Treatment and recovery centers tend to be very moralizing places, and you’d think a lot of the people who work at them would approve of someone wanting to stop using all opioids including prescribed methadone. But mostly these providers don’t want to be involved with methadone at all, even to get someone off of it. The ones inclined to help still haven’t known how, because they’ve never heard of someone doing it this way. But as much bureaucracy and judgment as I’ve voluntarily subjected myself to in the rehab system, it’s worth it to bypass the methadone clinic system.

In New Jersey at least, the treatment facilities that take Medicaid will start you at their short-term programs—usually 28 to 35 days. Or 21 to 28 days, if you spent your first week going through their detox. A lot of the ones I call are non-starters because they don’t provide methadone at all, or they’ll only work with you if your dose is 40 mg less. A lot of the places that do provide methadone are still non-starters, because they make it clear that whatever dose I come in at, they’re going to keep me there.

First I write a “sick call,” and within the next three to five days I see a provider. That’s when I explain my plan.

The facilities I’ve stayed at so far have been the ones that told me I’d be able to manage my dose myself, higher or lower, no problem. Of course, sometimes that would change once I was done signing the paperwork. But either way, for the minority of patients on methadone these facilities will run a little in-house mini clinic. Line up every morning for your cup of Methadose, drink it in front of them, drink a cup of water, speak some words, drink another cup of water, say some more words until they trust that you’ve swallowed it. But generally they’re less inclined to make your life miserable than their counterparts out in the real world.

First I write a “sick call” slip saying I want to adjust my dose, and within the next three to five days I see a provider. That’s when I explain my plan—every seven to 10 days they can lower the dose by up to 10 mg, so I tell them I want to drop 10 mg per week.

If all goes well then a month later I’m discharged into their longer-term program, which lasts three to four months. Or if by the end of that month I hate the place, as I often do, I make a lateral move to another facility’s short-term program. Or sometimes I can go straight into their long-term. 

After that the next stop on the conveyor belt after is a halfway house, but I usually jump off before then. Unless I haven’t figured out the next roof over my head, halfway houses don’t make sense for me—no methadone dispensed on the premises. They just send you out to a regular clinic every morning on your own, which is what I’m in rehab to avoid in the first place. So once I’m discharged from a long-term program, I go to the short-term at a new facility and start over.

Like homeless shelters, these places share a lot of common elements with jails and prisons.

For my purposes at least, the short programs are too short. The long programs are too cult-y. All of them are too much like jail.

Like homeless shelters, these facilities share a lot of common elements with jails and prisons—more than just the urine testing and bunk beds and general surveillance. At one place they didn’t even tell me that at night they locked everyone inside the building. Had to get myself kicked out of that one in order to leave.

None of them let you have a cell phone during your stay. The reason is always that they don’t want anyone making a private phone call and then heading out to buy drugs. One place kicked me out when they found my phone, which is the kind of thing that makes a person head out to buy drugs.

Vapes aren’t allowed, for basically the same reason; they just assume you’ve put marijuana in there. In my experience about the Medicaid facilities are about 50/50 in terms of whether their policies allow residents to have cigarettes, but I’ve never heard of any that will allow you to vape. The only residential facilities I’ve heard where you can have vapes are the “sober living” houses, which unlike the halfway houses are privately run and not tied to Medicaid. If someone’s paying out of pocket, no one cares what they do.

Most people I go through rehab with aren’t there because it was their idea. Sometimes it’s because their family pressured them, but a lot of the time it’s because of drug court. Over time, the more I’ve talked to other patients the more I’ve noticed that the ones who come in by way of drug courts get a lot more leeway than the rest of us. The general feeling is that the people who run these facilities want to stay on the good side of judges who refer people into their program, so they’re not in as much of a rush to do an administrative discharge over a cell phone.

Unlimited Xanax and Klonopin helped me drop from 170 mg to 90 mg in under six weeks.

I first got on methadone in 2009 and stayed on it until 2014. This was right before New Jersey prescription drug monitoring programs expanded their reach, so I had a dozen prescribers at a time writing me whatever I could pay for in cash. Unlimited Xanax and Klonopin helped me drop my methadone from 170 mg down to 90 mg in under six weeks.

I wasn’t in any residential program at the time. By the end I wasn’t even in a methadone program—I’d lost my take-homes due to a “community violation” (got arrested) and since I happened to have a stockpile of take-home bottles at home and was super pissed at the program, I figured I’d do the last leg on my own.

It’s hard to imagine the stars ever aligning quite like this again, but I actually pulled together my own case management team. I had a primary care physician, a talk therapist and an addiction specialist who were all in communication with each other and would check in with me on conference calls. When I got my methadone down to 30 mg, the addiction specialist prescribed me a 10-day supply of the 30 mg roxies (AKA oxycodone) to bridge me through the transition to bupe.

The roxies only lasted a couple of days, but that was okay. Since I was doing this unsupervised, I could just keep going to get the benzodiazepines that saw me through the rest of the way.

And it worked. I got off methadone. I spent the next three years with a 24 mg prescription of Subutex, which I never had to take in full if I wanted to take less. Around 2019 I started screwing around with street supply again, which had become fentanyl-based in the intervening time. But in between I had a great year or so of just … being normal. Being treated like I belonged in the world.

A lot of programs won’t even help you move from methadone to bupe, let alone prescribe Xanax along the way; too much paperwork. So access to benzos—or to whatever actually works for you, in whatever amounts actually work for you—is the upside of doing this on your own. It’s also the downside of doing this on your own, you’re inevitably putting yourself back in the same environments you’re trying to get away from.

I hold no ill will toward methadone. It served its purpose.

Even at 60 mg, I’m feeling the nod much more deeply than I want to. But I hold no ill will toward methadone. It served its purpose. It kept me alive through the shitshow of the early pandemic, through neighborhood sellers trying to figure out their xylezine ratios. I hold a lot of ill will toward the clinic system. 

I don’t know anyone else whose methadone taper took anywhere near this much time. I didn’t realize I’d be doing it this long when I started, but of course it hasn’t been a linear process. I’d often lose a lot of progress during the transition from one facility to the next. Two steps forward, one step back, that kind of thing.

But I feel good about what I’m doing. It’s been a winding path, but I’ve managed to avoid setting foot in an actual clinic, which is saying something. And I’ve learned a lot about myself over the past year or two. I’ve spent most of my rehab time journaling, as there isn’t much else to do in the Medicaid places. You get what you pay for, which is nothing. And a much better deal than you’ll get from the clinic system.

Image via Helen Redmond and Marilena Marchetti

The post Tapering Off Methadone Without a Clinic, in Just Two Years and 13 Rehabs appeared first on Filter.

Georgia Medicaid currently covers people living with Acquired Immunodeficiency Syndrome (AIDS), but not those living with the human immunodeficiency virus (HIV), which can lead to AIDS—especially without care. Though HIV cannot be cured, it can be managed with antiretroviral medications to prevent the virus from causing AIDS or being transmitted to others. On March 6, the deadline by which current bills had to move out of their original chamber, legislators chose not to advance the bipartisan House Bill 226, which would have made such medications more affordable.

“We have to listen to Georgians, and our citizens impacted by HIV are asking for this legislation,” Representative Solomon Adesanya, one of the bill’s sponsors, told Filter. “Lawmakers too often turn a deaf ear to those who need resources the most. This is especially true when the issue affects a marginalized community … we need to show our constituents with HIV that we are listening to them.”

More than 50,000 people in Georgia are currently living with HIV, which disproportionately impacts people in the South. Approximately 71 percent of Georgians with HIV are Black.

“This bill will reduce health disparities in this state, especially [among] Black people,” Christopher Reed, policy and advocacy program manager at Atlanta-based HIV advocacy group SisterLove Inc., told Filter. It would be “a step in the right direction to full Medicaid expansion.”

“This bill is not only morally imperative, it is an investment in our state.”

At least 1.2 million people in Georgia currently do not have health insurance, unable to afford private coverage and ineligible for Medicaid. The state is set to expand Medicaid in July 2023, but only partially. Republican Governor Brian Kemp has long fought against even limited expansion, despite the fact that Medicaid access would lower both human and economic costs.

“This bill is not only morally imperative, it is an investment in our state,” Rep. Adesanya said.

Full expansion would make health insurance accessible to about 600,000 uninsured people in Georgia. This would include many of the approximately 12,500 people enrolled in the AIDS Drug Assistance Program and Ryan White HIV/AIDS Program, which provide limited services for those without insurance. House Bill 226 would be federally funded, and so would ease the burden on these programs without diverting any resources away from them.

Though the bill will not become law in 2023, the sponsors intend to reintroduce it in future legislative sessions. But they’re braced for Gov. Kemp to continue to oppose Medicaid expansion, even in limited forms. 

“We should all be concerned about that prospect,” Adesanya said. “Though this bill is bipartisan … still some Republicans won’t support it. On our side, we are lucky to have an inclusive group of legislators who are willing to bring attention to this bill, and I know that we will continue the fight for this bill until it is signed into law.”

Photograph via United States Department of Health and Human Services

The post Amid Rising Crisis, Georgia Denies Medicaid Expansion to HIV Patients appeared first on Filter.

Hep C, a curable liver infection that is commonly transmitted through shared needle use, currently affects more than 30,000 people in Alabama. Yet the state “denies [hep C] treatment to otherwise eligible Medicaid enrollees who cannot prove they did not use drugs or alcohol within the last six months.” Prospective patients must also agree to not use drugs, including alcohol, during the treatment. Out of pocket, a standard regimen of hep C medication costs tens of thousands of dollars.

Use of state-banned drugs like heroin, fentanyl, cocaine and methamphetamine does not interfere with the efficacy of the medication. The only substance of concern is alcohol, since hep C affects the liver and the additional strain from alcohol can make it more difficult for the medication to do its job. But the public health-based approach is to not withhold lifesaving treatment just because someone consumes alcohol; rather, patients are advised to abstain for the duration of treatment—typically eight to 12 weeks—if possible, and if not to just reduce their drinking as best they can.

Alabama Medicaid patients found to be using drugs, including alcohol, while taking the medication face their treatment being discontinued. But it is unclear how Alabama Medicaid would monitor this, or whether drug-testing would be involved. Neither Alabama Medicaid nor the DOJ responded to Filter’s request for comment.

The policy could not only prevent some patients from curing their hep c now, but prevent them from ever being cured.

Discontinuing hep C treatment partway through can result in a patient’s system developing a resistance to the medication, meaning that this policy could not only prevent some patients from being cured during the current attempt, but prevent them from ever being cured.

“On an individual level, for a single person seeking hep C treatment, it means the difference between being cured of hepatitis C and continuing to live with this very dangerous illness that, in many cases, can lead to liver scarring, liver cancer and even death,” Suzanne Davies, an attorney and CHLPI clinical fellow, told Filter.

Alabama is not alone in maintaining these prohibitive requirements around hep C medication. “A lot of state Medicaid organizations put a lot of restrictions into their policies,” Davies said, prompted by “what they perceived to be the high cost of treating people.”

If these states “made an effort to do the opposite of what they are doing,” she continued, “then that would have a really big public health impact in not just curing individual people, but helping to make sure that [hep C] doesn’t continue to spread.”

Still, Davies added that Alabama’s sobriety clause is something of a hold-over from an earlier time, as in recent years many states have removed these policies.

While CHLPI and AIDS Alabama could have started a legal case against Alabama Medicaid—and did against Texas Medicaid’s practices in 2021—they decided to go through the DOJ because it is the federal entity tasked with enforcing Title II of the Americans with Disabilities Act, which oversees anti-discrimination among state or local government entities like Medicaid.

“In this case, looking at the past couple of years, we have noticed that the [DOJ] has been involved in several settlements with public entities and private entities involving issues regarding substance use disorder,” Davies said. “People had reported discrimination against them based on their substance use, and the [DOJ] had settled cases with some of those entities.”

Petitioning DOJ to investigate state Medicaid systems can be an effective way of combatting Title II discrimination. In an administrative complaint of this kind, one party submits information about what happened for the DOJ to evaluate, and then decide whether to begin its own investigation into the matter.

DOJ taking up the complaint “would be such a big step in the right direction,” Morgan Farrington, founder of Alabama-based harm reduction organization GoodWorks, told Filter.

But the timeline on which DOJ will respond to the complaint is uncertain. It “could be a fast turnaround,” Davies said, “or it could take years.”

Photograph via Centers for Disease Control and Prevention

The post Alabama Medicaid Under Fire for Denying Drug Users Hep C Cure appeared first on Filter.

“I’ve listened with a broken heart to your stories of loss from opioid abuse,” Hochul said. “Sadly, similar to what happened to my nephew.”

Hochul’s nephew died after he was unable to access medication for opioid use disorder (MOUD) because of the high barriers facing people on Medicaid.

As governor, Hochul will have the authority to sign into law Senate Bill 649A, which would prohibit Medicaid from requiring prior authorization for people to access MOUD. Prior authorizations allow insurance companies to delay your prescriptions while they review them, and deny access to anything they decide isn’t medically necessary.

The bill has already passed through the Assembly and Senate. All that remains is a governor’s signature.

Hochul signing S649A would be a lifesaving intervention for low-income New Yorkers—and a repudiation of her predecessor, who notoriously vetoed that same legislation in January 2020, despite signing a separate bill that removed prior authorization for New Yorkers with private insurance.

Hochul did not elaborate on overdose crisis, nor mention any of the state’s other harm reduction agenda items. Those include expanding of MOUD for incarcerated people, decriminalizing syringes for drug use or the fate of the state’s long-awaited safe consumption sites, which Cuomo has stonewalled for the past three years.

Her mention of her nephew and the circumstances of his death may have been intended only as a general acknowledgment of the opioid-involved overdose crisis. But in a speech that lasted only around 10 minutes and did not reference a host of New York’s most urgent policy crises, it’s notable that Hochul chose to reference one for which a bill now waits at her desk.

Photograph via New York State

The post Hochul Inaugural Address Hints at Potential Harm Reduction Agenda appeared first on Filter.

In Kentucky, voters elected Democratic Attorney General Andy Beshear as their new Governor with 49.2 percent of the vote. Incumbent Republican Governor Matt Bevin has not conceded yet.

In Mississippi, voters elected Republican Lieutenant Governor Tate Reeves as their new Governor with 52.2 percent of the vote.

The results are significant for their effects on whether or not upwards of a million people in either state will have access to a state Medicaid program implemented through the Affordable Care Act (ACA). As part of the ACA signed by President Barack Obama in 2010, adults with incomes up to 138 percent of the federal poverty level are eligible for Medicaid health insurance.

But due to a 2012 US Supreme Court ruling, states have to opt in to what’s called the Medicaid expansion. The federal government pays for the bulk of the program’s cost for each state, covering 90 percent as of 2020 and in the future. State governments pay for the remaining 10 percent. Because now 31 states and the District of Columbia have expanded Medicaid, over 13 million Americans have become enrolled in those states between 2013 and 2019.

In other important election news, Democrats are projected to flip both chambers of the state legislature in Virginia, giving them complete control of Virginia for the first time in over 20 years. These results will also have significant consequences for healthcare access in Virginia, allowing the state to strengthen gains it has made after enrolling over 325,000 people through its Medicaid expansion.

Where do Kentucky and Mississippi stand on Medicaid expansion?

Kentucky and Mississippi are in different places on Medicaid expansion. Former Kentucky Governor Steve Beshear (Governor-Elect Andy’s father) successfully implemented Medicaid expansion in 2013, bringing nearly a half million Kentuckians into the program. That number represented an increase in enrollment of over 99 percent.

But former Governor Beshear’s successor Governor Bevin has tried to undermine the program by implementing controversial work requirements that may remove hundreds of thousands from the Medicaid program. A US District Court judge for the District of Columbia blocked this policy, prompting Bevin and even President Trump to appeal the decision.

Governor-Elect Beshear ran on protecting the state’s Medicaid program, as well as other healthcare issues like fighting the federal court ruling that jeopardizes health care coverage for people with pre-existing conditions.

But the fight in Mississippi was fought over different lines. Mississippi is one of 14 states that have refused to expand Medicaid to their citizens. Both candidates sparred on this issue during the election.

“I am opposed to Obamacare expansion in Mississippi. I am opposed to Obamacare expansion in Mississippi. I am opposed to Obamacare expansion in Mississippi,” said Lt. Governor Reeves in January. Meanwhile, AG Hood’s campaign stated, “In Mississippi, around 300,000 adults would benefit from reforming Medicaid—nearly 100,000 of those individuals live in poverty without health insurance.”

What Do These Results Mean for People Who Use Drugs?

This whole issue has significant impact for Kentuckians and Mississippians who use drugs or have substance use disorders. Lack of healthcare access often prevents, for example, people with opioid use disorder receiving a medication like buprenorphine. But it also means they lack simple primary care and treatment for physical and mental illnesses, including for infectious diseases like HIV/AIDS and hepatitis C caused by injection drug use.

The Kaiser Family Foundation found in 2019 that 18 percent of American adults under age 65 with an opioid use disorder are uninsured. This population is more likely to have low incomes, report being in fair or poor health, have a mental illness, and have an unmet need for drug treatment. Not insignificant proportions of this population also suffer a disability and a chronic condition or cancer.

Kentucky has a particularly severe fatal overdose crisis. According to the CDC, Kentucky has among the highest overdose death rates in the US at 37.2 per 100,000 residents.  This is well above the national average of 21.7 per 100,000.

And its overdose deaths involving opioids, at 27.9 per 100,000 in 2017, are nearly double the national average of 14.6 per 100,000, NIDA numbers show. It also has among the highest rates of opioid prescriptions in the US. In addition, over 6,600 people live with HIV diagnoses, and 43,000 people live with hepatitis C.

As for Mississippi, it has a drug overdose death rate of 12.2 per 100,000 (2017), below the national average. But that has more than doubled from its drug death rate in 1999, and roughly doubled compared to the national drug death rate in 1999. In a state of less than 3 million people, over 9,200 people live with an HIV diagnosis, and 23,300 people live with hepatitis C.

For Kentucky Governor-Elect Beshear, he will likely still face challenges in implementing progressive healthcare policy given Republican control of both state legislative chambers. And Mississippi Governor-Elect Reeves will likely face little pressure to do the same, as his party now controls all of the state government.

Any reform in these states, for better or worse, will have significant consequences for people who use drugs and experience difficult healthcare barriers. But if the new governors wish to substantially reduce their historically high rates of drug overdose deaths, they should be thinking about expanding healthcare access to their most marginalized constituents.

Image of Kentucky Governor-elect Andy Beshear, from Andy Beshear via Facebook.

The post What Kentucky, Mississippi Gubernatorial Results May Mean for Medicaid appeared first on Filter.