The morning fix - methadone before work

By Charlene Smith
Huntington, West Virginia – It’s 4am and cars snake around three blocks. People stand outside their vehicles chatting. If it wasn’t for the hour you would think they were waiting to get into a sports stadium, instead it’s a methadone clinic, they’re getting their fix before getting the kids ready for school and going to work.
Seventy percent of those standing outside the Huntington Treatment Center, a private methadone clinic, are employed, they are all white. They pay $12 a day for a hit of methadone or suboxone, supposedly to wean themselves off opioid painkillers. For the man in the new SUV next to me, it’s a way to get an added high. He smoothes a piece of paper before sprinkling a crushed pill onto it, probably Oxycontin, the opioid painkiller which is the drug of choice for most, and inhaling.

At $80 for the average 80mg Oxycontin, you can’t be poor, you need to have a good job and the medical insurance with it or receive Medicaid (the US’s crumbling national health insurer).

Three miles away, Professor Ahmet Ozturk, a clinical professor at the Marshall University School of Medicine agrees with the assessment of a nurse at the clinic that methadone or suboxone is little more than “a bandaid.”
Edith Urner, supervisor of the Chemical Dependency Recovery Center at Huntington Memorial Hospital across the country in wealthy Pasadena, California is more cutting: “It’s easier to go through four to seven days of withdrawal from heroin than the absolute hell of three weeks to get off methadone or subaxone so-called treatment. They are potent and long acting.” But Urner says, not enough doctors know enough about helping addicts. “It’s not dangerous to stop opioids abruptly, but it is dangerous to try the same with benzodiazepans (eg Valium) or barbiturates.”

And while there are many out-patient clinics, an inpatient facility like the CDRC in Pasadena costs $1 000 a day, average treatment needed? Ten days for opioid addiction. In that time they start a process of teaching patients non-drug alternatives.

The two hospitals, one in a wealthy area, and the other in an economically depressed zone have nothing in common but for the challenge of dealing with what the White House in April called “an epidemic” of prescription drug abuse.
This epidemic, Ozturk, Urner and others agree is making all other drug addiction scenarios look like childs play. Already 27,000 Americans are dying every year because of prescription drug overdoses – in Florida where pill-mills are common, there are seven overdose deaths a day and around 20 percent of babies are born addicted.

Prescription drug addiction in the USA is so extensive it has all but killed the cocaine trade and has ousted marijuana as the gateway drug for teens. The National Survey on Drug Use and Health reported in 2010, “a marked decrease in the use of some illegal drugs like cocaine.” The quantity of cocaine seized in El Salvador and destined for the United States plummeted for the second consecutive year, from 4,074 kg in 2007 to 394 kg in 2009, according to the International Narcotics Control Board.

The INCB expressed concern about the rapid increase in prescription drug abuse in the U.S.A. and observed that in 2009, 4.8 million Americans used cocaine compared to 12.4 million Americans who abused prescription pain relievers. The number of emergency room visits involving legal drugs more than doubled from 2004 to 2008, mainly as a result of the abuse of hydrocodone, methadone and oxycodone.

But its good for job creation around this legal drug trade. Around the Huntington Treatment Center are two pawn shops, a 24-hour MacDonald’s, a large Walgreens drive-thru pharmacy and loads of free parking. This Treatment Center, one of a few in this small town that borders Ohio and Michigan, sees an average of 700 patients a day while its parent company, CRC Health Group, has 150 clinics that sees 30,000 nationwide. National spokesperson Kristen Hayes, rejected an interview request and slammed the phone down when questions were asked.
Dr Ozturk shrugs, “CRC don’t take referrals from physcians and they won’t tell us if a patient is on methadone… If they don’t tell us we cannot co-ordinate treatment. Section 42CRF under federal law the Addiction Act says that patient history or current treatment is strictly protected, but the law also says that when medically necessary patient information should be released. They won’t it give to us but then again everyone is afraid of getting sued… “
There is little doubt that the primary dealers are doctors, yet when they are arrested, often after multiple overdoses among patients, their jail terms are low, most often they will get a $15 000 fine and a suspended sentence.

Most doctors overprescribe because of ignorance. Dr David Kloth of the American Society of Interventional Pain Physicians says a lack of training in pain management at medical schools is to blame.

For example, “most spinal surgeons have no formal training in pain management, nor do radiologists. Of those who are extremely qualified and certified to do intervention pain management, there are maybe only 7 000 to 8 000 across the USA.
“There are a lot of doctors prescribing medications that do not have proper expertise, I am not trying to put the doctors down, but these are highly addictive substances that interact with other medications.”
The world prescription drug market was worth $856 billion in 2010 – it has almost doubled in value in a decade. In the United States prescription drugs netted a cool $307.4 billion for pharmaceutical companies in 2010 ($270.3 billion in 2006). By far the biggest seller is hydrocodone/acetaminophen, a Schedule Three painkiller and cough syrup. It netted $131.2 million in legal sales in 2010.
Hydrocodone is a semi-synthetic opioid derived from codeine and thebaine and is often compounded with paracetamol or ibuprofen. Codeine and cough syrups are routinely abused in South Africa and the INCB has expressed concern that “In Africa, the illicit manufacture of psychotropic substances for local abuse takes place mainly in South Africa…The illicitly manufactured drugs are predominantly methamphetamine, methcathinone and methaqualone (Mandrax). The precursor chemicals … are usually imported into South Africa legally but then diverted from domestic distribution channels.”
Prof Charles Parry, director of the Alcohol & Drug Abuse Research Unit at the South African Medical Research Council says prescription drug abuse in South Africa is “absolutely” a problem. “And one that is somewhat hidden. The prime prescription drugs of abuse are benzodiazepines (e.g. Valium, Ativan, Alzam), analgesics (containing codeine – though many can be bought without prescription) and stimulant drugs such as Ritalin (methylphenidate) used to treat ADHD. Among physicians, abuse of pethidine (an analgesic) has been an issue in the past.”
Whereas the profile of those most addicted in the USA is white educated, working men aged 30 to 60, “In South Africa women feature more heavily than men in the abuse of over-the-counter (OTC) and prescription drugs… and middle and upper classes are more likely to abuse prescription medicines. A recent study in Cape Town found that abusers of OTCs and prescription medicines were primarily from the White population followed by Coloureds and Indians.
“A lot depends on what steps are taken to address the potential for the abuse of products , for example, real time prescription registers that prevent people filling scripts fraudulently across multiple pharmacies (this is starting to happen now with pharmacies that are linked, like the Clicks network, but we need to link pharmacies together that are not in the same networks). We also need to work with medical aid companies to look into why certain clients remain on benzodiazepines for long periods of time following an acute incident. Doctors need to prescribe where needed but to be mindful of the abuse potential when giving repeat scripts.”

And that is in part, where some of the problem lies, it can be so profitable for a doctor to have addicted clients.

The US Drug Enforcement Administration says that, “Hydrocodone is the most frequently prescribed opiate in the United States with more than 139 million prescriptions for hydrocodone-containing products dispensed in 2010 and more than 36 million in the first quarter of 2011.” In Oklahoma, as an example, where the number of deaths annually due to accidental overdose of prescription drugs has nearly tripled in the past decade, according to Oklahoma Medical Examiner’s office, hydrocodone is most often involved, followed by the anti-anxiety drug alprazolam, and two other painkillers: oxycodone and morphine.
The US has adopted drug-takeback days and launched a variety of initiatives, not one of which yet, does anything meaningful to address an epidemic that cuts to the heart of its working population at a time of economic crisis.