By Christopher Williams, Sun Journal
Bangor Daily News May 27, 2012
When Zachary Tomaselli was sent to prison for sex crimes last month, he asked the judge to delay his sentence for a week.
The Lewiston man said he needed those seven days to wean himself off methadone, the drug he had been getting at a clinic to help him kick a prescription drug habit.
Thousands of addicts living “on the outside” visit Maine’s for-profit clinics for weeks, months and even years for their prescribed methadone doses. A large majority of those addicts are MaineCare clients, paying for methadone treatments with taxpayer dollars.
According to the Department of Health and Human Services, Maine spends about $9 million in state and federal funds every year to dose just over 3,100 MaineCare and Medicare clients every day. The state spends another $7 million a year to transport clients to methadone clinics.
That’s $5,140 per MaineCare patient per year.
Under the recently passed state budget, MaineCare clients are subject to a 24-month lifetime cap for methadone treatment. That cap is expected to save Maine more than $1.3 million a year.
According to Susan Sullivan, director of CAP Quality Care Clinic in Westbrook, patients there “are anxious and afraid of losing their treatment. Some are looking to be proactive and starting to taper themselves out because they don’t know what’s going to happen.”
If Tomaselli believed he could lick his drug habit in just a week, why wouldn’t — or shouldn’t — every drug addict do the same?
The answer, according to experts, is as complex as the subject of drug addiction itself.
Withdrawal is harsh reality
The good news for Tomaselli, experts say, is that he likely wasn’t in any danger of serious health risks had he decided to go cold turkey before trading his street clothes for jail garb.
The bad news — depending on how long he had been treated with methadone and at what dosage — is that his withdrawal might have been more grueling than his looming 3½-year prison sentence.
Dr. Michael E. Kelley, chief of psychiatry at St. Mary’s Regional Medical Center in Lewiston, said the effects of withdrawal from methadone are unique.
Because the medication is used as a maintenance narcotic for clients limited to a single dose each day, the drug typically stays in the body longer than other narcotics, he said.
“It is incredibly long-lasting,” he said.
That means withdrawal from that drug can linger for a week or longer. Sometimes up to a month.
Although not physically dangerous in an otherwise healthy adult, withdrawal can make you feel like you’re dying, Kelley said in an interview at the hospital, where he works as an addiction specialist, treating people with chemical dependency in residential and day programs.
“They can have a very miserable withdrawal,” he said.
It often includes severe flulike symptoms, including vomiting, diarrhea, sweating, chills and muscle cramps.
“But you won’t die,” Kelley said. The only possible medical risk is dehydration, he said.
The greater risk for narcotic addicts is relapse, experts say.
‘Jail isn’t a hospital’
While withdrawal from narcotics, including methadone, is usually safe, withdrawal from certain other drugs and alcohol can be dangerous, even fatal, according to medical experts.
Withdrawal from alcohol, benzodiazepines (tranquilizers) and barbiturates can be “very dangerous,” Kelley said.
Stopping those drugs too quickly can sometimes trigger seizures, heart arrhythmias and delirium tremens (in alcoholics), he said. The latter can be dangerous because those patients become disoriented and may inadvertently harm themselves.
Jails sometimes bring prisoners into the emergency room if they’re suspected of alcoholism or addiction to tranquilizers and show signs of withdrawal, Kelley said.
While the jail might let someone addicted to narcotics “tough it out,” they won’t take a chance on the other addictive populations, Kelley said.
“The jail’s not going to risk that,” he said. “The jail isn’t a hospital.”
When inmates come to St. Mary’s emergency department for medical clearance, hospital staff screens patients for drugs and toxic substances, checking their general health.
Doctors quiz the patients about drug use.
“Hopefully, they’ll be honest.” he said. But, too often they’re not. They fear their candor might get back to their probation officers. Although emergency room chats with doctors are confidential, inmates are on their guard generally and may not confide in the medical staff.
“Sometimes they lie to us,” Kelley said, “which is part of the scary thing.”
Doctors typically watch inmates suspected of drug or alcohol abuse for 12-16 hours, he said, but added, “There is no magic [time] line.” And there is no predicting a patient’s tolerance based on his or her history of drug or alcohol use.
No methadone for prisoners
At Maine’s correctional facilities, including its prisons, the state contracts its medical services with Corizon, a national company based in Tennessee. Three county jails in Maine, including Androscoggin County Jail in Auburn, also have contracts with Corizon.
The company has 150 health care professionals working at the state facilities. An additional 65 workers staff the three jails, according to Pat Nolan, a company spokesman.
Corizon would provide only written answers to questions posed by the Sun Journal for this story.
While it declined to detail how chemically dependent inmates are treated during intake at Maine’s prisons and jails, the company said it uses “standard, humane and medically approved detox protocols for these addictions.”
Inmates who attend methadone clinics prior to incarceration are not dispensed methadone at any of the correctional facilities where Corizon is under contract. Pregnant inmates using methadone are treated by an off-site OB-GYN doctor licensed in prescribing Buprenorphine, a semisynthetic opioid used to treat opiate-based drug addiction. After delivery, those inmates follow the standard detox protocols, Nolan said.
If an inmate were to come to jail or prison with a current prescription for Oxycontin or oxycodone, those drugs wouldn’t be dispensed, except in “very rare” cases, the company said.
Inmates with a medical marijuana certificate won’t be dispensed that drug at Maine’s prisons and jails, either, but substitutions could be considered on a case-by-case basis, the company said.
In all, roughly 90 percent of the inmates who enter Maine’s prisons and other correctional facilities have a history of addiction to one or more drugs (including narcotics, benzodiazepines or barbiturates) or alcohol.
Relapse rate is high
So, why don’t all methadone addicts spend a week weaning themselves from the drug like Tomaselli?
Some may try. But most will need more time. And a small percentage likely will need to stay on methadone until they die, experts say.
Sullivan, the director at CAP, where opioid addicts are treated with methadone, said the first goal is to stabilize clients on a suitable dose of medication.
Opioid addiction is a brain disease, she said, best treated with medication and psychosocial support. Clients who come to her clinic get both.
Like any addiction, “It’s a progressive disease,” she said. “The longer you use, the worse it gets and the more you use … so that treatment is based on the individual.”
Studies have found that patients with this chronic disease undergo a change in brain chemistry in which they are lacking free endorphins which, for many, means they likely will need medication throughout their lifetimes, she said.
The long-term goal of treatment is to improve a client’s ability to function at home, at a job and in the world.
Studies show it works.
Typically, relapse rates are 70-90 percent among those who leave methadone maintenance treatment, she said, even among those who taper to zero.
An alternative for opioid addicts to being on a maintenance program at a methadone clinic may be to seek street drugs, which can expose addicts to hepatitis C and HIV through shared and dirty needles, blood clots and possible overdose, among other health risks.
Some may try prescription shopping, a ploy medical professionals are increasingly more aware of and on which federal and state drug agencies have cracked down.
A patient on Sullivan’s caseload was in methadone treatment before he tapered his dosage to zero and left, she said.
“Within a year, he relapsed,” she said. “And then he came to this clinic and he’s been here about 9½ years and he’s tapering out, decreasing his medication so he can leave. To zero eventually. That’s his desire.”
By taking a gradual approach, that client is more likely to succeed, she said.
She said patients and staff at CAP are anxious about the new 24-month MaineCare cap. Under the new DHHS rule, that cap can be exceeded with prior MaineCare authorization.
However, Sullivan said, “We’re waiting for the criteria for prior authorization. We have no idea what that’s going to be.” Once that process is established, “that will probably be the determinant on who loses treatment,” she said.
In the 10 years her clinic has been open, Sullivan said the number of clients has averaged about 550 at any given time.
“We’ve had over 3,000 patients come and go,” she said. “And some stay.”
The MaineCare cap will have an adverse effect on methadone clinics across the state, Sullivan said. Nearly 70 percent of all clients are on MaineCare. And, under the MaineCare reimbursement cap, that patient load is likely to decrease if MaineCare-capped patients can’t pay out-of-pocket.
Fewer than 200 methadone patients pay for treatments with private insurance, which leaves about 1,000 patients without MaineCare or private insurance paying for their own treatments.
Although her clinic exists to treat addiction to narcotics, some people who became addicted started with a doctor’s prescription for pain, she said.
Pain and narcotic addiction “are not necessarily mutually exclusive,” she said.
“Even addicts get real pain,” St. Mary’s Dr. Kelley said. Those are the ones who are likely to stay on methadone or Suboxone (a partial narcotic, offered by St. Mary’s instead of methadone) the rest of their lives, he said.
The other group that would have to stay on clinical treatment includes those who are so addicted they likely would harm themselves otherwise through risky drug behavior. No rehab program, however proven and long-term, is going to work for them.
“There’s just that once-in-a-while person that everything’s failed, no matter what,” he said.
But studies he’s seen show that opioid addicts who attend methadone clinics are less likely to contract HIV or hepatitis C and less likely to be charged with crimes. They work more days and achieve higher levels of education.
“So it does reduce the harm, not only to them, but to society, in many ways [to maintain methadone treatments],” he said.
St. Mary’s approach to addiction is that 99.9 percent of addicts can be weaned off and can stay off drugs and alcohol — “all chemicals,” Kelley said.
“And that requires a hell of a lot more than just taking a pill,” he said. “It requires learning about yourself, doing what we call the recovery work … learning why I use, how I can cope with life without drugs.”
Addicts who have been using drugs to cope with life will have to relearn how to cope without them. “That’s how they dealt with every single emotion,” he said.
And some addicts who have been abusing drugs since their early teens will have to learn those coping skills for the first time.
“How many coping skills do you have at 13 years old?” Kelley said. “Once you start using drugs for everything, you don’t learn new coping skills because you don’t need to. You’ve got a coping skill. It’s right there in your pocket. And so, some of these people are starting from scratch.”
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