Early Bird Specials at the Methadone Clinic? by Pat Conrad MD
Call me a cynic – please – but I’m irritated, and even bored with all the chicken-little hand waving and shrieking over the opioid “crisis.” Who the hell determined it was a “crisis” anyway, apart from the two least trustworthy sources available, media and government? I’m tired of everything the ostentatious do-gooders cite as the crisis de jour, and I’m tired of medicine constantly being dragged into everyone else’s ideas of social engineering. And before anyone gets on their ear about my insensitivity, recall how only a few years ago the seeming LACK of plentiful opioid options was a “crisis.”
An AP article has some handwringing from a lightly older angle, crying that “for those [older Americans] who develop a dangerous addiction there is one treatment Medicare won’t cover: methadone.” Boiled down, it means that the shuffleboard set can only get their methadone paid for by Medicare Part D i.e. the taxpayer if prescribed for pain, but not for addiction. This entire mechanism is a ball of wrong held together by greed, and wrapped in foolishness.
Maintenance methadone cannot be prescribed from retail pharmacies, hence cannot be covered by Medicare Part D. So hit the government clinic daily, or … Congress is considering legislation allowing methadoners with good urine records to take home weekly supplies. In a show of bipartisan sanctimony, bill house sponsor Rep. George Holding, R-North Carolina said, “The epidemic is affecting all populations, including our seniors. Medicare beneficiaries have among the highest and fastest growing rate of opioid use disorder, but they don’t currently have coverage for the most effective treatment.” His co-nitwit in the Senate, Sen. Bob Casey, D-Pennsylvania, ranking member of the Special Committee on Aging, bleated, “We have a sacred responsibility to find solutions that help everyone who may be affected.” If that sort of self-important rhetoric didn’t send you rushing for a vomit bag, then you are primed to react to …
– “An estimated 300,000 Medicare patients have been diagnosed with opioid addiction, and health officials estimate nearly 90,000 are at high risk for opioid misuse or overdose.”
– “Opioid overdoses killed 1,354 Americans ages 65 and older in 2016, about 3 percent of the 42,000 opioid overdoses that year.”
– Most Medicare docs surprisingly don’t want to fool with Buprenorphine: “A recent study of Medicare claims found prescriptions for buprenorphine for only 81,000 patients.”
It’s a crisis I tells ya!!
“Mark Parrino, president of the American Association for the Treatment of Opioid Dependence, thinks more people would seek methadone treatment if Medicare covered it.” Of course he does. Right now Medicare methadoners pay out-of-pocket $80/week, or get it via Medicaid. Why would the taxpayer want to encourage any of these bad options for seniors OR taxpayers? An addiction physician quoted thinks that methadone might be a better alternative to the “astronomical dose” she presently takes, but worries about the stigma associated with the methadone clinics. So much like the witches in Oz, I guess there are “bad” addicts and “good” addicts. And absent the back alleys and whispered deals, how did the good addicts get that way? Might it have been through bad doctoring compounded by government guidance?
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The article’s obligatory human face on methadone “used heroin for more than a decade in his youth, later took opioids prescribed by specialists for back pain. He was put on Medicaid-methadone “after his pain doctor’s office was shut down for overprescribing.” The patient sums it up: “Some people think of methadone as a crutch for addiction but it’s not. It’s a tool that allows people to live a somewhat normal life.” Would it be more palatable for this guy if we thought of methadone as a wheelchair?
There are patients who need chronic opioids, but far fewer, and at far lower doses, than is often the custom. Government cannot, will not fix this. Until some colleague turns my thinking around, I cannot see any point to methadone clinics to replace an existing addiction with a government-monitored one. The only “sacred duty” in any of this falls on physicians to be better, and work with their individual patients. Until then all government can do is prevent appropriate pain control by threatening physicians, blowing more taxpayer money it doesn’t have, and keeping a plant illegal.
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I personally don’t understand the logic of the use of methadone to “treat” opioid addiction. I have been told by MANY opioid addicts that methadone is much more addictive than other opioids. If that is true than the notion that one would put a person on methadone and then try to wean them off it entirely is BS. In practice I don’t know if I have ever met anyone who has successfully been cured of opioid addiction by being placed on methadone and then weaned off. Most of the people I have seen who are in treatment are on “maintenance” therapy which is essentially government sanctioned opioid abuse. I guess there are some studies that show that people who are on methadone maintenance have a “lower risk” of opioid overdose but I would also imagine that it is impossible to craft a study looking at this without it being very influenced by selection bias. Plus comparing opioid overdose deaths among methadone treatment patients to street heroin users is applying moral relevance to medicine; the comparison group should be non-users. It would be like me prescribing light cigarettes to someone.
Your views on methadone for treating substance abuse are the same as mine. It’s a nice gig for the junkie to get a regular fix paid for by us (the public). And even if they have to pay for it, it is predictable, safe, and price controlled. As mentioned above, many of these patients are on the system. Often they are dual enrolled (Medicare with Medicaid). If they work, they always seem to be trying to get out of working. It is simply legalized monitored drug abuse.
Dual system in more ways than one. Notice in the story how the human interest subject was a heroin abuser, then he moved on to a pain clinic (no doubt he didn’t reveal his abuse history to the physician nor that he was really there to score narcotics because he is an opioid addict) and now on to a opioid addiction treatment clinic.
Lance, thanks – not defining specifically “over 65” completely got by me, and is another great way of using the non-elderly to fabricate sympathy for the Golden Girls watchers.
“An estimated 300,000 Medicare patients have been diagnosed with opioid addiction…”
— Medicare patients. Not “Medicare patients over 65.”
Most of these are non-elderly people on “Disability,” possibly even on Disability FOR being addicted.
I think the difference here (between the media, legislators, et al, and Reality) is in having ever actually met and dealt with junkies. Those of us who have, know that their addiction robs them of their actual humanity, making them (except in extremely rare cases) into lying, stealing, non-human pieces of crap. Neither I nor most people who actually have dealt with them have any sympathy for them at all, nor do we really care what happens to them, so long as they aren’t stealing our car stereos.
Make it all legal, let the chips fall where they may, and let those of us who are not addicts alone.