Breadman came to me recently with a harrowing story. Aged 43, he lives in South Philadelphia and acquired his nickname (which I’ll use to protect him despite his saying that I could use his real name) because he used to drive a bread truck. He seems to know everyone in the drug-using community of South Philly, which has a fatal overdose rate second only to Kensington among Philadelphia neighborhoods (though Kensington’s more visible drug use draws far more media attention).
According to Breadman, he had recently missed three days at his methadone clinic. He had been busy helping to tend to his sick mother, who is frequently in and out of the hospital. Afterwards, he returned to his clinic (officially an Opioid Treatment Program, or OTP) for reinstatement.
Under that OTP’s policy, if you miss three days of attendance or longer, you are no longer considered a patient and need to reapply. In most cases, this just means a wasted day filling out paperwork that the clinic already has in a file somewhere. For some it means missing work, with implications for job security.
For Breadman, the stakes turned out to be higher. After an hour-long, one-on-one therapy session with his OTP counselor, he was handed a form. But instead of confirming his reinstatement, the form notified him that he would not be able to return to his clinic until he got a letter from his private doctor.
This letter would need to assure Breadman’s counselor—who, I assure you, is not a psychiatrist—that Breadman would no longer be prescribed the Adderall that he takes for his attention-deficit hyperactivity disorder (ADHD).
Breadman felt it was important to tell me that as well as taking Adderall, he had sold some pills to help support himself. “I mean, I want to make sure you have the whole story,” he said. “I wasn’t totally innocent.”
But his counselor didn’t know that.
What the OTP did know—or should have—is that there are no contraindications between methadone and amphetamine salts, that no federal or state guidelines prohibit their concurrent use, and that Breadman had a legitimate prescription for it. And that’s all that should have mattered.
Instead, Breadman, who was taking 140 mg of methadone a day, was forced to choose between two medications prescribed by two different doctors. As such, he represents the collateral damage of a new, knee-jerk Adderall policy that he said was adopted by his OTP.
He said they had no problem with his Adderall use previously. However, according to Breadman, another client at the clinic had recently been told by her counselor to stop taking the drug or face consequences. After she complained loudly about the hypocrisy of other patients still being allowed to take the medicine, they nixed it for everyone.
The policy immediately sent Breadman—who chose to keep up his Adderall prescription—back to street heroin.
Breadman’s former clinic did not respond to Filter’s request for comment by publication time.
The policy won’t stop illicit trade in Adderall. In fact, during the Adderall shortage I recently described for Filter, the drug was more readily available on several popular corners in Kensington than in licensed pharmacies, though the price went as high as $12 for a single 20 mg pill.
What the policy did do was to immediately send Breadman—who chose to keep up his Adderall prescription despite now suffering acute withdrawal from methadone—back to street heroin. Just about all of Philadelphia’s heroin, as I have reported for Filter, contains fentanyl.
The clinic didn’t have an obligation to wean him down off of methadone, because after missing three days of attendance he was technically no longer their problem.
The OTP system, which hasn’t faced any significant reforms in more than two decades, needs a lot of work, and some would say that it shouldn’t exist in anything like its current form. One failing is the sheer power that clinics wield over patients under a siloed system.
Clients can shop around for a better provider (there are about half a dozen well known clinics in Philly) but the best have waiting lists, and transfer requires paperwork from the transferring clinic. Depending upon your standing with your counselor, that could take days or weeks.
In this context, a pervasive attitude among many operators that clients are by nature irresponsible, at best, or manipulative, at worst—an attitude independently described to me by many sources in Philly and beyond—is left unchecked.
Under a special client’s bill of rights, a formal grievance process exists for addressing issues like Breadman’s, but I’ve never spoken to anyone who pursued the process. Over the past few months alone, three methadone patients known to me have walked out of their clinic—at least two due to interpersonal conflicts with counselors or other staff.
Many patients say they seek help in part to feel “normal” again. But the way they’re often treated might as well be designed to achieve the opposite.
Federally, OTPs are regulated by the Drug Enforcement Administration—and what business the DEA has overseeing a health program is anybody’s guess. But much of the problem is not that federal guidelines are too stringent, it’s that they are misinterpreted or ignored.
More unnecessary regulation is imposed by states and counties. And individual OTPs are authorized to create their own restrictive policies that often infantilize and degrade clients who have already faced years of stigma and criminalization.
Many patients say they seek help in part to feel “normal” again. But the way they’re often treated might as well be designed to achieve the opposite. Rules and restrictions imposed frequently include limited windows of time to get doses, or counseling sessions whether or not you want them. Some clinics also require, for example, an extra annual visit to have a nurse check the results of their annual tuberculosis tine test.
Medications besides Adderall are also impacted by many OTPs’ policies. Many people, for example, avoid trying methadone treatment because they believe they’ll be required to stop taking their anti-anxiety medication. And numerous clinics do have anti-benzodiazepine policies—even though federal rules don’t require this if benzos are taken as prescribed (a reasonable caveat given the potential dangers of mixing).
Of the half-dozen clinics in Philadelphia that I’m familiar with, just one allows patients to continue taking prescribed benzodiazepines.
Withholding the methadone itself, or the threat of it, is frequently used as leverage to enforce rules. Numerous methadone patients have told me of their doses being withheld for minor infractions, or to “incentivize” something as routine as an annual physical.
The rationale, presumably, is that only the threat of withdrawal will keep a person with opioid disorder playing ball. If we medicate them, they’ll have no incentive to cooperate, I imagine the thinking goes.
But what kind of message does this coercion send to people who are voluntarily attempting to lead different lives?
The implication that people with opioid use disorder aren’t responsible enough to deserve choices over their own health and lives perpetuates anti-methadone stigma and can become self-fulfilling.
Having heard about these conditions, most heroin or fentanyl users I speak with about methadone fight tooth-and-nail against going to a clinic. Restrictive policies—particularly those regarding take-home doses of methadone, which studies have associated with improved outcomes and fewer hospitalizations—are most often cited, as well as travel time and time-worn street myths, like the misconception that methadone rots your teeth.
“I have to take two buses and the subway to get to my clinic and we don’t even get take-homes on holidays,” one methadone patient told me for a story about rehab failures I wrote for Daily Beast.
“I watched my daughter open presents on Christmas morning and then had to leave her at home with my mother to get to the clinic and dose,” another methadone patient in Philadelphia said.
Under federal guidelines, a patient in “good standing” is entitled to 28 days of take-home doses, or more if extenuating circumstances apply.
Yet the number of doses that patients who “earn” them actually get to take home varies dramatically. Some states follow the federal guidelines, while others apply their own, stricter rules. Pennsylvania, for example, caps take-home doses at six. And yet again, individual clinics can make their own policies.
Patients subjected to this degree of control are surely being denied the opportunity to “recover” in any holistic sense.
Methadone may keep people from using dangerously adulterated heroin, and the evidence unequivocally supports a big reduction in mortality for people with opioid use disorder. So why set up these extra barriers to access?
Beyond simple stigma and disdain for clients, many proponents of stringent policies would likely cite the risk of diversion as their rationale for keeping a rein on, say, take-home doses. In fact, periodic spikes in methadone-involved fatalities more often occur within the chronic pain community.)
Whatever the thinking, patients subjected to this degree of control are surely being denied the opportunity to “recover” in any holistic sense—to exercise independent judgment, to make a living or build a future by keeping a job with unconventional hours, for example, or to strengthen critical relationships by traveling to visit loved ones without having to organize daily guest-dosing at a strange clinic.
Those patients who are lucky enough to get take-homes can lose the “privilege” at any time for insufficient reason–like testing positive for THC, which is not even included on the list of substances that the Substance Abuse and Mental Health Services Administration (SAMHSA) recommends testing for. (In fact, marijuana shows positive potential for people with opioid use disorder.)
Methadone remains the single most effective treatment for opioid use disorder. However, without major reforms–including requiring clinics that receive Medicaid dollars to unify their policies to adhere to federal guidelines–this inexpensive lifesaver will remain massively under-utilized.
“I’m a good dude, believe me I hate this life, I really do. I’m gonna get out.”
The last time I saw Breadman, who I have not known very long, was a few nights ago when I went to his house to shoot the photo accompanying this piece. “I swear I thought you were a cop,” he laughed.
Then he said something I’ve heard more times than I can count while reporting on the overdose crisis. “Chris, I’m a good dude, believe me I hate this life, I really do. I’m gonna get out.”
Imagine if he could just rely on his local pharmacist for the combination of medications he needs.
Photo of Breadman near his South Philadelphia home by Christopher Moraff.