Feature: Pennsylvania Lawmakers' Aim at Reducing Methadone Deaths, But Shoot Wide

Late last month, Pennsylvania state Senate Republicans -- and one Senate Democrat -- held a press conference at the statehouse in Harrisburg to roll out their "Methadone Accountability Package." The package, they said, aims at increasing safety and fiscal accountability and reducing the illicit use of methadone and methadone overdose deaths. A related Senate resolution is also calling for a moratorium on new methadone treatment centers. But methadone treatment advocates and researchers are cautioning that the package may be unnecessary, and are calling for any legislation on methadone to be based on facts and scientific evidence -- rather than overheated rhetoric and anecdotes.

Drug overdoses have risen nationally in recent years, with the increase generally being attributed to increased use of prescription medications such as methadone and buprenorphine. Advocates have suggested overdose prevention approaches such as "Good Samaritan" policies protecting people who call for help -- Washington state's legislature enacted one this week -- or distribution of the overdose antidote naloxone, as ways of stemming the tide. But the PA package announced this week goes a different direction.

http://www.stopthedrugwar.org/files/pamethadonebills.jpg
the dark side: legislators seeking dramatic methadone restrictions
While the bundle of bills addresses keeping track of methadone-related deaths (SB 1293), diversion control (SB 1376), driving while using methadone (SB 1377, SB 1378), and micromanaging methadone maintenance treatment (SB 1382, SB 1383), the bill that strikes most directly at methadone maintenance treatment for opiate-dependent individuals, is SB 1294, the Methadone Addiction Prevention and Treatment Act, introduced by Sen. Mike Stack (D-District 5). Stack's bill would mandate that:

  • Potential patients be addicted to opiates for at least one year before methadone treatment is considered;
  • Potential patients must have twice failed other forms of treatment;
  • Patients have a written plan with goals and dates to be free from drug dependence, including methadone, within two to three years;
  • Patients must have a designated driver come with them to the clinic for the first two weeks of treatment; and
  • Driving under the influence of more than the prescribed dose of methadone be a violation of state driving under the influence laws.

"Pennsylvania needs better laws to prevent methadone abuse and provide patients with the proper protections and treatment plans they need to achieve a lifetime of sobriety," Sen. Stack said. "This package of bills is a solid step toward achieving those goals."

"Pennsylvania's law has not kept pace with the changes in the prescription of methadone -- and too frequently with deadly consequences," said Sen. John Eichelberger (R-District 30). "Methadone is a drug with its own unique properties. One pill or one dose can kill a non- or low-opiate-tolerant person. Even a day or two after the drug is taken, it has led to fatalities for those who mix alcohol or other drugs."

The senators cited reports from the National Drug Intelligence Center that unlawful diversion of methadone had more than doubled between 2003 and 2007 and from the National Center for Health Statistics that the number of methadone overdose deaths had increased nearly five-fold, with OD deaths among young people (15-24) increasing eleven-fold.

Not so fast, say experts. "Let's be careful about this; there are a lot of lives at stake here," said Eric Hulsey, director of performance, evaluation, and program development at the Institute for Research, Education, and Training in Addictions in Pittsburgh. "If the intention behind this stuff is better clinical care, that's a great thing, but we have to caution that it needs to be grounded on evidence-based practice."

Hulsey and National Association for Medication Assisted Recovery president Roxanne Baker also questioned some of the specifics in SB 1294. For Baker, the objections are a bill-killer.

"I would have to oppose this bill because it's too restrictive," she said. "There are already state and federal regulations on methadone treatment centers. Medicine is best left to doctors, not legislators."

Baker objected to the bill's provision for pushing methadone maintenance patients to get off the drug. "They really push the methadone abstinence schedule, don't they," she said. "Here in California, they just say it would be 'harmful to the patient' to taper off. I don't know why that needs to be in there; they don't make you taper off thyroid medication or insulin."

Hulsey didn't see a lot of evidence that methadone maintenance clinics are behind the problems being cited by the politicians. "Methadone prescribing has gone up seven-fold around the country, and we've seen all these methadone overdoses. Most of the federal reports and researchers have concluded that this is coming from the pain management clinics, yet everyone wants to crack down on the methadone treatment clinics."

Methadone treatment clinics are operated under different and stricter sets of regulations than pain clinics, Hulsey said. "It's unclear what the pain clinics are doing to prevent adverse incidents at their facilities, but it is clear that most diverted meds are coming from pain management, therefore, let's legislate against methadone maintenance clinics?"

Not that cracking down on pain clinics is the answer either, according to NAMA's Baker. Pointing out that methadone maintenance clinics are not the problem is fine, she said, but let's not be too quick to go after pain doctors. Citing the massive under-treatment of chronic pain in this country and her own decades-long experience with methadone in both the treatment and the pain clinic milieus, she said methadone patients already face enough barriers.

"I've been taking methadone since 1974," she said. "I stood in those methadone treatment lines, but now I get my medication from a pain specialist. A lot of people want to do that because they treat you better -- if you can find one who will treat you at all."

And that is a problem, Baker said. "A lot of doctors don't want to treat pain patients because they have the DEA breathing down their necks. We don't need more obstacles."

"This is misdirected legislation," said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence. "Methadone treatment programs have been functioning for more than 40 years with a considerable degree of safety. There have been at least four federal studies showing that increasing methadone mortality is based on that fact that it is increasingly being used in pain management. If the legislation doesn't address the cause of the problem, it has no basis for existing."

"The science doesn't support a hard and fast rule to get off licit opiates," said Hulsey. "It can be very dangerous to put arbitrary deadlines on that. Treatment has to be individualized to promote recovery."

For Hulsey, the bill's requirement that potential patients first twice fail at treatment is just not good policy. "I am not aware of science that supports 'you fail first' policies," he said. "If you go to the expert consensus guidelines for management of methadone facilities, and more importantly, accepted patient placement criteria, you must demonstrate a year's dependency, as well as other thresholds, and that is what should determine appropriate placement. 'Fail first' doesn't capture the full range of factors that experts have agreed upon as the best approach for opiate-dependent individuals."

The consensus guidelines Hulsey cited were SAMSHA/CSAT's Treatment Improvement Protocol 43 and the American Society of Addiction Medicine's Patient Placement Criteria.

"Those are the gold standard for treatment," he said. "They provide a six-dimensional approach to dependence, and you would need to meet those criteria to be appropriately placed in methadone maintenance. It's not appropriate for everybody. Some people may require a detox approach rather than long-term maintenance."

For Hulsey, having the designated driver requirement for new patients was "good risk management," but creating methadone-impaired driving offenses seemed unnecessary. "There are already laws on the books regarding impairment," he said.

Nobody thought the moratorium on new methadone maintenance clinics was a smart move. "They shouldn't do that," said NAMA's Baker. "They don't put moratoriums on doctors who prescribe treatments for diabetics. But there is a lot of NIMBYism in Pennsylvania."

"Addiction is a chronic disease that is treatable when appropriate evidence-based treatment approaches are applied," said Hulsey. "We want to promote recovery and support people rather than limiting access. If we limit the treatment opportunities, we make these people criminals."

Parrino didn't think much of the moratorium idea, either. "You can have a moratorium, but that doesn't reduce the demand for treatment, so what's the rationale for restricting access to care? Do we think the number of people who need this has capped out? That state has to be careful saying that a moratorium seems smart, especially when the problem is not related to the treatment programs you're dealing with," he said.

But methadone maintenance clinics make convenient targets for a number of reasons, said Parrino. "There is NIMBYism, and there is a general stigma about treating addiction, which increases markedly when you talk about the use of medications to treat opiate addiction," he pointed out.

"And elected officials always feel like 'we must do something,'" he continued. "But unless the legislature is able to be more precise in identifying the problem and how to deal with it, I would suggest that they are not addressing the real source of the problem, but doing what seems manageable and convenient. It's easy to say let's put more restrictions on top of a system that is already highly regulated, but pain doctors aren't regulated at all."

So faced with mounting methadone mortality and increasing diversion not linked to methadone maintenance clinics, Pennsylvania legislators are aiming squarely at those clinics. The legislature and the people of Pennsylvania would be better served if this package of bills went back to the drawing board.

Permission to Reprint: This article is licensed under a modified Creative Commons Attribution license.
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PA Regs

I applaud Ms. Baker and Mr Parrino's comments--they are right on target! What these lawmakers are proposing is, just as Mr Parrino said, "convenient and manageable" rather than addressing the TRUE source of the problem. Two major studies done by SAMHSA in 2003 and 2007 on Methadone Mortality found that the vast majority of diversion and deaths were coming from sources OTHER than the clinics and clinic patients. Senator Rockefeller (WV) asked that the White House GAC do a study as well, which was completed last year, and found the same results as the SAMHSA studies. Yet these lawmakers continue to relentlessly target clinics and clinic patients, and to go completely against established science and Best Practice guidelines in making recommendations which seem to be based solely on what they think their constituents want to hear.

Limiting time in treatment is, in my opinion, the most harmful aspect of this bill and the one that flies most blatantly in the face of what we know about methadone treatment and opioid addiction. The relapse rate of those forced out of methadone treatment is 90% within the first year. In fact, the relapse rates of even those who leave methadone treatment of their own free will are sky high. Yet, the rate of success (i.e., free of illicit drugs, behaving in a law abiding, responsible manner, etc) for those who remain IN treatment is higher than with any other treatment method by far. There is absolutely NO medical justification anywhere to limit time in treatment. The purpose of MMT is not to be a quick detox aid for the opioid addicted. In fact, it works to stabilize and normalize the brain chemistry of long term opioid addicts, who often have permanent changes in their brain chemistry as a result of opioid abuse--and many of these folks will need long term--even life long--treatment. Methadone does not CURE addiction--it controls the symptoms. We don't push people with depression, bipolar disorder or schizophrenia to get off their medications--conditions that are also caused by problems with brain chemistry--because we know that if they do, relapse to active disease is highly likely. The same is true of methadone treatment.

I urge these lawmakers strongly to reconsider what they are trying to accomplish with this bill, and to consider why they are targeting clinics and clinic patients when the crux of the problem is clearly elsewhere.

The legislators might do

The legislators might do well to inform themselves of the target of their bill by seeing the brief video, "In My Backyard" @ http://www.icaatnimbyvideo.info/

New Methadone Law in Penn.

I don't think this is the solution, it's going to leave too many drug addicts on the streets to committ crimes for their opiate addiction and pain addictions. There are far too many people addicted to pills now, I don't understand how it got so bad? But, it's not shrinking anytime soon either? I don't know what the correct solution is yet, but we sure need to study this and find on fast. A good one that's going to benefit addicts as well as Govt. & State officials and doctors also.

what happens when you let republicans write laws

This has got to be the stupidest bill there ever was.
After I got into methadone maintenance treatment, it took me almost FIVE years to get clean from heroin & other drugs. The idiots who wrote this bill don't seem to be aware of the fact that for many people, methadone is a lifelong medication... just as insulin is to diabetics. Cutting patients off after a couple years in GUARANTEED to send them back out onto heroin. Maybe that's what these republicans want... they are probably on the take from the drug lords, because if I were a heroin dealer I'd be VERY happy about this bill: it would give me all of my customers back after just a couple years!

July 1988 Mayor Guiliani of NY to close clinics

It is not quite as bad as when Mayor Guiliani attempted to drive the methadone clinics out of NY city. Barry McCaffrey was able to change his mind.

http://www.ndsn.org/sepoct98/treat2.html

Time for some good re-consideration of the facts.

George

insane

This is insane. Since when do politicians practice medicine? Why is methadone treatment being treated differently than any other type of treatment? What next designated drivers for people visiting their physician, dentist, pharmacy. Why don't these lawmakers concentrate on reducing our ever increasing debt instead of limiting access to treatment. Sounds like discrimination doesn't it.

When you live in the country....

As the Director for the PA chapter of NAMA-Recovery, I am in a constant battle just to give communities some basic education on methadone before the "not in my backyard" battle cry becomes deafening. The unfortunate reality is that there is an ingrained stigma toward methadone treatment for opiate addiction that does not crossover into pain management. This bill is a vote-getter. It was released in an election year when many legislators are sweating to retain their seats. By publicly commenting on this bill, they are feeding on the stigma and using it to their advantage by allowing ignorance to garner votes. The only true way to table this bill is to get enough voters in PA to call and demand its revocation. If these legislators believe that continuing with this bill is political suicide, then it will disappear. But at this point, as I said before, ignorance is speaking loudly and those who are unaware believe that this bill is going to "protect them from the bad drug addicts".

How do you stop the overdoses?

I don't know. But the best thing that comes to mind at the time, is that maybe a lot of those who are dying were not well educated about how to use the drug. Doctors in todays world are very busy, and they don't seem to have time to sit down with their patients and educate them. This is a problem (one that i don't know how to fix), but it seems likely that there are a lot of doctors out there that just give people strong pills and tell them "take this much, no more, no less", and they just send them on their way. If the patient sticks to the dose, then they'll probably be fine, but unfortunately, it takes more than that to prevent a tragedy. I think the best thing is to somehow make sure that anyone taking any strong medication be as thoroughly educated as possible about it; including dosing and drug interactions. You can't just limit access. Those types of regulations will never work. There is no way to make drug use less dangerous except by making the only people who truly have control of the situation (the patients), as knowledgeable as possible.

Sign Petition to Oppose PA Methadone Accountability Package

Please sign the petition to Urge the PA General Assembly to Oppose the Methadone Accountability Package: http://healthcare.change.org/petitions/view/urge_the_pa_general_assembly... . This petition will send an e-mail immediately, and will also be faxed after a certain number of signatures are obtained, to the PA senate committee members on Public Health & Welfare and the sponsor and co-sponsors of this legislation, and if you are in PA, it will send it to your districts senator as well. You can add your own personal message to the petition or sign it as is. And when you sign it you have the option to not reveal your identity to the public if you don't want to. If we want to stop this insane law that would put an artificial limit on the length of treatment, addicts in PA will suffer. Don't allow the PA state government to practice medicine, sign the petition. This petition has already helped gain us support in the committee that the bills are being considered in, the PA senate's committee on Public Health & Welfare. We have got the support of the committee member, the senator who introduced the PA senates version of the PA medical marijuana bill, and with more signatures we will get more allies. Lets kill this package of legislation in committee so it never gets to the floor of the General Assembly for a vote.

Legislators practicing medicine.

I always thought it was illegal to practice medicine without a license but that is what these legislators ae doing.

As a chronic pain patient I have been given methadone to help control my pain.  Although it did not help me

I do not want a congressperson deciding how I should be given treatment, how it is offered and handled.

We are already victimized, and demonized, by the DEA.  Now the Pa. senate wants to get into the act.

Let doctors do their job, whether as pain management specialist or drug (rehabilitation) specialists.

Thank you.

Carol Levy

author, A PAINED LIFE, a chronic pain journey

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