Clinic's troubles a setback for addicts

On July 21, addiction specialist Marc Shinderman was found guilty of 58 crimes connected with his practice of forging another doctor's name and federal registration number on prescriptions for patients of his Westbrook methadone clinic. He now faces a prison sentence, and his clinic, CAP Quality Care Inc., is the subject of a federal civil action.

That threatens the future of his clinic, which currently serves 488 clients and runs a waiting list, and could have a chilling effect on the creation of new clinics in the state, said Kim Johnson, director of the state Office of Substance Abuse.

"I'm worried about losing that clinic," Johnson said. "I'm worried that we will not be able to find physicians to serve as medical directors. I'm worried that doctors will feel targeted if they work with these clients."

Addicts use methadone to stabilize their need for opiates by taking daily doses of the drug, which also is habit-forming. Methadone always has been controversial with the public, but treatment providers say it should be used more to combat a worsening drug problem.

Johnson and others believe Shinderman was targeted by law enforcement in the wake of a record number of overdose deaths in 2002, the first year of his clinic's operation. But Johnson points out that, although some of the deaths were linked to prescribed methadone that was diverted outside the clinic, the victims were rarely patients. In some cases, they were on waiting lists for methadone treatment.

Law enforcement officials say they were only following leads when the overdose investigation led them to Shinderman. He remains the only methadone provider who has been charged criminally or civilly in Maine.

"People were dying on the streets of Portland and methadone was associated with those deaths," said U.S. Attorney for Maine Paula Silsby. "That does not mean we are targeting methadone."

Opiate addiction remains Maine's most deadly drug problem. Last year, 178 people died of drug overdoses, a record for Maine, with the total exceeding highway fatalities as a cause of death for the first time.

Maine has methadone clinics in Bangor, Calais and Waterville, and two in Greater Portland - CAP Quality Care in Westbrook and Discovery House in South Portland. A new clinic in Rockland has received permits, after the owners sued the city in federal court.

Johnson said she would like to see additional clinics to serve clients in Lewiston-Auburn and Augusta, as well as a third Portland-area clinic to serve an additional 300 people. Statewide, she would like to add 700 slots for patients but is worried that controversy created by the Shinderman case could slow that progress.

Methadone is more likely to be present in overdose cases than any other drug, although most overdoses involve multiple drugs, and it is often impossible to know which was the fatal drug. Sgt. Scott Pelletier of the Maine Drug Enforcement Agency said that undercover drug buys and seizures have netted both prescription methadone used for chronic pain treatment, and clinic methadone used to treat drug dependence.

Pelletier admits that, in his work, he doesn't see the methadone success stories. People who have stabilized their addiction and live quiet, productive lives don't come into contact with drug agents.

But he questions whether the ones he does see, who sometimes sell their methadone or try to supplement it with illicit drugs such as crack cocaine, benefit from their program. He wonders why there isn't more of an effort to get opiate addicts detoxified and move them into a drug free-life.

"Some treatment is better than none. However, do we still want to say that this is the best that we can do?" he said.

Methadone providers say the treatment is misunderstood by much of the public, but has proven to be effective.

"This is the very best treatment for opiate addiction that there is, and it's not going to go away," said Joseph Py, medical director for Discovery House, a nonprofit company that runs methadone clinics in South Portland, Waterville and Calais.

Methadone is a synthetic drug that acts like opium in the system. It is slow to take effect and is long-lasting.

That means it does not give the user a "hit" the way other opioids do, but holds off cravings and withdrawal symptoms for a longer time.

It also dulls the effect of other opiates, making methadone patients less likely to supplement it with street drugs.

"They are maintained," he said. "It gives them the freedom to put their lives back together."

Shinderman came under fire for his position on dosing, detailed in an article titled, "When Enough Isn't Enough," in which he advocated doses up to 10 times what had previously been considered the therapeutic dose.

But Py said Shinderman's practices represent the latest thinking in addiction medicine, even if they are not yet mainstream. Some patients' biochemistry metabolized methadone quickly, and they need more medication to make it through a day.

One of the most controversial aspects of methadone treatment is the idea that addicts are exchanging one addiction for another, and clinics offer no incentive to get off drugs completely.

Py said that through counseling many patients do go off methadone and stay drug-free. Others may always need methadone.

Some people are born with a deficiency of the opiate-like chemicals naturally created in their bodies, Py said, and seek out opiates to medicate themselves.

He said whether someone ever gets off methadone also may have a lot to do with their personal drug history.

"With heroin addicts, I would say, nine out of 10 will continue (on methadone) forever," he said.

Even so, methadone allows them to escape the harsh economics of an addict's life. Instead of having to raise as much as $400 a day to support a drug habit that, in many cases, makes holding a job impossible, they can take care of their cravings and withdrawal symptoms with a daily dose.

"The question is, what if they're on it for the rest of their lives?" Py said. "If they are not climbing through windows and stealing TVs, if they have a family and are going to work, who's to say that's wrong?"

Johnson believes that Shinderman came under scrutiny by law enforcement because of his outspoken support of methadone treatment and his published belief that some patients should receive much higher doses than what had commonly been considered enough to ease cravings and withdrawal.

Shinderman's clinic was the subject of a search in 2003 by more than 30 armed police and federal agents, who seized records and copied computer files. A review of the records uncovered Shinderman's prescription writing practice, which led to his criminal prosecution.

Silsby, the U.S. attorney, denies that there is any anti-methadone campaign in her office.

"Methadone is an accepted opiate addiction treatment modality, and it is not the province of this office to opine on what might be a good or bad form of treatment," she said. "I don't know whether it works or it doesn't work, but we prosecuted this case just as we would any doctor, hospital, nursing home, doctor, physician's assistant or anyone else in health care who fails to comply with federal law."

Py said he doesn't think Shinderman's prosecution will have much effect on the distribution of methadone.

"The issues he was convicted of were things that nobody should be doing anyway," Py said. "It doesn't help people's attitudes about treating addicts, but other than that, I don't think it will have much effect on the other clinics."

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