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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