Friday, February 23, 2007

From the Archives of Addict-L

Jerry Costley


We have a director of a local Methadone clinic who has his doctoral degree in social work. He teaches substance abuse counselor (LSAC) courses at the local university. He is hung up on diversion possibilities and doesn't allow anyone take-home privileges for the first several months--he prides himself that his clinic is open seven days a week, 365 days a year. After two years someone can earn up to one week take-home privileges, max. I have asked him about trying to accommodate for people's employment, noting that research has suggested a good job is a huge predictor of success, and his response has been that individuals need to decide what is more important, employment or treatment, as though they are mutually exclusive. He also prides himself on never having applied for a federal exception for an individual. His clinic serves largely people who are on Medicaid or receive public assistance, so they don't have much of a choice. Most of the public dollars go to his clinic because the public funders feel more comfortable with the "tight ship" he is running….



To Jerry and the List:

What you describe of this methadone clinic is the kind of bullshit, counter-productive, paternalistic, humiliating crap that methadone accreditation was supposed to prevent. A well-written letter to the accrediting body may be the most effective way to fix such defunct practices. The vast majority of methadone programs are accredited either by JCAHO or by CARF. For CARF, the way to submit a complaint is at:

or just

For JCAHO, it's at:

or just

Each site has a directory to see if a given program is accredited with them.

Best wishes,

Steve Coulter, MD
SteveMDFP -at- gmail -dot- com

Hi Steve,

Sorry to say the accreditation bodies service the providers, not the patients. Their words, not mine.
As for clinic policies, the Federal regulations are the most lenient, but the states can impose additional
restrictions and the individual clinics, even more restrictions. While some methadone clinics have
come around and are doing excellent work under difficult circumstances others just demonstrate
control, control and more control. Exactly what complaint would you file against the clinic director?


Howard S. Lotsof, President
Dora Weiner Foundation
46 Oxford Place
Staten Island, NY 10301

Dir. Tel: 1 718 442-2754
Dir. Fax: 1 718 442-1957


To Howard and the List:

I really don't share your cynicism about accreditation bodies. They do get their income from the organizations being accredited, but my experience is that they take their work very seriously, and consider their chief customer to be the public at large. A few years ago, a well-regarded local hospital came very close to shutting its doors because of a complaint filed with JCAHO. My hunch is that they receive very few well-written complaints, especially from programs serving the poor and uninsured.

Accredited methadone programs must meet the federal accreditation guidelines, and any additional requirements of their particular accreditation body. The federal guidelines are at:

An excerpt:

1. Patients have the right to treatment that:
a. is given with full informed consent;
b. is individualized and participatory;
c. responds adequately to patient needs;
d. promotes dignity and is humane;
e. promotes autonomy and patient responsibility;
f. protects confidentiality;
g. protects and promotes overall health and well-being.
2. Program administration obtains and is responsive to patients' feedback concerning their care.

The approach to take-home doses is supposed to be individualized. A policy of "we don't give anyone more than two days of take-homes" violates the accreditation standards. I'd be very surprised if the accreditation body didn't pursue a well-written complaint.

Best wishes,

Steve Coulter, MD
SteveMDFP -at- gmail -dot- com


"High" Howard! (official addictions treatment salutation)

I would like to chime in here briefly. I believe that I could speak for JCAHO but I will not since I am not directly involved with them. I have been a CARF accreditation surveyor for many years now & was involved with the "Opioid Treatment Program accreditation project" almost from inception. I conducted the two initial pilot tests of the study of whether or not accreditation was a viable model for improving patient care for "methadone programs" & I have consulted with or surveyed many U.S. "OTP's" since that time having worked with them since the early 1970's. I ensure you that patient-focused/centered care & client rights are a HUGE part of accreditation. There are many mechanisms built in an accreditation survey to determine whether or not the organization and program is in conformance to the standards surrounding and underlying these rudimentary practices. I cannot imagine that a complaint such as the one listed in this thread would not be taken VERY seriously by an accreditation body. If I were an accreditation surveyor visiting this organization, I would certainly pay close attention to this issue and it would have a SIGNIFICANT impact upon my findings and report. If this organization is accredited by CARF and you or anyone else would like to file a complaint, you should contact Bettye Harrison at . Patients can, and should file complaints as well. Another good place to check is .

Director of Operations
Addiction Recovery Systems
Three Mill Road, Suite #200
Wilmington, DE 19806
904-307-6548 Mobile


On 2/22/07, <> wrote:

I'm with Howard, here, MIke. I also have been involved with the OTP accreditation process from the beginning, and from my view, all accreditation has done is increased costs to patients and made more "make work" for already overburdened clinic staff. ARM has filed complaints to both CARF and JCAHO and unless the complaint meets an "accreditation element" (most of which have nothing to do with quality treatment) they do not do anything to help. In fact, the accreditors have never resolved a complaint that we have filed, we ALWAYS have to go all the way to the Feds at CSAT.

And remember Betty Harrison refers to herself as the "Queen of Forms" and thats exactly what CARF accreditation is......a TON of paperwork.

The intent of the accreditation system was good, but from the patients perspective it has been a huge failure.

Chris Kelly


Advocates for Recovery through Medicine

Washington DC CHapter


To Chris and the List:

I certainly can't argue with your experience on this matter. I'm surprised and outraged. Respectful, individualized, compassionate, flexible methadone treatment that enhances autonomy, employment and larger recovery are "accreditation elements." If JCAHO and CARF are not enforcing these accreditation elements, then these organizations themselves are subject to complaints filed at SAMHSA's CSAT. I would urge anyone with specific information to send such a letter. A cc to one's Senators and Representative tends to multiply the effectiveness of efforts to get federal agencies to do the jobs they're supposed to. An additional cc to JCAHO and CARF would be useful, too.

Really, you're describing failure of federal licensees (CARF and JCAHO) to fulfill their contractual obligations. I believe the Inspector General of HHS has authority to investigate failure of contractors to perform their obligations.

So, the specific people to inform would be:

Center for Substance Abuse Treatment
Division of Pharmacologic Therapies
Substance Abuse and Mental Health Services Administration
Attention: OTP Certification Program
1 Choke Cherry Road, Suite 2-1073
Rockville, MD 20857

Phone and e-mail would seem to be:
Telephone: 1-866-INFO OTP (463-6687); e-mail:





And, for one's congress-critters, you can look up your own Representatives and Senators at:

The laws, regulations, and standards are all already in place. All that's needed is a little dogged determination to make various people do the jobs they're paid to do. I think Addict-L has enough dedicated people to fix this problem.

Best wishes,

Steve Coulter, MD
SteveMDFP -at- gmail -dot- com





I have been a "lurker" on the list for some time now, quietly observing from the shadows & I have been GREATLY impressed and inspired by the depth of some participant's passion and knowledge. This is a topic on which I can & will speak. While I cannot & will not address others' experiences I will share the accounts of my own adventures over the past decades, which have been many.

I have worked in the field of "medication assisted treatment" for over 30 years. I have also had a great deal of additional experience but for the purposes of this thread I will focus on my work with opioid treatment programs. We have been under the regulatory control of the DEA & FDA since "the beginning of time", which focused on the control of the medication itself. The decision to transition away from the FDA & to move programs under the auspices of CSAT was a shift in the right direction in my opinion. The desire to finally instill some national standards for patient care was long overdue. I can tell you many "horror stories" of programs I have visited through the years where the words "patient care" could not be used in the same sentence. Too often rules & regulations came first & patients/families came second at best.

My experience as an accreditation surveyor (& I do emphasize that this is MY experience) has been extremely positive. The programs I have worked with as a consultant & as a surveyor have consistently reported that the accreditation process has significantly improved the quality of patient care as demonstrated by measurable outcomes & based upon solicited feedback from the organizations' various stakeholders. We worked together to streamline systems so that redundancy was reduced so that resources are better allocated to patient needs & in some instances, paperwork was cut rather than increased. Patients consistently report that they are more empowered and engaged in their programs because that is something we measure as heightened participation is a desirable positive outcome. Barriers were reduced or eliminated altogether and bridges were constructed so that accessibility to services was increased. We know this because we measured it & we used that data in an on-going effort to improve at what we do. Wait-time for services was reduced and employee retention was increased as staff competencies were improved. Counseling services focused on use of effective therapeutic "tools" (discussed here) such as cognitive behavioral therapies, motivational enhancement/interviewing techniques, brief intervention, etc. & this was reflected in progress noting and treatment planning so that it could be clearly seen. ETC.

I don't know if I'm being very clear as I'm doing too many things right now to write as well as many of you on this list who post on a regular basis but I hope that I've made my point in at least a satisfactory manner. I agree with Dr. Steve's post [above]. If you have complaints, PLEASE COMPLAIN as that's the only way that the system stands any chance of getting adjusted. I promise you that when I see/find problems that I fuss & fume loud & long because the bottom line is that the bad stuff has an adverse impact on patients & their families. However, when you see something that works to help patients & families, take a little time to "give it a little push" as well.

Director of Operations
Addiction Recovery Systems
Three Mill Road, Suite #200
Wilmington, DE 19806
904-307-6548 Mobile



Hi Mike,

My experience as a member of the Board of Directors of the National Alliance of Methadone Advocates and an observer of patient/clinic activities is that there was a rash of improvement in clinics during the accreditation process. Patient committees were supported. Things were spruced up around the clinic but for the most part once accreditation was achieved the clinics withdrew support for many of the activities they paraded in front of CARF and JCAHO during accreditation visits. My experience is that the accreditation organizations so distanced themselves from patient issues as to be of no value to patients at all. I must admit I haven't been on the front lines of these matters for 18 months or so but, I have heard nothing exemplary as to CARF and JCAHO from a patient perspective either.

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