Methadone Clinics Need to Get With the Program — ASAP

Patients shouldn’t have to risk their lives in order to get their medicine.

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People who are presently part of a medication-assisted recovery program are unwillingly endangering themselves — simply by trying to save themselves.

Patients who spend time inside methadone clinics need safety — and they need it now.

Most folks who opt to participate in recovery treatment programs, like methadone, are usually doing so because they're trying to overcome an opiate addiction in order to better — or possibly save — their own lives. Unfortunately, the clinics that these patients must frequent in order to acquire the necessary medication are not making it very easy.

Clinic Days

For those who aren’t familiar, methadone is a prescription medication used to aid those who are trying to quit heroin and/or other opioids. It can also be prescribed for relief of chronic pain — though I wouldn’t recommend it unless it is an absolute last resort, mostly because it’s really tough to discontinue treatment. If and when a person is ready to stop methadone altogether, they need to be gradually weaned off; they cannot abruptly stop without harsh physical repercussions.

Methadone must be administered by a specialized and highly regulated clinic, where an on-site doctor or nurse practitioner prescribes each individual patient with a proper dosage. Upon beginning the program, patients are initially assigned a number. Each day they come and check-in with this number at the front desk, and then remain in the lobby or stand in line while awaiting their number to be called — which could take minutes or hours, depending on the day and how many other patients are waiting.

Once their patient number has been called, they walk back to a dispensing window where a nurse hands them a medication cup through a small hole cut in the plexiglass. The patient must drink the medication immediately while being observed, and they must also show that the medicine has been swallowed completely before leaving the window.

Patients must go through this routine each day until they’ve been in the program for a while, after which they can earn privileges to take home some or all (up to 27) of their doses in daily individual medication bottles, which are numbered and dated. In many states, it’s required that every single one of those bottles be saved and returned on the next clinic visit.

Patients can earn these ‘take homes’ based on the amount of time spent in the program in combination with clean urine test results. Many people spend years earning enough take-home privileges to get to the point where they can live their lives like a regular person, being able to go out of town or on vacation.

Then again, there are people who spend years in the program and don’t make any progress at all.

For many, a daily visit to the clinic is still mandatory and cannot be skipped, otherwise, they will be penalized and possibly kicked off of the program, resulting in an even worse situation.

If a methadone patient doesn’t take their medication, they will become very ill and experience aggressive and brutal withdrawal symptoms. Just like with heroin withdrawal, methadone withdrawal can be extremely agonizing, and with that comes the temptation to seek out any possible relief from the discomfort, thus squandering any prior progress of recovery.

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Some clinics are superior and far more professional than others, but most of them can get pretty gritty and downright disgusting on a sanitary level. In addition, many of these clinics operate without a security guard on-site, and doing so has its own risks: some patients yell at the staff, slam doors, and storm in and out of the building; there have been attempted thefts of the medication (the clinic actually puts a padlock on the dumpster lids, plus the patients must take the lids off of their returned bottles before throwing them away in order to make sure there’s next to nothing left in the bottles for the dumpster divers); fights have broken out among patients who are frustrated about waiting in line forever… profanities yelled, punches thrown, weapons pulled.

I’ve seen all of those things happen.

These are all issues that are always around, even without a pandemic added on.

Methadone clinics have the highest measure of rules and guidelines for patients when it comes to prescription and medication dispensing.

Yet, from what I’ve seen, these clinics also have the lowest upkeep and follow-through on maintaining the facilities in general.

In short: Clinics have a lot of rules enforced that the patients MUST follow to obtain their much-needed medication, but not a lot of enforcement when it comes to maintaining a safe and healthy environment for those patients.

With Covid-19 eating up the globe, you would think these places would crack down and run a tighter, cleaner ship… right?

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Federal Adjustments

The Substance Abuse and Mental Health Services Administration, or SAMHSA, is a federal agency within the U.S. Department of Health and Human Services. They basically lay down the law for methadone treatment facilities and the like. SAMHSA has long-established rules and regulations set in place that these clinics must follow, and understandably so — usually.

There are a few things they need to re-evaluate and follow up on amidst Covid-19.

Different states in the U.S. have different criteria for ordinances when it comes to this particular medication, but the federal outline is the base structure that overrides all.

A few months ago, SAMHSA released a few short statements issuing updated ‘blanket’ adjustments for a few of the guidelines, which were to be applied during the coronavirus pandemic. One portion of the update states that all patients can now take home between 14 and 28 doses of methadone at a time, depending on the stability of the patient. This way, the patients don’t need to come into the clinic every day, which is great. The less social contact the better.

They have also stated that any patients with Covid-19 symptoms, or who have tested positive, should stay home and call to inform their clinic of the situation. The clinic would then schedule an alternative method for the patient to receive their medication, such as staying in their car and having a nurse walk the medication out to them directly, or having a reliable member of the patient's household come in and pick it up.

Federal guidelines have also made it clear that the staff should be regularly cleaning and disinfecting all public spaces — including dispensing windows, reception and lobby areas, and bathrooms.

Protocol Undermined & ‘Call-backs’

Since Covid-19 hit, there have been reports coming in from several different states across the country, by both treatment facility patients and staff members, all citing less than stellar goings-on at their respective clinics.

Some are reporting no social distancing whatsoever inside their clinic; they’re being packed into excessively over-crowded hallways, having to stand in line for hours at a time with tens of dozens of other patients while they await their turn. In a confined space like that, it could very well turn into a cesspool of Covid-19 if even one person in that compact space has the virus — symptomatic or not.

Other reports tell of patients who are sick, or even worse, have already tested positive for Covid-19 and still are being forced to come into the clinic to take their medicine in-person, affecting and possibly infecting everyone else in the building.

What’s more — many patients still aren’t receiving their extra allotted ‘pandemic’ medication doses, and they are having to return to these crowded clinics each and every day.

Image by author

There are also clinics that are still performing ‘call-backs’, or ‘bottle checks.’

This means the clinic telephones patients at random and issues them 24 hours to come in-person to the office, so the nurses can count their bottles and make sure everything is in order. They do this at least once every quarter for the patients who have earned the maximum allotted take-home bottles: 27.

During these ‘call-backs,’ patients also have to perform an immediate on-site mandatory drug test — which means they have to use the clinic’s single public patient bathroom, which is inconvenient, unsanitary, and unhygienic at most times, but during Covid-19… it’s a straight-up safety hazard.

It pretty much defeats the purpose of giving patients extra ‘take-homes’ during the pandemic, if the clinics are going to continue to call everyone back into the office to do bottle counts.

The bottle checks/call-backs were originally put into the system because, at the beginning of treatment, the clinics don’t know if patients are trustworthy enough to handle their methadone. It started with the purpose of testing the patients’ responsibility and stability, and to make sure a patient isn’t selling or misusing their medication.

There comes a time, though, when the clinics and their staff know if a certain patient is honest and completely capable of administering their own medication.

Patients need to be treated as individuals. Some patients still need that structure, but some need a little breathing room in order to show they can thrive on their own.

During this pandemic, if the clinics must do these call-backs, they should be done via FaceTime, Zoom, or any other conferencing service, in order to keep more patients at home instead of inside the clinic walls, whenever possible.

Most medical facilities and doctor’s offices are presently consulting with patients and providing standard healthcare appointments via telehealth and FaceTime or Microsoft Teams.

These treatment clinics can and should do the same. It would free up the clinics from the patients who would have had to come in there for some possibly unnecessary bottle-check, thus keeping the social distancing a bit more intact.

Stigma

Some people don’t see recovery patients as human beings; whether the patient is still using, or not, they view them as nothing but seedy, low-life losers. I’ve been looked at like that before. Even at the clinics.

In my past years of recovery, I’ve had nurses, doctors, and even counselors — who were supposed to be there with the sole purpose of helping me through my journey— treat me like total shit. Not because of my behavior or anything in particular that I’d done, but simply because they looked down on addicts. They saw them as a lower form of life. (Why these folks were working in that field to begin with is beyond me.)

Lightening up on the way patients are viewed could change things for the better. Showing a hard-working, loyal patient a little already-earned trust and responsibility can do a lot for their recovery — and their confidence. It takes a long time and a lot of healing (inside and out) for recovery patients to start feeling like a normal person again. Years, sometimes. But, showing a little faith in them can go a long way.

Clinic Restrooms

No one wants to use a public restroom during the pandemic, especially an unkempt methadone clinic bathroom.

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During the call-backs and bottle-checks, patients must give a urine screen. When they come in for their annual clinic physical, patients must give a urine screen. When patients have 27 take-home bottles, they must give a urine screen every 27 days.

So, if someone with 27 take-home bottles comes in the first week of a month to retrieve new doses, then returns the next week for their physical, then again a few days after that to check on the TB test injected into their arm during the physical, and then the following week they get called in yet again for a bottle-check — that’s four visits to the clinic and three urine tests done inside the gross clinic bathroom in less than a month’s time, during what was supposed to be a 27-day relief period from the clinic. It’s completely messed up.

The bathroom in my town’s local clinic has always been a complete disaster: the toilet paper roll is never in the dispenser — and always on the ground; there’s usually urine AND pubic hair all over the floor and toilet seats (I don’t know what the hell these people are doing in there, but I do know there’s nobody cleaning the crap up); the trash is endlessly overflowing and spilling onto the floor — which includes the used urine cups, and often there’s no soap or toilet paper at all.

There was one time when I had to avoid brown poopy shit skidmarks on the walls and on the back of the toilet tank while trying to piss into a tiny shot-glass-sized plastic cup as I held the bottoms of my pant legs up off the ground. Basically, the place is filthy.

I’d like to see the owners and staff members use that bathroom.

After that incident, I began bringing my own cleaning supplies and spending a few minutes semi-sanitizing the bathroom before I sat down on the provided toilet seat cover (which the receptionist grabs from somewhere behind her desk and physically hands over to you before you enter the restroom). So yes, even the toilet seat cover has been handled by someone else first before it touches you.

Safety Non-Measures

Some clinics have implemented a couple of superficial safety measures during these uber-infectious times. Our local clinic put feet-shaped stickers on the ground to show people where to stand in order to maintain social distance, but nobody ever stands on them and the staff doesn’t enforce anything.

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They have also implemented a half-hour block of time intended for the ‘highly-at-risk’ patients (who have prior medical issues) to come in and obtain their medication without having to be exposed to too many other patients. Again, this isn’t enforced, and the at-risk folks still end up having to wait with everyone else.

The medication dispensing windows sit side-by-side. When two patients are receiving their dosage at once, they’re basically shoulder to shoulder. Yet another overlooked social distancing violation.

The patients have to set their personal lockboxes down on the dispensing counters, which have held every other patient’s box as well. The nurse then hands the patient a plastic cup, which she's filled with a mixed solution of methadone and water. The patient must then take off their mask in order to drink the medication, then put the mask back on. The nurse fills any ‘takehome’ bottles with medication, screws the lids on by hand, and passes them to the patient one by one to put into the lockbox.

Image by author

That’s a lot of touching, passing around, and possible contamination happening.

There have been instances where the dispensing nurse has gone back and forth between filling bottles, typing on her computer keyboard, touching other items on the counter and desk, and then switching back to filling the medicine bottles and screwing lids on. Those now-possibly-contaminated bottles will directly touch the patients’ mouths when they drink their medication.

There have also been occasions at our local clinic where the nurse was wearing no gloves at all while dispensing medication. Big no-no.

Who knows where this nurse has been? Who knows if she has kids, who play with other kids and then come home and hug mommy, who then comes into the clinic for work. One or all of them could be infected. Anyone can have the virus. Anyone can pass it on.

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Patients are more than just case numbers on the computer. Everyone has a different story in their file. Some patients are more diligent than others in their recovery. Some haven’t quite gotten there yet, but they can.

There are some who truly respect the program — they give nothing but their very best: clean urine screens; always accomodating to their counselors’ schedules; have never been absent or missed a dose. Many patients take the program very seriously and treat it with a lot of appreciation.

Yet still, none of it gets taken into consideration when it comes to the way many clinics treat their patients. Yes, it’s a business. But, it’s a sensitive business that has people’s lives at stake. Especially right now.

Most people have the option of choosing whether or not they go out in public during the pandemic. Medication-assisted recovery patients do not.

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In Summary

Throughout the years, I’ve documented just about everything that has happened within the clinic walls. I’ve learned to pick my battles and accept the fact that some things won’t change. But, that was ‘BC’ — Before COVID.

It’s no longer just a minor health and safety issue. For some, it’s now the difference between living and dying.

We’re battling a life or death situation every day and everywhere, now.

These clinics and the organizations who make the rules need to seriously sit down and take EVERYTHING into consideration. Think about the whole picture. Don’t just change some guidelines, leaving the adjoining ones as they stand (like giving patients extra ‘takehomes’ but forcing them in for ‘callbacks’ and physicals a few days later). It makes no sense.

It’s good that SAMHSA has made some adjustments to the federal guidelines for the time being, but they should be checking on the clinics regularly (and in-person) during these times to ensure the individually owned facilities and their staff members are following the Covid-19 protocols and stricter sanitary guidelines.

They must make sure the clinics are following through and putting the patients' safety first. Otherwise, it’s just like leading lambs to slaughter. These patients have no choice; they have to be at these clinics in-person if they want their medication.

Recovery patients need to know they’re as safe as possible when they enter their clinic. They’ve already taken the first (or in some cases the fifth, six, or seventh) step on their path towards a better quality of life. Some of them are there because they’ve tried everything else and it was the last and final option attempted in order to save their life.

Treatment facilities should be a place of trust and safety. Patients shouldn’t have to be worried about walking through those doors. Most other medical buildings and offices have established and followed through with stricter protocols during these times. There is no reason why SAMHSA and these corresponding clinics can’t follow suit.

In fact, methadone and other treatment facilities should have stricter sanitation and social distancing policies than most. Some of the patients are without the proper tools and basic everyday necessities to control the environment around them — which makes them even more vulnerable to contract the virus, which in turn can be spread to every other person who enters that building.

The issues have been, and are still being reported to SAMHSA, message centers for individual facilities, and other organizations and advocacy groups such as the National Alliance for Medication Assisted Recovery (NAMA), where the message can be passed along. Unfortunately, it seems being passed along is all that is happening to those reports.

Some action needs to happen.

Photo by Debby Hudson on Unsplash

Then again, how could those in charge think of these things… when they’re not the ones down in the trenches dealing with the subpar clinic environment.

I reached out to SAMHSA three months ago in order to find out their resolve, if any, on these current matters. I have yet to receive any response.

(References and resources drawn from the author’s personal experiences, STAT, Verywellmind.com, SAMHSA, NAMA, and NY Daily News)

I write about life, death.... and anything else I need to get off my chest.

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