By Julia Landau
California Health Report
Lance Robinson wasn’t a very good criminal. He once tried to rob a Radio Shack, his hand gesturing under his jacket like a gun, but he couldn’t even get the clerk to open the drawer. Police arrested him a few blocks away. The most recent felony was when he tried to cash a fake check. Security guards surrounded him while he was still at the teller’s window.
“That was the worst point, in the mid-90s,” Robinson said. “I was really off into my addiction then.”
For Robinson, methadone is essential to staying heroin-free. But the process of getting it—as an uninsured and unemployed man—tested his dedication to live a drug-free life.
Like millions of other Americans, Robinson is too young, able-bodied, or childless to qualify for assistance. A substance abuse disorder has to be accompanied by “severe” mental illness to qualify as a disability covered under Medi-Cal, the state’s Medicaid program.
Robinson got into treatment through a “free slot”—a kind of methadone lottery, where the prize is six months of free treatment. Call an 800-number on Tuesday at 12:30; the first caller to get through gets on the list. A yearly grant from Alameda County pays for roughly twelve free slots a year. Slots are coveted and the line is terminally busy.
Robinson’s access to methadone amounted to random luck.
He sat in the waiting room of the HAART methadone clinic in East Oakland earlier this year to see a counselor. At 9 a.m., dosing time, clients flowed in. Most of the clinic’s patients are on Medi-Cal, which covers methadone for people who show they’ve tried to quit without medication.
If the health reform law is successful in expanding Medicaid to people like Robinson, his chances at addiction treatment will also improve. The Affordable Care Act states that mental health services will be reimbursed on par with medical procedures. Analysts say this will free up providers to see more addiction patients, and treatment services will increase in turn. But methadone’s role in this equation is unclear.
Long considered the “gold standard” of opiate addiction treatment, methadone treatment is routine, but it is also stigmatized. Federally sanctioned clinics dispense the medication, but the program is segregated from all other medical care.
While counseling and group therapy—usually based on a 12-step program—are considered standard addiction treatment, methadone is not readily available in such programs. Only stand-alone clinics can dispense it. And most private insurers don’t cover methadone, a fact that undercuts its function as a feature of basic medical care.
Out-of-pocket, methadone costs $280 to $380 a month at the clinic. For some, it’s easier to get illegally—they can buy it from people who need cash more than they need methadone. Selling doses on the street is a reliable hustle.
Vincent Dole, a doctor who led the development of methadone treatment in the 1960s, observed that opiate addiction was uniquely intractable; without a pharmaceutical aid, he concluded, it was extremely difficult for patients to continue heroin-free for an extended period of time.
Methadone is known medically as a full opioid agonist—it supplies the brain’s opiate receptors with a “reward” effect, but tapers rather than rushes into the brain.* People who’ve used it describe methadone’s effect as muted in contrast to heroin and fast-acting painkillers like Vicodin.
There are two treatment plans for methadone. Detoxification, usually for a period of 21 days, uses methadone to wean a patient from heroin while avoiding withdrawal sickness. Methadone maintenance is a long-term treatment plan. Maintenance patients take a daily dose for as long as they feel they need it, much like an SSRI for depression. Either way, most methadone patients must fill their prescriptions daily.
Studies show that if they discontinue methadone after a short time, close to 80 percent of opiate addicts will relapse to heroin within two years. Though still called a controversial treatment by many in the medical profession, the National Institutes of Health declared that coverage for methadone should be a required benefit for both public and private insurance.
Medi-Cal covers long-term treatment if patients present an “annual justification” for continuation. According to Sage Loats, program director of HAART East Oakland, that’s not difficult. “There’s enough science to back up its efficacy,” he said. “We’re able to show the client’s improvements: fewer arrests, children out of foster care, employment, housing.”
In terms of overall economic burden, methadone is cheap compared to heroin, which carries more social and medical complications. Methadone, by decreasing overdoses, infections, and HIV and hepatitis C transmission, has proven cost-effective in health care. And numerous studies have shown that methadone treatment costs taxpayers a fraction of what heroin use eventually does; without methadone, drug users had more hospital stays and short-term rehabilitation services—“detoxes”—and medical emergencies. Patients on methadone had fewer police run-ins, higher employment, and lower mortality.
Robinson has never overdosed, he said, but he’s called ambulances for friends. “They’ll pay for you to go to the E.R. any night,” Robinson said. “But they won’t pay for you to have methadone.”
Savannah O’Neill, a 22-year-old counselor-in-training, fields the free slot callers. The phone starts ringing at 12:30 sharp and doesn’t stop.
“It isn’t ideal,” O’Neill said. “Sometimes I have to tell them we don’t even have any free slots this week.” But Robinson, she said, was persistent. “Most people can’t hold on to that determination. That desire, getting through the door, is a key moment.”
*Note. An earlier version of this story described methadone as a “partial agonist.” The correct medical term is “full opioid agonist.”
