This is part two in a three-part series on methadone treatment and prescription drug abuse in the Midcoast. Part three will take a look at the financial impact on taxpayers of methadone treatment and substance abuse.

As an OxyContin addict, Kristan Hilchey found herself living without power or water, unable to pay bills and struggling to raise her child.

Spending $200 or more per day for her drug habit, she was at a house when it was raided by police. At one point her father threatened to take her 9-year-old daughter.

“You can’t think clearly because, unfortunately, at that point there’s nothing else that matters,” she said of her drug addiction. Looking back on those days, she said, she feels guilt, shame and remorse as a parent, but at the time her thinking was not so clear.

“You rationalize it,” she said.

Hilchey is now a patient at the Turning Tide methadone clinic in Rockland. She has been using the medication for six years as a treatment for her drug addiction.

She said she will probably take methadone for the rest of her life.

“I’m not treating my drug use, I’m treating the obsession with drug use,” she said. “I know that sounds like semantics but it’s really not. My goal is to have a better life. My goal is to stop obsessing about drugs. My goal is to get back to work and get back to being a parent, and for whatever reason, I could not do that without medication.”

Methadone maintenance treatments have helped Hilchey regain control of her life and maintain employment.

“I’m the same person I was before I became an opiate addict, and that was my goal,” she said.

Hilchey is not alone. Turning Tide has about 278 patients, according to President and Program Director Angel Fuller-McMahan, a number that has increased steadily since the clinic opened in 2007. It is licensed to have up to 500 patients.

The clinic at 166 New County Road near the Thomaston town line on Route 1 provides liquid methadone that is taken, for the most part, on site. Methadone is a synthetic drug that has been used for more than 45 years in the treatment of opiate addiction. It can be taken in place of other drugs to prevent drug craving and painful withdrawals. Staff members at Turning Tide said it does not fog one’s perception or produce a high.

It is most commonly associated with treatment for heroin addiction, but staff members at Turning Tide said few of their clients are coming in for heroin problems. The abuse of prescription opiates and opioids has eclipsed the use of street drugs including heroin, cocaine and crack.

Fuller-McMahan started the program in Rockland because she saw a need for the service in the Midcoast.

“If I hadn’t gotten into methadone treatment myself, I would have been dead,” she said.

Before Turning Tide opened, those in treatment had to drive to Portland, Waterville or Bangor for methadone.

“I did it for over a year,” Fuller-McMahan said. “Every single day and then I’d come back and go to work.”

She knew others in the area who needed methadone treatments, but they could not get time off from work each day to drive to Portland.

In addition to a growing clientele, Turning Tide plans to expand its treatment options. Fuller-McMahan said the clinic is in the process of securing the licenses to treat mental health issues and the clinic plans to start a limited Suboxone treatment program. Suboxone is another medication that can be used in the treatment of opiate addiction.

“It means that this is not just a methadone clinic anymore,” she said.

Her goal is to be able to provide a variety of medication-assisted treatments and counseling services to meet the needs of any client walking through the door. Patients would be able to receive treatment for other substance abuse issues including alcoholism and cocaine addiction, she said.

Signs of success

Guy Cousins, director of the Maine Office of Substance Abuse, said methadone is a scientifically proven treatment option for Maine residents.

Data has been collected from 1,046 methadone clinic patients in Maine comparing their situation at the time of their admission to a methadone program with the progress made while in treatment. More than 4,000 Maine residents receive methadone treatment each year, according to Cousins.

“Of the 1,046 patients included in the current sample, the percent of persons using a primary drug decreased from 85 percent to 5 percent, while the percent employed full time, part time or on an irregular basis increased from 37 percent to 43 percent,” he wrote in an e-mail. “In addition, of the 591 patients that had dependent children, the percent that were able to have their children living with them increased from 45 percent at admission to 57 percent while in treatment.”

Cousins said addicts face a stigma in society and there is also a stigma about treating them with medication. He argues, however, that other people can develop health problems such as heart disease due to lifestyle choices and have to take medication to maintain their health for the rest of their lives. These patients do not share the same stigma.

“No one picks up a beer and says, ‘I want to become addicted,'” he said.

Critics of the program argue that the methadone treatment is just substituting one drug for another.

“I don’t see anybody supplying free alcohol to the alcoholics,” said licensed alcohol and drug counselor Wesley Hohfeld of Eureka Counseling Services in Rockland. “Somehow it’s OK to supply methadone to opiate addicts.”

Hohfeld has a master’s degree in clinical psychology and is a recovering addict. He said he has abstained from alcohol and drugs for 25 years. Hohfeld said methadone should be a measure of absolute last resort. Other treatment options ranging from in-patient counseling and abstinence programs to Narcotics Anonymous and treatment with other medications should be tried first, he said.

Both Fuller-McMahan and Turning Tide Clinical Director Mike Franklin have also said methadone should be the last resort.

“This should be the final choice,” Franklin said.

How Turning Tide works

The process of becoming a methadone patient at Turning Tide starts with a telephone screening. Staff members ask potential patients about their use of substances and the impact it has had on their lives. Have they given up any activities because of their use? What financial problems have they experienced, and what impact has their use had on their relationships?

The staff then determines whether the individual meets the criteria. For some people, it is not the appropriate treatment. For example, Turning Tide does not treat chronic pain, according to Fuller-McMahan. In some cases, the person’s drug habit may not be severe enough to merit methadone treatment. The individual may be better served by other treatment options.

Ideally, Franklin said, the ultimate goal is abstinence.

If the individual does meet the criteria, he or she comes in for an appointment to speak to a counselor at length. The clinic leadership said medication-assisted treatment should go hand-in-hand with counseling.

Turning Tide has a staff of about 17 including a medical director, a nurse practitioner, a pharmacist, nurses and others, according to Fuller-McMahan.

A licensed nurse at the clinic dispenses the liquid methadone. Patients are required to take their doses of methadone at the clinic and are watched while taking it. They are also required to speak after they take their dose to ensure they are not holding it in their mouth and then spitting it into a bottle or other container in their possession. This practice is called “cheeking” in the drug community.

If the drug could be captured in this way, it could be taken from the facility and shared with others or sold.

Fuller-McMahan said no cups or containers are allowed in the dosing area. The patients are not allowed to wear hats or sunglasses.

The clinic also performs random urine and breathalyzer tests. Everyone gets at least one random urine test per month, according to Franklin. Fuller-McMahan said the urine tests are not observed, but the clinic takes the temperature of every urine sample to ensure no one is trying to smuggle in clean urine. The urine is also tested for commercial products used to flush a person’s system of drugs and help them pass these tests.

The patients come in on a daily basis for their methadone and do not become eligible to take the medication home for the first 90 days of their treatment. Clinic leaders said the patients have to earn their take-home doses by complying with all of the rules of the clinic.

The methadone administered in clinics comes as a clear liquid. The take-home doses are dyed purple to identify them, so it is easy to track the source of methadone. It is also easy to spot the difference between liquid methadone from a clinic and methadone pills prescribed by doctors to treat pain.

Methadone dangers

Opiates account for 72 percent of the overdose deaths in Maine, according to University of Maine Research Associate Professor Marcella Sorg, who serves as director of the Rural Drug and Alcohol Research Program. Sorg also works closely with the Maine Office of the Chief Medical Examiner.

She added that methadone is the largest single type of opiate involved in deaths.

In 2007 (the most recent year for which data are available), there were 57 deaths in Maine in which methadone was listed as a cause, according to the Drug Abuse Warning Network. There were four deaths from heroin that year. All other opiates and opioids accounted for a combined total of 68 deaths. Alcohol was listed as a cause in 22 deaths and cocaine was listed in 28. Antidepressants were listed as the cause in 31 deaths and benzodiazepines (anti-anxiety medications) were listed as the cause in 29 deaths.

Other recent years show a similar pattern in the Drug Abuse Warning Network reports. What makes looking at these figures tricky is that in many cases more than one drug is present in a fatal overdose.

Sorg, the Maine Office of Substance Abuse, the administrators of Turning Tide and other experts agree that in most deaths involving methadone, the methadone pill prescribed to treat chronic pain was used rather than the methadone liquid administered at clinics to treat addiction.

Sorg said that in methadone overdose cases, the Medical Examiner’s Office and law enforcement investigate and are often able to determine whether the drug came from a prescription pill or the liquid form dispensed at clinics. The investigators look at whether the person was a patient at a clinic and check whether the individual had a prescription for the pills.

In cases where methadone is a cause of death either alone or in combination with other drugs, 60 percent of the cases involve the pill rather than the liquid, according to Sorg. “That’s the number for the cases where we know,” she said. “Frequently we don’t know.”

“You rarely, rarely, rarely see a methadone patient overdose if there’s only methadone in the system,” Fuller-McMahan said.

Methadone and benzodiazepines

Experts in the field agree that mixing drugs can be extremely dangerous.

Mixing tranquilizers used to treat anxiety or insomnia with opiates is hazardous unless a doctor is directing the dosage, according to Sorg and Franklin. That includes benzodiazepines, Klonopin, Valium and Xanax, according to Fuller-McMahan.

These medications are central nervous system depressants, as is methadone. Franklin said that when a depressant is taken on top of a depressant, people can asphyxiate.

Drug addicts may be motivated to mix benzodiazepines with their methadone treatment because that mixture can produce a high similar to that of heroin, according to Hohfeld.

He said an addict can go to a doctor and ask for anti-anxiety medication without telling the doctor about the methadone being taken.

“Here’s part of the problem,” Franklin said. “You have a fragmented medical care and psychiatric care system in the state. There’s a shortage of psychiatrists, so what you have is a lot of primary care physicians, who lack the training prescribing mental health medications like benzodiazapines. You also have primary cares that are prescribing for pain, which is a very, very specialized area. There are not that many pain specialists and pain clinics in Maine.”

Public Safety Commissioner Anne Jordan said out-of-state pain clinics may be a source of the prescription medications that are being diverted and sold on the street in Maine.

Franklin sees two solutions. Effective Oct. 1, any Turning Tide patient testing positive for illicit benzodiazepines will be discharged from treatment.

Those who have anxiety disorders can work with their counselor and sign a release so that the clinic and their doctor can talk to each other. The medications can be taken safely together with a doctor’s supervision and direction, Franklin said.

Prescription Monitoring Program

Another tool for helping prevent potentially lethal drug interactions is the Prescription Monitoring Program, a computer database that allows doctors in the system to see all the prescriptions a patient is having filled.

Jordan said one doctor looked in the secure system and found a patient had 13 different doctors writing prescriptions.

Other drug interactions

When asked if their patients could risk overdose from taking more drugs on the outside after their methadone treatment, Franklin and Fuller-McMahan said their patients are monitored closely.

Franklin said that scenario is a possibility, but he checks the patients’ urine screens for other opiates, especially when they are new patients.

“It wouldn’t be unusual for somebody in the first couple of weeks to supplement because they’re not getting enough,” Franklin said.

“If somebody went outside and took something else or took more, the way that we do this dosing induction, they would have to take [lots of] drugs to overdose,” Fuller-McMahan said. “We’re watching them closely and we’re going very slow.”

During the early part of the treatment, the clinic starts patients at a low dose and then builds it up as it calculates what is needed to stop the craving and withdrawals for the individual. Different patients build up different levels of tolerance to the drugs.

“Methadone has a method of action that its half-life is 24 to 36 hours,” Franklin said. “So it reaches its peak in the blood system about three to four hours after its dose is taken. So if you have say some kid at a party, who has no experience with this, and he takes methadone, three to four hours later he’s not really feeling a whole lot, or even just one or two hours, and he’s not getting off, so he takes another one, and that’s how a number of overdoses happen.”

Fuller-McMahan said she does not believe the methadone dispensed at her clinic has contributed to any deaths.

“I think that the good we do here definitely outweighs the bad, but that’s not going to make up for someone if they have overdosed or they have died,” she said. “We give people medication. We try to help them, and they are adults, and when they leave here they know the risks. We educate them. Would I feel horrible [if there were an overdose]? Absolutely, but I have to think of those 274 other patients who are doing well. And it depends on whether it was their responsibility too, I guess.”

Alternatives to methadone treatment

One of the reasons to look at alternatives to methadone treatment is that it is addictive and difficult to stop using.

“History tells us, because methadone has been used as a treatment for opioid addiction for over 45 years, that a person will have to be on it probably on average three to four years before they get to a point where they feel confident enough and they’re stable enough to start tapering,” Franklin said.

Suboxone is one of the medications that can be used instead of methadone to treat opiate and opioid addiction. Franklin said that if someone is taking Suboxone and they take an opiate drug, the Suboxone will block the effects of the other drug. One of its advantages is that the withdrawals from Suboxone are much milder than from methadone, he said.

Turning Tide plans to implement Suboxone treatment as a limited pilot program, according to Fuller-McMahan.

She said there are no federal regulations or state regulations for Suboxone, while methadone is highly regulated. She added that Suboxone has become a highly diverted drug in Knox County.

“You can go to a doctor and be prescribed Suboxone and not have to do any counseling,” Franklin said. “Which we have an issue with.”

Turning Tide’s program will require the patients to do counseling.

Fuller-McMahan said she originally wanted to have the methadone clinic attached to Penobscot Bay Medical Center in Rockport. She said the hospital thought it was going to have its own Suboxone program, but that never happened.

Dr. Frederick Goggans, head of the Psychiatric and Addiction Recovery Center at PBMC, said Suboxone is available in the area through a limited number of primary care providers. It may also be used as part of the PARC unit’s inpatient detoxification program, but that would only be during a short-term stay in the unit. For longer term Suboxone treatment, patients would be referred to participating doctors.

“There is a shortage of providers for this treatment,” Goggans said.

Hohfeld sees Suboxone as a good alternative to methadone. “It doesn’t have a lot of the problems methadone seems to have,” he said.

There are not many treatment options available to drug addicts, in part due to economic factors. Hohfeld said there is only one 28-day in-patient treatment program left in the state — at the Aroostook Mental Health Center in Limestone. He said there are benefits to a 28-day program where a person is in a controlled environment receiving group therapy and one-on-one therapy. It serves as a jump-start to recovery and begins an addict on a lifelong 12-step program.

These kinds of programs are somewhat out of vogue when compared with out-patient treatment, in part for economic reasons.

Hohfeld said abstinence-based counseling and Narcotics Anonymous work. He said many have found long-term sobriety and recovery through these alternatives.

Another medication that can be used to treat addiction is Naltrexone, according to Hohfeld. This drug blocks the effects of other opioids, taking away the reward or high associated with taking drugs. However, it may not stop cravings, according to information from the U.S. Department of Health and Human Services. Any medication should be taken only with the supervision and direction of a doctor.

Cousins said research shows long-term opiate addicts do not do well in abstinence-based programs.

Whatever the means of treatment, all the experts agree that addiction is a chronic disease. Most addicts will struggle with it for the rest of their lives, and most cannot find recovery without help and counseling.

“It’s so hard to talk to somebody when they’re in that position,” said Hilchey, when asked what her advice is for addicts who feel their situation is hopeless. “… You cannot think about anything else [other than drugs]. It’s an obsession beyond obsession. You really can’t and you do not care about anything else including yourself, your children, nothing.”

Most addicts have to hit bottom before they seek recovery and the bottom looks different for different addicts. For some, it’s being arrested. For others, it’s losing custody of their children or losing their financial stability. In some cases it’s a health scare.

“Something needs to jolt you out of that situation,” Hilchey said.

“The only thing you can say is get help,” she said. “It does work.”

This article is not intended to provide medical advice. Anyone who has questions about how drugs might affect them, or the substances or medications they are using, should consult a doctor.

















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