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SO MANY WAYS TO DIE IN INDIANA!



Unfortunately it only applied to opiate addicts. Especially prior to Indiana Medicaid reimbursement in the year 2018.

Not everyone. Just the opiate addicts.

This next portion is the precursor to what occurred in my life following my departure from the methadone maintenance clinic.

There were two significant changes that took place which affected patients recieving medicated assisted treatment in the state of Indiana. The most recent change occurred in the year 2018 when Indiana Medicaid started to finally reimburse providers for medicated assisted treatment. It changed the lives of many people forevermore. This change was for the best. It was also embarrassingly slow to occur. Indiana had once been ranked as the second most likely place to die of an overdose in the county. It’s nothing short of tragic that so many addicts died waiting on Indiana legislation to acknowledge opioid addicts deserve medication.

I also remember something else that took place way before the year 2018 that was as equally exciting for patients as the day providers started being reimbursed by Indiana Medicaid.

Sometime around the year 2002-2003 a brand new magic pill had most of Midtown’s patients pretty excited. That’s when Suboxone was first  being prescribed for opioid addiction. That in itself was wonderful news because it meant methadone maintenance wasn’t the only option available to treat opioid addiction. For a period of time while waiting in line to be dosed each morning it was the guaranteed topic of discussion amongst Midtown’s patients. Initially Suboxone was presumed to be a tool that methadone clients could use to eliminate most if not all of the withdraw from methadone. At that time many patients seemed to be under the impression that Suboxone was designed exclusively to help methadone maintenance patients who no longer wanted to be on methadone, finally get off. Methadone is notoriously difficult to get off of. Alot patients had been struggling for years to gradually ween themselves off but found it physically too challenging. In addition to the physical symptoms it posed other challenges. Methadone’s long self- life meant residual amounts could still be present weeks after their last dose. Rumor was that Suboxone could be used to allievate the methadone withdraw and after a few weeks no longer need to keep taking it. For someone feeling chained to their methadone clinic that prospect was quite intriguing! The idea of being able to visit a doctor, then fill a prescription themselves at the local pharmacy instead of rearranging their entire lives around standing in line to be dosed every twenty-four hours was almost too good to be true! A normal medical experience had been elusive for methadone “clients”.
Many people thought that Suboxone or buprenorphine was not an opioid based medication. Which quite obviously isn’t true.
It was also rumored that you couldn’t suffer physical withdrawal from taking Suboxone. Which isn’t true either. However it is more likely someone will be able to manage the withdraws from Suboxone versus methadone.

Suboxone was the long awaited answer for many of Midtown’s patients who wanted to exit the program entirely but we’re unable to deal with  withdrawal.
Although it didn’t take long for Suboxone’s initial luster to wear off.  Then the skeptics chimed in. People then began hearing stories about opioid addicts suffering through the agony of something called “precipitated withdrawal”  which sounded far worst than methadone withdrawal. (For the record, yes it is in fact God awful. Be afraid! Be very very afraid!!)!
In the end during that time I hadn’t been convinced that it was a practical solution. Although I was still intrigued by the possibility.

And being “intrigued” by Suboxone’s possible use was about as close as I could get to actually being prescribed Suboxone back in those days.  That’s because if you happened to be a poor opiate addict in the state of Indiana prior to Medicaid reimbursement in the year 2018- Your odds of being struck by lightning were slightly better than being able to afford treatment with Suboxone! The words “financially absurd” come to mind.

Suboxone’s price was by far it’s most unattractive feature. Suboxone shared the same problem that methadone maintenance shared. Anyone being prescribed Suboxone for the purposes of opioid addiction wasn’t going to receive insurance coverage. I had occasionally heard of people with exceptionally good insurance that paid for the office visits but not the cost of the prescription itself. But even that was rare. Each Suboxone (films two dollars more than tablets) was approximately $18 a piece. And patient’s were usually prescribed two to three doses a day. That adds up real quick when paying for it over at the pharmacy. And truthfully it’s cheaper to buy drugs on the street (heroin) than it is to pay for a legitimate evidence based form of treatment such as Suboxone.
 
It’s no mystery why Indiana happened to be the second most likely state to die from a drug overdose. Sadly, it was financial considerations which undoubtedly claimed so many good lives. Heroin in contrast to Suboxone, as well as methadone maintenance. Was relatively inexpensive and widely available. Even if an addict couldn’t afford their money order on Monday morning over at the clinic, they’d likely still be able to cough up a $20 and head straight to a dealer. Over time it’s comparable to applying a band aide to a gaping head wound! But opiate withdraw doesn’t care. You’ll agree to it’s terms in the moment. Thus the possibility of dying from an overdose was born.

And unbelievably Indiana opiate addicts had another strike against them besides the expense associated with opioid medications.

Any doctor prescribing Suboxone was required to have the proper credentials. I could be wrong but I thought a special prescribing license was required.
I’m positive that I’m not wrong though when I say it was just bureaucratic money generating bullshit that required any doctor to pay for hours worth of training in order to be qualified to write Suboxone prescriptions for addiction. All Suboxone doctors had to pay for their credentials or they couldn’t prescribe Suboxone.

Now personally I don’t think it’s necessary to require a doctor to hold special credentials when writing Suboxone scripts. It’s not as if the prescribers hadn’t ALREADY attended medical school for years and years. I can’t speak for all physicians but I’m betting they’re capable of comprehending the medical aspects of prescribing Suboxone/buprenorphine in general! Of course bear in mind that I’m no trained medical expert here. I’m not even qualified to administer first aide to my doggie.

It appeared to be just one more interference aimed at harming poor people who were desperate to receive treatment with Suboxone.
However unbelievably STILL there was another problem running interference with being prescribed Suboxone.
The 100 patient maximum.
Each highly skilled, “properly accredited” addiction doctor was only allowed to prescribe Suboxone/ buprenorphine for no more than 100 patients at any given time.

Go ahead and do the math and then ask yourself the same question I did- WTF(??)

HUNDREDS and THOUSANDS of opiate addicts   were living with a condition that the DSMV-5 considers to be an honest to God disease. OPIOID ADDICTION/OPIOID DEPENDENCY and needed medication.

And how does society respond to this problem?

By requiring a select group of specialists to first become accredited. Stipulation only 100 patients at a time for each specialist treating addiction. And charging an insane amount money for office visits followed by charging an insane amount to fill the prescription. I don’t remember but it seemed likely there wasn’t even a generic being filled regularly back then either. As was probably assumed standard cash based operations ONLY.

That was how Indiana first introduced Suboxone to opiate addicts.

I guess technically there was another response to opioid addiction that I was forgetting about. Since most people can’t fathom what it really means to enroll in methadone maintenance. I’ll be happy to provide a detailed account. A realistic one. Here’s how legislatures originally responded.

Well first they insist on forcing opioid addicts to be present every twenty-four hours, seven days a week (don’t forget XMAS too)! That means driving to a location, which probably won’t be all that close to one’s home or work. (Not an abundance of methadone maintenance clinics around in the first place. Hence the saying, in Indiana goes,
“Methadone doesn’t grow on trees”
Then requiring them to stand in long lines, usually while outside during hellish weather conditions for what might be hours (in God’s hands really).

There’s statistically speaking hundreds maybe even thousands of potential hold ups while waiting in line to be dosed. I should probably sit down and make out a long list of all the hold-ups I’ve ever personally experienced over seventeen years while attending the methadone clinic.
*Naw, Naturally I’m just kidding!
I don’t have enough time to list all the possible hold ups that I myself was present for in line. Even without a day job.
Quite a few hold ups***

Then guidelines require anyone who was enrolled to be dosed in the presence of a registered nurse up at the dosing window or station. There’s always the possibility you’ll not actually be dosed due to fate randomly forcing you to submit a urine sample. You’ll first need to go locate a member of the clinic’s staff and ask them to please “drop” you. Mindful that not just any old person will do.  All drops were observed. Meaning anyone administering the urine test must be the same sex you are. (They frown on opposite sex dropping! Believe me, I’ve tried begging back years ago when I couldn’t locate a female staff member and was running late to work.).
No worries-by the time you locate someone that’s the same sex as you are and then head over to the official “drop” restroom, sign off on the lab slip etc. You’ll probably be finished in approximately ten to thirty or possibly forty minutes, Tops! And if you don’t actually have any urine to be providing randomly when asked,  you may want to teach yourself how to “will” your bladder into peeing. Takes some practice I admit but-Hey, whatever it’s going take to get to work on time. Cheer up though! Odds are still pretty decent you can make to your job on time.  It’s not always going to cause delays when you get a random.
Not out of the game yet…as they say!

Unfortunately though there’s another old saying that applies here, “It ain’t over until the fat lady sings!” And it’s not only randomized testing that may interfere with you earning a living. Or making sure you get back home on time to wake up your children for their school bus.

Occasionally you’ll have to attend a one-on-one session with your clinician. I Might be incorrect but last I knew every methadone maintenance patient was required to spend a certain number of hours with their clinician on an individual basis. A counseling session essentially. And once again I’m positive this is another one of those bureaucratic bullshit requirements. Pretty safe bet anyways.
Usually a person’s clinician will schedule the session in advance making an effort to accommodate work and school commitments. That’s certainly no guarantee that it won’t still interfere though. Sometimes the clinician herself is late which causes problems. Since anyone still needing to get their required session in for the month can’t be dosed until they’ve completed their “activities”. Anyone who has never been a patient at a methadone clinic before probably doesn’t understand what the problem is. Why not just get in the usual line to be dosed if your clinician is late for the session? After all it isn’t your fault she’s in the drive thru line over at Starbucks instead of in her office. Logically it’s more important that you aren’t terminated from your job rather than waiting around to fulfill bullshit administrative requirements for your doctor’s office is. Right?

Simply insist on receiving your dose so you’re not late to your job over waiting around for your tardy clinician to show! Truthfully that won’t really help you if you throw a tantrum. But feel free to do it regardless. Foolish…so naive..(cough cough).

That may be a reasonable assumption if you were a patient over at another doctor’s office but remember that this is the methadone maintenance clinic! And common sense doesn’t ALWAYS apply.
Silly rabbit! Common sense is for use in any other medical facility! You can’t use it now that you’re a methadone maintenance “client”!
(Ha ha ha ha ha diabolical laughter. Coughing)*

From a certain point onward all methadone maintenance clinics became computerized. Virtually every single aspect of a patient’s care was based on whatever the “computer” dictated. That in itself isn’t unusual.
However consider what happens when you are arriving for care every twenty four hours, seven days a week (don’t forget XMAS day) for care?
Clinicians didn’t schedule appointments using a pencil and work planner any longer. Part of their daily duties was to enter each person’s regimen into the system. Even when recieving your dose each morning. (Eventually you’ll make it up to the dosing window. Don’t give up now. Be patient)

A nurse no longer measured out the exact amount of methadone by hand, as she once had in the past. Instead she types in the patients information or identity and the methadone is distributed or flows out of the machine. Like ordering a fountain Coke from a fast food restaurant. Closer still is the Hawaiian punch machine used at concession stands during baseball games.
All that your dosing nurse is required to do manually, is hand it over to you along with a tiny cup of water to wash the nasty taste from your mouth. I’d imagine gasoline is tastier but some people claimed to actually like the flavor. Yucky!!

If a person’s is listed as having an appointment then the computer can’t measure any methadone out. It places them on a freeze or “HOLD” when it detects an incomplete activity. It’s also not something that can be easily reversed or rescheduled. Only a person’s clinician has the power to alter it. And since your clinician is still waiting for a latte in the drive thru, you’re at her mercy ALONE. Apparently allowing just any qualified healthcare worker from the clinic to go in the system and lift “HOLDS”  would be making it EASIER on the clients. That would prevent you from being late to work. And unfortunately that would be a reasonable thing to do since you have to be dosed and get to your job on time.
Silly rabbit ….

Here’s a few other reasons you won’t be able to arrive and be dosed in a timely fashion while as a patient over at the methadone clinic.  Guarantee on a long enough time line. (DISCLAIMER: Plan accordingly)(??) I’d recommend a crystal ball but some people prefer good old fashioned fortune tellers and a deck of tarot cards. Sadly probably the only way to predict these kinds of troubles

1.  Transportation issues.
2. Car accidents or speeding ticket(time factor)
3. Alarm doesn’t go off
4.  Security guard that has the building keys doesn’t show up to open it. Inexplicably and often.
5. Physical or verbal confrontation while in line. Your own or someone else’s.
6.  Treatment Team meeting (personal favorite)
5. Clinician forgot to remove a previous “hold”
6. Methadone machine has to be refilled.
7. Methadone machine malfunctions
8. Annual appointment with Doctor
9. Unable to pay (or unable to find a place selling a money order at five am downtown. Same diff)
10. Illnesses(remember no sick days)
11. Any particular reason your clinician needs to see you before dosing.

12. Even power outages which means staff hussle to revert back to the days of manual labor. Major hold up

Hopefully by now a clearer picture is developing concerning the realities of being opioid dependant and enrolled in a methadone maintenance clinic. The methadone clinic is a major commitment and treatment wasn’t set up to be reasonable or user friendly.
Any number of things can go wrong. It will have to take priority over both your work and personal pursuits. There’s no calling in sick either. No aspect of your life won’t be affected to some degree. Nothing is wholly off limits. However it’s employment that will likely be impacted the very most. I can’t think of anyone whose job wasn’t negatively Impacted by the methadone clinic.
Your best bet was to simply go ahead and tell your employer honestly about attending the clinic.  Otherwise you will eventually run out of good excuses for the repeated tardiness. Most employers won’t consider it a positive attribute that you’re actively enrolled in a methadone clinic. Not likely to commend your recovery or shake your hand. Technically I’ve personally lost at least three different jobs either due to discrimination or because I didn’t tell my employer in the first place and later experienced problems. In most cases I was ashamed of telling my managers or co workers. Methadone is heavily stigmatized. It’s certainly not fair but it continues to prevail. Bear in mind that there’s very little you can do about the upcoming tardies in your future. Even the best of efforts will still result in complications. If you’re fortunate you’ll be able to share this private information and your employer will understand and work with you. If you are unlucky then it’s likely to be only a matter of time before losing  your job.

I was always bothered by the fact that I felt I had a right not to tell my employer about something so highly personal but felt pressured to disclose it regardless.

The clinic can be like a revolving door for active opiate addicts, heroin users. They may want to use methadone to combat the withdrawal from opioids but once they started attending and saw what life was like they’d quit and continue to seek out relief on the streets again. Drug dealers accept cash payments. Day or night as long as they’re answering the door or phone. They also aren’t forcing you to sit in waiting rooms or be subjected to random drug testing and other clinic appointments that can cause dire reprecussions. Now of course in order to properly address an opiate addiction you’ll have to become accountable. That’s definitely true. Except the methadone maintenance clinics are not logical. They demand far too much from people who are expected to make the clinic the highest priority in their lives. Truthfully they expect patients to treat it as if it’s the ONLY priority in their lives.

The added pressure of attending required group meetings doesn’t help. Relapsing meant showing up one day to be dosed and discovering that the labs from one week prior had finally been processed and you’re on a “HOLD”. That meant you had to address it in the clinician’s office and if they weren’t available right at that precise moment then you had to just take a seat in the waiting room and wait until they were available to speak with you. How long this might take is anyone’s guess. That’s going to be a problem and damage your attendance record at your job. It’s frustrating and it’s somewhat disrespectful towards addicts. Treating them as if they deserve problems due to the fact they used a substance. One clinician many years ago said to me
“If you can’t do the time don’t do the crime Majority”

After I reminded her that I needed to get to work that morning. I’d taken one Valium the week before. Did I have to lose my job as a punishment for my sin? That’s not going to help me recover. That won’t teach me how to manage what the DSMV-5 considers to be a disease.

No wonder statistics revealed that people were overdosing throughout the state. Legislative problems combined with poverty and society’s lack of compassion all conspired to seal an opiate addict’s fate in many instances.
Hmmm, I wonder what the problems were?

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One response to “SO MANY WAYS TO DIE IN INDIANA!”

  1. Dr David McCartney Avatar
    Dr David McCartney

    Great piece, but quite difficult to read – does not sound patient-centred.

    Like

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