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February 23, 2000
Patients Are Pissed
Dave Michon
One subject sure to anger all MMT patients is urine testing. The warped clinics use them as a whip. The tests themselves are utterly unreliable. Problems with urine tests constitute our second most common complaint from patients. I know if they're lying and it's very rare. They all know they can ask us how to cheat and we'll be more than happy to tell them! We're always on the lookout for new and improved methods to beat these tests. It's the free man and women's response to tyranny.
Drug-Testing is big business in America. Big business selling a product which is completely unreliable. Only in Drug War Land, eh? More than any other objection, this lack of reliance is an indictment of the practice. Decisions which affect our lives are taken on the basis of tests which are damnably useless. There is no reasonable purpose to these tests. They can be thwarted easily. There are so many deceptions which can obviate the test that they are completely pointless. Pointless, that is, if the real purpose is to uncover drug use. The real reason is therefore something else. The way these tests are used in MMT clinics is an outrage. Clinic staff should know that the tests are only an indication, at best, and not a scientific conclusion. To be accurate, a positive test must be verified. The procedures available to verify a test are very expensive. Today's clinics are in existence to make money so we know that they aren't going to be sending the 'presumptive positives' out for Gas Chromatography verification. Rather than acknowledge this conundrum, however, the majority of the clinics just hold their nose and use the suspect results as if they were gospel. A few clinics offer confirmatory testing but want the patient to fork over seven or eight hundred dollars for it. Patients should not be made to pay to verify a test they never asked for in the first place. What the hell are we doing here?
Withholding 'Take-Home' medication is another common complaint from our readers. It is abundantly clear that the dysfunctional clinics and staff members use this so-called 'privilege' to browbeat the patients into submission to their sober authority. I have corresponded with this sort of clinic employee and operator and some of them are honest enough to tell me that they, "need the Take-Homes for leverage to control the patient's behavior." This kind of paternalism is loathesome and says a lot about the person from whom it issues. It runs throughout the 'Step' mindset. It leads to many disturbing conclusions in the mind of patients. After all, there's not much you can do about inane authority other than to outwit it. Every beginner parent knows that if you treat your kids as children, they will behave that way. I'm not even comfortable with that analogy but it is most apropos to the issue.
Poorly-run clinics usually require transfer patients, for instance, to begin all over again 'earning' Take-Homes. This is nothing more than presenting that patient with a brand-new set off asses to kiss to get the flexibility they may need in their schedule to earn a living. This sort of thing is pervasive and illustrates what happens when you give people too much power over their fellow human beings. I sometimes wonder if regulators and policy makers have ever given any thought to how much control these doctors and so-called counselors have over their patients. Anybody who ever took an intro psyche class knows what this breeds in the human animal. The government has, in effect, given total control over a group of human beings that the government defines as lazy, immoral good-for-nothings to untrained and often part-time employees. It should come as no surprise that there are abuses. What is surprising is that so many wonderful people have found a way to work through this system to actually help the patients they work with. There aren't many of them, but it truly is something special to see what they do. They are the Oskar Shindlers of today.
The punitive approach uses the lowest common denominator of behavior and responsibility to set policies of clinic-patient interaction. There will be some patients new off the streets that will attempt to use dope in addition to their medication.
It is part and parcel of the syndrome. We don't need to turn our clinics into interrogation rooms because of it. The problem with disruptive patients is always worse at the clinics run by dogmatic boneheads. These clinics typically have dosage caps and make you walk through fire to get your dose raised to a level where it actually does what it's supposed to do.They also have the surly macho nurses and the 12-Step Preachin' counselors. It's really interesting to see the results of almost a year of collecting MMT patient complaints. The bad clinics are the same across the entire country. The complaints all read remarkably alike. The good clinics also have the same attributes showing through consistently.
There will always be a Trogladyte or two that shows up for MMT. It's inevitable; every large group of humans has it's abject examples.There will be Trogladytes that show up for kidney dialysis as well. Their unruly behavior is no reason to treat all the patients as untrustworthy dolts. Every clinic I've ever attended had a number of patients who were far more functional and well-balanced than most of the staff. Addiction is not definitive of human personality and ability. As the cardiology clinic sees many different examples of humanity pass through, so does the MMT clinic. In refusing to see this we are not asking the patients to improve themselves. We are forcing them to beat a stupid system which has all the hallmarks of having been set up to mollify the moralizing bozos in Congress.
It doesn't have to be like this. We know that what we've been doing does not allow MMT to function to it's full potential. Once Heroin Maintenance is finally unshackled clinic operators will be to blame if the majority of patients elect to switch over. The switch will be as a result of the bad taste so many of us have in our mouth when someone says, "Methadone Clinic." People in their forties, fifties, and sixties just do not want to be ordered to urinate in a cup by a 22 year old kid. They also don't want any 'counseling' from such a neophyte. The same principle extends to those counselors who have 'experience' with alcoholism and AA. It is a farce to put these people in charge of addicts. It's just not the same thing and it's a big waste of time and money to pretend that it is.
The way the counselors, doctors, and nurses use the red-herring that "the regs are to blame," to excuse their high-handed behavior betrays the fact that they know, instinctively, that what they're doing is wrong. This smokescreen has also completely misled those who would seek to improve MMT, via the 'Proposal,' to place all their attention on the regulations when, in fact, the reforms needed are much more comprehensive than just re- writing the regulations or bringing in new people to implement them. Thus the 'regs' have been used as a straw-man to deflect legitimate inquiry from the regulators as well as the regulated. The Proposal is based on what the clinics have been telling the regulators. A once in a lifetime opportunity lost unless, of course, the Drug War continues to collapse of it's own weight.
There are, I'm sure, political implications in all this. Must our friends at CSAT, SAMHSA, and FDA keep urinalysis in the MMT clinics to mollify the likes of a Bob Barr, John McCain, or Bill Bennett? Perhaps, but, if so, nobody is letting us, the 'consumer,' know. We have to demand that the hard questions get asked. Methadone patients are often paying big money to come into a facility and be browbeaten. In what other field would paying customers be 'disciplined?' It defies belief! You can't have it both ways. If you want patients to pay for treatment, because Congress won't face up to it's obligations for all the harm Drug Prohibition has caused this country, then those patients have to have the choice of service provider inherent in a free-market. The monopolies must be quashed. Bringing methadone into Schedule Two, as provided for in the CSA, without any special regulations, would do just that.
But what can realistically be done about it? The simple answer to that question is to begin using the 'Carrot' instead of the 'Stick.' Any clinic has patients in varying stages of their lives and their addictions. It's time to recognize this far more than we do presently. A patient that is 50 years old and has been clean for twenty years should be giving counseling, not sitting through it! Currently, the only inducement to progress for a patient has been to achieve the maximum number of 'Take-Homes.' Time alone takes care of this in most cases and in recognition of the profit motive. I believe that MMT patients should be able to 'Graduate' from the clinic to simple maintenance. The procedure would best be a graduated progression, to maintain interest. You'll forgive me if I suggest that us current old timers be 'Grandfathered in.' This status should not have urine- testing and counseling requirements. The medication should be dispensed through the regular pharmacy system, giving these older patients the maximum in flexibility. MMT is getting older. MMT is going gray. This is undeniable. Take a look around. What do older people do with their time? Well, one of the things that older folks have always done is travel. Must older MMT patients be denied the chance to travel? If they are tethered to a clinic it will just not be possible in any real sense. This is wrong and the MMT hardliners had better be aware that Senior Citizen MMT will command a much better response in Congress.
There are many possibilities. Rather than be judged by the amount of 'Dirty Urines' (the term itself is revolting) or missed counseling appointments, why not designate certain accomplishments and requirements for several different levels of addiction experience and self-management? Each new category would have further freedoms from the childish restrictions. It's very simple and I will leave it to you to consider all the possibilities. The main improvement is that there would be no inappropriate activities such as forcing a Senior Citizen to pee in a cup.
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