counselors can work on other things. The program is not a ‘methadone program’, as they are called; they are treatment programs, and patients are not allowed to use them if they do not progress in counseling.

My comment about other drugs is best shown by an example. First, though, understand that it is NOT appropriate or legal to punish people by lowering their dose of methadone. If a patient gets angry and cusses out the staff, I cannot respond by lowering the dose of methadone—unless the person was being discharged, and the reduction was part of that process.

So for example a patient comes in for treatment, and has been using heroin along with stimulants, benzos, cocaine, and THC (all pretty common these days). By law, the highest dose of methadone I can dispense is 30 mg per day. I can increase the dose over time, but in WI I have to see patients in person for every dose increase. So I see the person every 7-10 days, and assess whether their methadone dose should be raised to treat withdrawal. My job is to decide whether the dose can safely be raised and by how much. I ask about withdrawal symptoms, and assess alertness. I look at pupils size, and look for fresh needle marks. I look at counseling notes to see if the patient has ever appeared sleepy or ‘nodding’ at those times. I see if there are any notes by the receptionist about sedation in the lobby area.

I also look at drug tests, which are done 3-4 times per week, sometimes witnessed. The blood level of methadone is checked every 3 months the first year, so I look at the blood level and level of metabolites. If the level is higher than expected I have to consider whether the patient is taking extra methadone.

I’m going to save this and keep typing in the next reply….


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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

  • Board Certified Psychiatrist
  • Asst Clinical Professor, Medical College of Wisconsin

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