I’ve been hesitant to write this article for awhile, as my early training and getting my feet wet in addiction counseling took place in the world of daily dispense. I was afraid it might seem hypocritical to critique a modality of treatment, and job, that kept a roof over my head and paid the bills for the better part of 6 years. However, after two years of working around, and in, a different form of medication assisted treatment I feel like I need to address some of the reasons that we need to seriously consider moving away from the daily dispense model and toward something different.
This article is not intended to be a condemnation of methadone, as I have seen it do wonders for people in addiction when used appropriately. This is not a slight against counselors who choose to continue to work in that field, as some of the best counselors I have met have worked in daily dispense programs for years. This is not an article based on scientific research as to the effectiveness of one medication versus another. What it “IS” is an attempt to discuss a different, and I think in most cases, a better way of doing things based on my personal experience in the field and what I have heard and seen from the patients I continue to work with. I am also not advocating a complete discontinuation of daily dispense programs. I simply think they are completely over utilized, when there are better options available.
These are some of the particular reasons I believe we need to move away from daily dispense or what are wrongly called “Methadone clinics,” for people with opiate addiction issues.
1. Daily Dispense is counter productive to what we are trying to do in order to help people with addiction issues get better.- One of the major goals for people I currently work with is to get them to return to a life of “normalization.” In other words, doing the same things the rest of the world does on daily basis, minus alcohol and drug use. Things like spending time with family, working, being social, having membership in the community at large. What is not normal is going, sometimes daily, to stand in a line to receive medication from a window and then having someone observe you while you take that medication to make sure you took it. Having to refer to yourself by a number instead of a name is not normal. All of those things reinforce the notion in the mind of the person doing it that they are “different.” Name any other disease for which we require people to get treatment in this manner. You can’t, because we don’t. Imagine the outrage if we treated cancer, HIV/AIDS, or even mental health patients like that. The environment itself removes a certain amount of dignity and reinforces the stigma that comes with the disease of addiction.
What is normal is going to a doctor, receiving a prescription, waiting to see that doctor in a waiting room with other patients, and then going about your day. In normal life we do that all the time. Treatment is not supposed to resemble a cattle call. It should resemble the treatment you would receive for any other disease. Which leads me to the next point…
2.Access to actual medical staff is extremely limited- In the world of daily dispense you normally will see a doctor (more likely a nurse practitioner) on your first day of treatment. After that, aside from a nurse or LPN handing you your medication through a window, the only time the patient is going to have access to the medical staff is if the patient screws up big time or they are pregnant. The whole process of getting anything done takes place with the patient filling out paperwork, handing it to a counselor (who is already overloaded with a huge caseload), and then hoping they get it into the medical directors hands on the one day of the week that they come in for a brief “staffing.” A patient has no way to talk to a doctor, or advocate for themselves directly. This again reinforces the notion that they are somehow different then anyone else receiving treatment for a disease.
3.Most daily dispense programs are run by major corporations and the focus is on profit first- Now I understand that many treatment programs are for profit. Most of us are required to collect fees and receive payment in order to keep the doors open. However, nowhere in my experience, have I seen that model more prevalent then in the world of daily dispense. Counselors, at my previous place of employment, while well meaning, were constantly pushed to make “productivity numbers.” This whole idea of productivity was hidden behind a thinly veiled ideology of being “therapeutic.” What we all knew, and the patients certainly understood, was that they were simply looked at as income, and when the counselors through sheer force of will got those productivity numbers (based on attendance at groups or counseling sessions) where they were supposed to be, then the numbers would be raised again. The motive for keeping those numbers up wasn’t a financial one (no bonuses, at least not for line staff) but the fact that as a counselor you knew you were replaceable.
This whole profit and productivity driven environment sets up a “you vs. the patient” mentality. The patient was no longer a person you were supposed to be helping. The patient became the person who was standing in the way of you hitting your goals for the month and you were damn well going to make sure they did what they were supposed to do. The patients that needed extra help, or weren’t as compliant, became the enemy.
When I came to my current job, and suggested some of the methods we had used to “manipulate” patients into doing what we wanted them to do, I got looked at like I had a third eye. People were shocked I even suggested the strategies (including guilt trips, withholding medications, etc…) to motivate patients at our clinic.
4.The turn over rate of counselors creates a culture of abandonment for the patients- At both daily dispense programs I worked at the most common question I got from new patients on my case load was “Are you going to stick around?” Several of them had upwards of a dozen different counselors over the course of a couple years. They had given up on the idea of forming a therapeutic relationship with their counselor, because they knew they could just show up one day and the counselor would be gone with no explanation. The whole idea behind being a counselor is forming a bond with the people you work with and even if they have no one else to go to, they have you. The ultimate goal is to help people be self sufficient, but that requires developing the initial trust needed to start the conversation of how to do that in the first place
In an environment where the counseling staff is absolutely dispensable, underpaid, and overworked, the turnover rate was ridiculous. People not willing to conform, were shown the door. Or feeling completely unappreciated for the work they were doing, the counselors simply left for greener pastures. My last clinic reinforced the whole abandonment ideology. They absolutely did not want patients forming bonds with the counseling staff. We were constantly told “They’re not your patients. They are (name of company left out) patients.” I was told when I put in my notice, upon moving to my current position, that I was not to tell any of my patients I was leaving. When I refused to do that, because it violates the Code of Ethics I am supposed to uphold, specifically as it relates to patient abandonment; and instead talked to them, worked with them to identify counselors with whom they might be a good fit, and help them to get closure, I was handed my last paycheck and escorted from the building by security.
5.They claim to be harm reduction, but they aren’t (really)- My definition of harm reduction is about helping people move forward with the best possible outcome, even if it’s not my personal definition of best. Partially due to federal guidelines that daily dispense programs operate under, and also because there is a vested financial interest in keeping patients coming to the clinic more often, these programs don’t meet my criteria for harm reduction.
Any counselor who works in addiction treatment knows there is a difference between a relapse and a lapse. A lapse is an event, one time use, wrong place at the wrong time, a bad decision. Relapse is a return to active addiction. Lapses are very common in early recovery. A good counselor knows that and finds ways to use the lapse to work with the patient to help them identify ways to avoid them in the future. It’s all about encouragement! A trait which gets obliterated when you have a person in daily dispense, who had been doing well, didn’t have to come to the clinic daily and therefore had less required therapeutic contacts, who had a lapse, and as a result was put back to square one. No half measures here! No working with them to help them stay on track. Drop them back to coming in daily, more treatment, and generally make them feel like all the progress they made was for nothing. It doesn’t matter what a counselor says so much as the actions that follow it. If I tell someone I get it, that it does happen, “Don’t beat yourself up, you’ll do better next time; BUT, by the way your right back where you started in terms of treatment. Sorry,” then anything I said gets devalued by the fact that they lose all progress. Lots of patients, rightly or wrongly, got frustrated over the whole thing, didn’t see a point in trying and just returned to active addiction. You want someone to believe they’re a failure, just treat them like one. It happens all too often in daily dispense programs.
6. It’s a huge “gotcha” culture that encourages addictive behavior and thinking- One of the biggest things we try and teach people to do in recovery is be honest. Well, if honesty gets you snapped back to day one, a loss of all progress, and no chance to advocate for yourself, then why would you tell the truth? Trying to “catch” people doing something became a full time job. Treat people like criminals and they’ll act like that. Treat people with the assumption that they are untrustworthy and they will behave in an untrustworthy manner. This whole notion of “catching people,” further cemented the “us vs. them” mentality that takes place in daily dispense all too often.
As counselors, we’re not supposed to do that! We are supposed to be on the same team. My job as a counselor is to help you succeed, not lie in wait for an opportunity to catch you in a slip and then throw the book at you. No matter how much daily dispense dresses it up (and they did try some positive things like patient advocacy groups) the message of that culture was still very clear; “Just let us catch you messing up and you’ll be sorry.”
7. The staff are treated like minimum wage workers at some fast food chain (probably worse). It was always very clear while working in daily dispense that you were replaceable. All you had to do was look at the constant turnover and you were quite aware there was another warm body out there to take your place. The second clinic I worked at had a culture of tearing down counselors when they left. Certainly no goodbye party or well wishes, or even a thanks for being here. As soon as a counselor left, not only were they torn down on a regular basis by management, who to their faces would tell them what a great job they were doing, but as stated previously, the patients were left feeling abandoned as they had no chance at closure.
When I was ceremoniously escorted out of the last clinic I asked before leaving that someone take over a group I was doing with people who had grown up in traumatic environments. We had been doing a lot of in depth work and many of them were working through some issues, that while healing, left them vulnerable. I was told that it would be handled. What I came to find out later from a coworker was that the clinical supervisor (who had been highly encouraging in starting this group) walked into the group the next week, told them it was canceled and that she had never approved of the idea of the group to begin with. Several of the patients from that group tried messaging me through social media, but due to ethical guidelines I was unable to respond to them (two wrongs don’t make a right). One of my former patients came to our program and when they saw me said, “We didn’t know where you went. No one would tell us anything. I lot of people were mad that they didn’t get to say goodbye.” My explaining that “they wouldn’t let me” felt empty and it’s taken a while to get over not being able to have that closure with several patients that probably could have used it. What’s sad is that with the few patients I was able to talk to before leaving, my message was always the same, “You’re going to be OKAY, you’ll get a great counselor, and no one is abandoning you.” The company simply didn’t trust their employees enough to do the right thing along with their need to have an almost obsessive control of everything that went on.
With all of this in place it’s no wonder that daily dispense programs can’t keep counselors. The ones they do have (in general) are fresh out of school and have little experience. Combine that with the fact that the world of daily dispense is highly stressful, and you have a huge burnout rate. I once heard a government representative for the state mental health and addiction services say, “Working at a methadone clinic is like counseling in dog years.” He wasn’t too far off.
8. I’ve seen more success and healing in two years of working in an outpatient, medical office based environment, than I did in six years of working in daily dispense- This all comes back to the adage that if you treat people like criminals, children, etc…they will behave that way. I have a group of patients here now who all came from the world of daily dispense, every last one of them talks about how much better it is here. How much more success they’ve had. There’s a reason for that, and it’s almost all about the way they are treated.
The other piece of the equation is environment. Most daily dispense programs did their best to have a clean, peaceful, professional looking environment, but as the saying goes, “You can put lipstick and a dress on a pig, take it to prom….and it’s still a pig.” No one who went there for treatment had any illusions about where they were. Patients who walk into an outpatient program based in medical offices can tell they’re in a medical office. They are not standing in line for anything, they’re waiting in a lobby to see a doctor or a counselor. They don’t go to a window to have someone hand them medication and then watch to make sure they take it. They’re given a prescription like an adult and they go fill it.
Going back to they way patients are treated, which is very different from daily dispense, is that if they have a slip, they aren’t knocked back to square one. Patients are given an opportunity to prove they can do better. Honesty is encouraged and when people figure out that we’re not about punishment, all the sudden they get more honest. One of the biggest messages I try and get across in new patient orientation is that “If you have a slip, tell us! We can’t help you if we don’t know. Don’t fake your UA, lie about it, or avoid coming in, because you are afraid your going to get knocked back to square one or kicked out. WE WILL NOT KICK YOU OUT FOR A SLIP!” Even after that little speech I still have people who lie about it, and their almost exclusively from daily dispense programs where they learned the lesson that honesty gets you nothing. It’s a hard habit to break.
Normally this is the part where I tell you all about our program and why you should come to us. I do believe that our program is amazing, I wouldn’t work here if I didn’t. But there are also other programs who operate along the same lines as us, staffed with doctors and clinicians who really do get it, and work to help people be successful. Those programs and ours do that by not only allowing people access to a doctor (it is a disease after all), and giving prescriptions instead of medication through a window, but most importantly treating people with addiction issues like human beings. No one here has a number they need to memorize. You’re “Fred,” or “Sarah,” or whoever. We realize there’s no shortage of people who need our help, so if you aren’t ready to do what you need to do to be successful, rather than try and force you or throw negative consequences at you, we’ll just simply let you find another place to get the help you need. No hard feelings.
Daily dispense programs aren’t going anywhere, anytime soon. At those clinics are many amazing people working under a set of conditions that often times ties their hands and prevents them from doing what they know is right. Some people do need the constant structure that daily dispense provides in order to be successful, but not at anywhere near the numbers that are currently being treated there.
If you or a loved one has an issues with addiction, give us a call. The most important thing is that you or they get help. My hope is that in reading this more people become aware that the days of “one kind of medication assisted treatment” for people with opiate issues are over. We’re having more success being less restrictive, and hope that we can help you be successful too.