Cover Story: Dealing drugs the legal way
Methadone clinics were supposed to save people from the ravages of heroin addiction. Why, then, did five people die here last year of methadone-related causes? And why isn't the state bothering to regularly inspect clinics?Wednesday April 4, 2001 12:04 am EDT
On January 3, 1996, Chris Brackett walked into a methadone clinic and met the woman who would counsel him through his treatment. She noted on an intake form that Brackett was 27 years old and a Methodist. He had finished three years of college and was starting work that week as a stagehand at the Fox.
The counselor also wrote that Brackett shot up heroin at least twice a day, and popped at least one Valium and one Xanax. Brackett agreed to a urine test, which, according to court documents, confirmed traces of those drugs. The clinic then started him on a 30 milligram dose of methadone. The intent was to curb his heroin cravings and withdrawal symptoms.
When Brackett returned to the clinic at 7 a.m. the next day, court documents say, a nurse gave him a 40 milligram dose, presumably because his cravings and symptoms hadn't ceased. He went home, to Canton, to rest. Brackett's live-in girlfriend walked into their apartment at 6 p.m. She found him dead on the couch. His autopsy listed the cause of death as "intoxication by multiple prescription medications, including methadone." The drugs allegedly had slowed Brackett's breathing until it stopped.
Brackett's parents, Barbara and Johnny, have filed a wrongful death lawsuit against the clinic, Lakeland Centres Atlanta. In their supporting affidavit, the Bracketts include testimony from Dr. Donald Jasinski, head of the Center for Chemical Dependence at Johns Hopkins Bayview Medical Center. "The treatment center should have known that he was not a suitable patient," Jasinski's affidavit reads. "It is medically well-documented that benzodiazepines Valium and Xanax adversely and sometimes fatally interact with methadone."
If the court finds the clinic erred, it wouldn't be the first clinic in metro Atlanta to make so egregious a mistake. A Creative Loafing examination of state inspection and autopsy reports, along with interviews of government officials, clinic workers and patients, shows that some local methadone providers regularly disregard government regulations, endanger the lives they're supposed to improve and seldom face even the mildest penalties. Among the findings:
There were five methadone-related deaths in Fulton County last year (heroin deaths numbered 14). Four of the people who died were current or former patients at methadone clinics, including a 20-year-old who had been kicked out of a clinic the day before his death. The fifth victim died from the combined effect of methadone and Ecstasy.
Clinics regularly give methadone to patients who haven't proved an addiction, increase dosages without a physician's approval and provide take-home doses even to patients who were caught selling previous take-home doses on the street.
Some of metro Atlanta's 10 methadone clinics have gone up to four years without state inspections, and some have faced no penalties or follow-up visits despite reports of multiple violations of state and federal regulations. One was skewered in a 1995 inspection report citing "serious violations," but the state didn't get around to visiting again until last year.
"It's an open-air drug market in those clinics," says Bill Reeves, a former heroin addict who spent three years in a methadone treatment program. "They're worse than dope dealers. The way it's dispensed is wrong."
The German pharmacists who developed methadone during World War II didn't intend for the synthetic narcotic they created to be dispensed as a substitute for heroin. They were looking for a non-addictive painkiller to give soldiers during surgery. Methadone hydrochloride wasn't the alternative they had hoped for. It caused nausea and vomiting, and there was no indication that people wouldn't get hooked.
But soon after the war, American drug companies saw potential profits in methadone. An uneasy argument was born between the new narcotic as a therapeutic panacea and as just another dangerous addiction. Commercial production and clinical trials of the new painkiller began in 1945. Two years later, an article in the Journal of the American Medical Association warned: "We believe that unless the manufacture and use of methadon methadone are controlled, addiction to it will become a serious health problem."
In 1963, two American psychiatrists began using the drug to treat addicts of heroin and other opiates. The psychiatrists theorized that once someone becomes addicted to an opiate, he suffers a disorder like diabetes and therefore needs his respective "insulin." With methadone, a patient could reach a "maintenance" dose, usually between 80 milligrams and 150 milligrams, where he was addicted — but would crave neither heroin nor an increase in methadone.
The U.S. Bureau of Narcotics threatened to shut down the experimental treatments, stating that they were illegal. Instead, the Food and Drug Administration and Drug Enforcement Administration passed strict regulations that would allow clinics to use the drug to treat opiate addicts. The logic was to pull the addict off the street — away from crime and disease — and into a "maintenance program" in a medically supervised clinic.
By 1970, methadone clinics had opened across the country. Approximately 800 clinics operate today; they have 115,000 patients.
Many of Atlanta's 1,500 methadone patients wake before dawn to stand in line for the dose that will get them through the day. The names of the clinics — Atlanta Metro, Southside and Georgia Therapy Associates, for example — are as nondescript as their locations, sometimes just a discreetly-marked house or a few rooms behind a door in a sterile office park.
Inside, patients step up to the dosing window. They drink their drug out of a plastic cup, spiked with Tang or cherry flavoring. They pay either $3 per dose at one of two public clinics in Atlanta, or between $9 and $12 at one of the area's eight private clinics.
The high is not as intense as heroin's, but it does create a euphoria, starting with warmth in the stomach and spreading to a pleasant heaviness in the arms and legs. Methadone's effects last 36 hours, versus heroin's 12.
"For somebody not an addict who wants to get high, 20 milligrams will pretty much waste you for a day and a half," says Reeves, 41, who quit methadone four months ago.
Until the late 1980s, methadone clinics in Georgia were almost entirely publicly-funded and operated. Methadone stayed out of the domain of regular doctors' offices partly because of the FDA, DEA and, later, state restrictions. But in the 1990s, private clinics began appearing. The business was proving profitable. Addicts pay up to $300 a month for methadone versus $100 a day for heroin. A clinic saves the addict money — and has the potential to bring a fair chunk of change to its owners as well. A private clinic with 200 patients is guaranteed a monthly income of almost $60,000.
"Now there are these programs competing with one another," says Dr. Thomas Hester, head of the state Department of Human Resources division that oversees methadone clinics. "Some of them are advertising, offering enticements if you brought somebody else in, giving you your dose cheaper. They were recruiting people."
With entrepreneurs capitalizing on people's addictions, the DHR to rethink the way it regulated clinics. Based on the growing number of private methadone programs and on the fact that the FDA had quit inspecting clinics, in 1997 Hester rewrote the state rules. He planned to enforce both his new rules and the unenforced federal ones.
"There's a risk for someone who's not an ethical provider to just give people what they ask for to keep them coming back and paying," he says. "We thought that it was very critical that there be credible regulations to protect the field, to be there for patients."
But the rules, which went into effect in April 1998, haven't always been enforced. In those three years, only six of the 10 metro Atlanta clinics have been inspected. Another three clinics have not been looked at since 1997. One more clinic has not been inspected since 1996. (There is nothing in state law that says how often the DHR must inspect clinics.)
Hester acknowledges that the clinics are not his top priority. He has other responsibilities. He oversees all eight state hospitals and is the chief administrator for 13 regional DHR offices. In fact, methadone clinics appear to have slipped through something of a crack in the state's regulatory structure. Other private medical facilities are now overseen by the separate DHR Office of Regulatory Services, which specializes in setting standards, regularly inspecting, enforcing regulations.
"We have not been in an ideal position to be as timely as we like," Hester says of the DHR's methadone program. "And unfortunately, there have been times when we've gotten much further behind in following up than I would prefer."
Of course, follow-ups haven't forced any improvements anyway. No Georgia methadone clinic has ever been fined. Indeed, there's no mechanism in state law to fine a methadone clinic. The state can revoke a clinic's license, but only once has threatened to revoke one in the metro area; that clinic changed ownership before the state followed through. With such minimal oversight, clinics are left to run as they please, with little more than their consciences- and the threat of lawsuits — to guide them.
DHR inspection reports, which CL obtained through the state's Open Records Act, reveal that at six of 10 Atlanta-area clinics, patients have been dosed, or have gotten dosage increases without the physician's required approval. At four clinics, patients have walked in for the first time and been given methadone without proving they suffered an opiate addiction. At four clinics, patients who failed urine tests for illicit drugs were allowed to take home supplies of methadone (a clinic in Texas was shut down in 1993 when state inspectors cited the same violation). Three clinics have stored their methadone in plain view and within access of staff and patients. And patients at two clinics have been caught selling their doses; still, their take-home supply wasn't cut off.
"There's a range of quality," Hester admits. "There's a number of providers that I think need technical assistance. And there are some safety issues, some real basic safety issues."
DHR inspectors visiting Atlanta Metro Treatment in Norcross found in February 1999 that the clinic was breaking nine state rules, ranging from overflowing trash cans and "an infestation of flying insects" to a clinic director who "did not seem familiar with some of the basic principles of substance abuse treatment." Inspectors made 13 recommendations for improvement and concluded, "There is much work to be done to bring this program into compliance."
Inspectors returned 10 months later and found that the clinic had one counselor handling all 187 patients (state rules require that there be at least one counselor per 40 patients). The DHR recommended that the clinic stop admitting new patients.
Atlanta Metro director Jerry Walters, who was hired last October, says the state has visited the clinic since his arrival, although CL found no documentation of that visit in state files. Walters says he has worked to come up with a new plan that meets state regulations and that the clinic has almost a whole new staff, including five counselors for the current 235 patients. That's still a counselor short of the counselor-to-patient ratio required by the state.
Cartersville Treatment Center was inspected by the DHR in August 1999 "when this office was informed that the medical director had resigned and had major concerns about program operations," Hester wrote. The state found that the clinic was without a physician for 17 days and that patients were getting dose increases without the required medical signature. Patients also complained that staff members didn't know what they were doing.
Cartersville director Troy Beaver says the inspectors returned a year later to interview him but have not conducted a follow-up inspection. Beaver referred further questions to the center's corporate office in Tennessee.
At GPA Treatment Center in Doraville, a patient caught selling methadone was allowed eight take-home doses the next month. Counselors, not physicians, had been writing medication orders for four years, according to a 1995 inspection report. For three days, the pharmacy door was left open. "The program's accountability for methadone was very poor," the DHR noted.
At the end of that inspection, the DHR listed more than a dozen violations and eight recommendations for improvement. Hester wrote: "It should be noted that all of the above recommendations concern serious violations of applicable rules and regulations." The letter urged the clinic to "take all steps necessary to come into compliance with all applicable state and federal rules and regulations."
That letter was sent shortly after the 1995 inspection. The DHR did not check on the clinic again until November 2000.
GPA Treatment Director Stacey Pearce says state inspections, although thorough, are arbitrary and misleading. She points out that during her clinic's November inspection, which revealed few violations, she was cited for allowing a patient to take home 27 doses of methadone (the limit is currently six). She then produced a signed document that showed she had received both state and federal approval for that specific patient.
"The relationship between the state and the clinics is very adversarial," she complains. "It's not a good relationship."
Pearce describes some state rules as "unenforceable." First-time patients are required, for example, to prove they have a one-year addiction to opiates. Pearce, whose mother owns the clinic and who started work there as a receptionist five years ago, argues that a drug-use history of that length is impossible to verify. "I can't contact everybody's drug dealers," she says.
To screen incoming patients, she says GPA tests their urine for opiates. Beyond that, if someone claims to be using heroin and has track marks, he gets methadone. She says someone who shows that he has prescriptions for pain pills at multiple pharmacies also will get dosed.
If someone has neither track marks nor prescriptions, if he claims to be addicted to pills he buys on the streets, Pearce says, "we basically have to go on their self-report."
Both addicts and recreational drug users have found ways to take advantage of lax enforcement of rules.
"You walk in with $10 and a picture ID, and you're high for two days," Reeves says of opportunistic patients he knows at one Atlanta-area clinic. "You take a drug test, but it doesn't come back for a week. It takes 30 minutes to get dosed. I didn't even see a doctor."
Patients interviewed by CL claim they can easily work the system to get more methadone. State rules say clinics can start a patient on a maximum dose of 30 milligrams and can increase the dosage until signs of withdrawal disappear. (A 50 milligram dose can kill someone who hasn't built up a tolerance to opiates.) A physician is supposed to approve dosage increases, and it's pretty standard to get five or 10 additional milligrams every few days until the dosage reaches between 60 milligrams and 100 milligrams, or until the patient no longer craves heroin.
Some patients say upping their dose is as easy as returning to a dealer to get more dope. If they complain of leg cramps, insomnia or other withdrawal symptoms, the dose goes up. Those symptoms can't be proved — or disproved.
"The first week or two that you get on it, you're still high. You don't get that big rush on it, but when you sit down you're nodding out," says one patient, who asked not to be named for fear of relatives recognizing him or of clinic retaliation. "The 30 milligrams helped me, kept me from getting sick. I asked for more only because I wanted more. I wanted to keep getting high."
His counselors said he could keep getting increases until he didn't want them anymore. The counselors told him to be sure not to use other drugs so that his tests would be clean and he would be a candidate for take-home doses. He said they never warned him that methadone, used with other drugs, could be lethal. And they didn't warn him about how addictive methadone is, or how painful its withdrawal symptoms can be.
"I'd rather kick heroin 10 times than kick methadone once," he says of his attempt to quit. "I didn't sleep for 16 days. All that shit's trying to come out of your joints and muscles. I broke my tailbone twice, while racing motorbikes and skateboarding. That hurt less."
He warned his friend, who had been addicted to heroin less than a year, not to get hooked on methadone. The friend opted to use methadone to mask the first week of heroin withdrawal. After a week on methadone last November, the friend quit both drugs.
"I really didn't want to be addicted to methadone," the friend says. "I saw the people coming in and they were just as desperate as people on the streets. It's like you've got an internal clock. It's either go to the dealer every day or go to the clinic every day. What's the difference?"
Not much, according to the current patient.
"They come across that they want to help you, but it's a trap," he says. "You're doing methadone because you want to help yourself, but you're doing something that's worse. They don't stress how hard it is to come off it. It's like legal dope. It's like government dope."
Patients with clean drug screens sometimes are rewarded by getting a dose or two to take home. After a year of clean urine tests, a patient can get up to a week of take-home doses (although inspection reports show that many clinics don't routinely drug test or that they dispense take-home doses to people who fail drug tests). That privilege can be abused. Giving an addict take-home drugs can be akin to giving poker chips to a compulsive gambler.
Because the high lasts so long, methadone can be more desirable than heroin. Reeves says it sells on the street for between 50 cents and $1 per milligram in liquid form. A 40 milligram tablet, which clinics are supposed to dilute in water but often don't, goes for $50.
Neither Atlanta police nor the Georgia Bureau of Investigation keeps drug statistics on methadone busts. The DEA's Bob Williamson says federal and local narcotic investigators don't crack down on methadone street sales because the drug moves in such tight-knit circles. Mark Burns, head chemist in the GBI crime lab, says arresting officers have sent him only two methadone samples to test in the past year. Those two samples and samples from years past have typically been the liquid methadone that comes from clinics.
"You can't give junkies extra dope, dope to walk with," says Reeves, who used to sell two doses a week so that he could buy other drugs. "I can't think of anybody with take-home doses who hasn't sold them."
The rapid growth of the methadone-clinic industry — and the public health and illegal-drug issues that surround it — have prompted a response from the federal government. As a result, the state may play a smaller role in methadone regulation or no role at all. But it's unclear whether new federal regulations, which begin to take effect next month, will solve the problems or simply shift them.
Nicholas Reuter, an analyst for the U.S. Department of Health and Human Services, says current regulations, established in 1972, are dated and apply to a breed of clinics that is practically extinct. The government pushed for five years to come up with new regulations that are applicable, appropriate and enforceable — especially for the private clinics that have supplanted public ones.
Under the new guidelines, clinics will have to be federally accredited, like hospitals. They will have to prove that they meet accreditation standards every three years, and they must be accredited by summer 2003. Three Atlanta-area clinics, including GPA Treatment, already have been accredited.
"We feel that the accreditation system does carry a degree of enforceability," Reuter says. "Programs that are seriously non-compliant with accreditation standards need to face sanctions. In some case, very, very severe sanctions."
The federal accreditation standards are similar in many ways to current state rules. Clinics will have to have policies in place for admitting patients, drug-testing them, increasing dosages and prescribing take-homes.
But the new standards ensure that the clinics are regularly checked, and they endorse a major philosophical switch that allows methadone to be treated more like traditionally prescribed medications. The most sweeping change is that certain patients will be able to take home 30 doses of methadone. The privilege will be reserved for those who have been on methadone at least two years and who have not failed a drug test in that time.
Reuter says that when he helped develop the new standards, he had to consider the risk that some of those 30 doses will be sold.
"We consulted with the DEA very closely on this provision and they supported it," he says. "There are many, many patients who can responsibly handle medication, who would derive a significant benefit from having a monthly take-home supply."
He says patients who have been stabilized on methadone for years ought not to have to visit the clinic once a week just to pick up medication. That doesn't contribute to their rehabilitation and may actually deter people from staying with the program.
"That was kind of a trade-off," he says of the take-home provision. "But I think it's a reasonable one and a realistic one."
Atlanta Metro director Walters says he would consider the 30-day take-homes for fewer than 10 of his 235 patients.
"I don't like it personally," Walters says. "You have somebody who's been on methadone that long, it's time for them to come off. Why give you that much medication? To me, you just open the door for a chance to make a mistake, to relapse."
Some people close to the addicts themselves are wary, to say the least, of the 30-day take-home idea.
"It's laughable," says one Atlanta drug counselor who deals with recovering heroin and methadone addicts.
Whatever the impact of federal accreditation, methadone will continue to present a danger that no set of regulations can fix: used exactly as intended, it can kill you.
Methadone is slow-acting, which is why patients only need to take it once a day. But because it stays in the body so long, it can start to accumulate after many overlapping doses. A patient can take 100 milligrams today and still be feeling the remnants of yesterday's dose or the dose from two days ago. "This effect may account for the deaths in patients that occurred when methadone was initiated at high doses in methadone maintenance programs," according to a study published in the Western Journal of Medicine.
While the industry marches on, new regulations in tow, some medical professionals are raising concerns about the way methadone is being used in clinics. A commentary in the same Western Journal issue, dated Jan. 1, 2000, asks whether methadone is a miracle cure or an evil substitute. "Simply providing a long acting synthetic opioid to patients who have ... pressures to maintain their addiction cannot be expected to prevent an overdose, the misuse of other drugs, infections and crime," wrote Dr. Robert Hoffman of the New York University School of Medicine.
Dr. Ganiat Jaiyesinmi, a psychiatrist who treats indigent drug abusers at the DeKalb Community Service Board, says methadone treatment — regardless of regulations — is inherently flawed.
"You become dependent on it. You become tolerant to it. You have to take a higher dose so it has the same effect. But when do you stop?" she says. "I just don't advocate it."
On the morning of January 12, 2000, Albert Kenneth Phillips' mother peeked at her dozing son, who'd been lying in bed for most of three days. She had been sick with the flu the week before, so she figured Albert had caught her bug. She woke him and asked if he'd been up earlier that morning to take his medicine. He hadn't, which was unusual.
She got him out of bed. He fell on the floor. He got up and stumbled in search of his shoes. She found him a pair and asked her other son to drive him up the street. They left. A few minutes later she heard a siren.
Phillips, 50, had collapsed outside the methadone clinic he'd visited almost every day for 10 years. He was pronounced dead an hour later at Grady Memorial Hospital.
It was likely a different kind of death from Chris Brackett's, who reportedly died after that second dose of methadone.
The autopsy listed Phillips' cause of death as accidental methadone poisoning, same as Brackett's. But Phillips didn't take methadone on the day he died, at least not at the clinic. Taken a day earlier, the methadone could have crept up on him.
Or it could be that the decade of treatment slowly killed Phillips.
From watching her son's evolving addiction, a mother has her own opinion.
"What I'm thinking it was, kind of like with alcohol poisoning, was that maybe the methadone built up over the years," the 72-year-old woman says. "I don't blame the methadone clinic. But I'm sure it was killing him. If they stay on it so long, I think it's really harmful to all of them."??