THE MISERY INDEX

Methadone Patients Desperate For Relief From Drug Withdrawals Make An
Entrepreneur's Dream Of Repeat Customers

"Heroin is the only thing, the only gift the darkness brings."

- -Steve Earle

Christopher has seen the deepest recesses of hell.

Ten years of mixing copious amounts of dangerous narcotics finally
culminated in a trip to the Intensive Care Unit at Saint Francis Hospital
two months ago.

He doesn't remember much. He'd been carelessly combining his regular
methadone treatments with a low dose of the benzodiazepine Xanax.

The methadone was being administered to him by a for-profit Tulsa clinic
that specializes in its distribution for the treatment of heroin addiction.
The Xanax was prescribed to treat anxiety by a private doctor who didn't
know Chris was on a methadone regimen.

His urine tests kept turning up dirty at the clinic, but the clinic didn't
do much about that, he says. Things went okay for a year or so mixing the two.

Things changed, however, when Chris mixed the cocktail with an
additionally, high-powered dose of Xanax he got from a friend who used it
to pay off a cash debt.

For a few nights in a row, Chris would consume the toxic combo producing a
fantastic high until finally trying to make his way home from the friend's
only to wake up an hour later passed out in his still-parked car.

"It's kind of like heroin junkies," Chris said. "When someone dies on a
shot, then people go buy that heroin, because they know it's really good.
If you're going to die from it, you're going to get a really good high from
it. Even though I knew that, I still did it."

He survived, but it was enough to bring his extensive life of drug
addiction to an end.

Chris can't recall the first time he shot dope, but he remembers when his
stomach began twisting into knots of excitement at the very sight of a needle.

Chris, of course, is not his real name.

Few recovering drug addicts are proud to recount to family and friends in
print the late nights smoking crack, eating pills, shooting coke, heroin
and Oxycontin, driving home from Austin after picking up better shit,
throwing up from the car window, a friend passing out at the wheel and
sending the car 180 degrees onto a dirt road off I-35 Christ knows where in
Texas, throwing up again after making it home in a trash can on the side of
the house while the parents ignorantly continue gardening, landing in the
hospital with Hepatitis C or skin bubbles caused by repeated injections in
the same area of the arm that burst and reveal a surreal image of the major
blood communicators beneath.

Indeed, he isn't proud of remembering that early group of friends.

"Amongst all those friends, about a third of them died, and a third of them
went to the clinic," he said. "Or, they're in prison."

Finally, that last night two months ago, his breathing began to slow. He
knew what was happening. He called his dad. His dad took him to the
emergency room.

All he remembers from there is waking up periodically and clutching
panicked at the plastic tubes snaking down his throat. The device was
delivering charcoal to his system, which clings to the narcotic and passes
it safely out of the body. The Narcan they'd shot him with didn't work.
Narcan instantly reverses the effects of narcotic overdose, but sends
addicts into a violent fit of withdrawal.

"It was bad," he said. "I aspirated and got pneumonia on top of withdrawals."

The withdrawals. Heroin withdrawals can take on such severity that they're
capable of killing some addicts, striking the body with deadly seizures.
Methadone withdrawals are considered a bit easier, but still painfully
halting. Sweating. Shaking. Cramps. Wild swings of emotion. The sensation
of intensely cool temperatures.

His family was there with him. He told them he was making it. Inside he was
crumbling. He did make it, but not without that few days of hell first.

For more than a year, he'd been attempting to lower his daily methadone
dosage and get clean completely. But the clinic he was going to, Tulsa
Rightway Medical, would only take him down five milligrams a week. Starting
at a daily dose of 110 milligrams, it would take months to escape--or a
near-death experience.

But drug addiction is more complex than a simple narrative of Chris's struggle.

An Urban Tulsa Weekly investigation reveals there are two distinct stories
to methadone in Tulsa.

One involves for-profit methadone treatment clinics enduring reams of
legally required paperwork and government regulation, legal battles, and
teams of sometimes cynical, embattled nurses and counseling staffs
encumbered by Al-Anon rhetoric and Social Workerease. Add to that a bottom
line that includes an incentive to make a profit.

The other story: Private medical practices are prescribing methadone to
chronic pain sufferers who often fail to fully grasp the pharmacology of
the drug and as a result, end up dead or wind up selling the drug on the
street.

Next week we'll report on the dramatic rise of methadone-related deaths
among chronic pain sufferers in Tulsa.

This week, we'll take a look at the clinics and two individuals working
toward an end to their addictions.

Be The End Of Me

Chris's boyish looks and comfortable middle-class background hardly fit the
profile of a criminal. He has, however, struggled with an addiction to
heroin, and an ambivalent relationship to the methadone that saved him.

The medical community has historically disassociated itself from the world
of substance-based addiction treatment enabling savvy entrepreneurs to
profit handily from a product that attracts a powerfully committed segment
of the consumer population with little need to advertise.

While methadone dispensers play an invaluable role in the world of drug
treatment, the city's for-profit clinics have strained to execute their
mission during a time when the approaches to treating drug addiction
nationally are slowly changing.

And while the stigma surrounding addiction has eased over the decades, drug
overdose is hardly relegated to the poor and uneducated as is often still
depicted in popular culture.

State death records show that early on April 20, 1975, Lawrence Richard
Wilcox, cousin to Tulsa Mayor Bill Lafortune, died of a heroin overdose.

He was 23.

Drug addiction is a brain disease, says Dr. William Yarborough, an
associate professor of medicine at the University of Oklahoma Schusterman
Center in Tulsa. He says the brain chemistry of some enables them to escape
a full-blown addiction following initial experimentation with an addictive
drug. It's not unlike a heavy smoker's undying commitment to cigarettes
compared to a smoker spending years only lighting up a few on the weekend
along with drinks while never becoming addicted.

Combine the brain chemistry of a born addict with the physically addictive
properties of opiate drugs and the result is a serious public health concern.

For some addicts, a simple inpatient, 30-day detox regimen at an
abstinence-based treatment center is enough to help them overcome
addiction. For others, brain chemistry and biosocial circumstances make
them highly vulnerable to relapse, which means repeated exposure to
infection from dirty rigs and a tragic cycle of failed sobriety.

"Abstinence is always the best first approach with drug addiction," said
Yarborough, who is also medical director for an area abstinence-based detox
program. "But abstinence from mind-altering substances doesn't always work
for everybody. The outcomes for community abstinence programs may only be
10 percent; sober for one or two years. Methadone programs may have 30, 40
and 50 percent success rates in keeping people out of trouble."

Methadone was first synthesized and used in Germany during World War II in
the 1940s to treat illicit drug use.

Early protocols for application of the drug failed until the 1960s when two
doctors changed their approach using longer-term methadone maintenance with
more success. Poorly considered preliminary regulatory schemes were too
weak to prevent widespread abuse and diversion of the drug until the 1970s
when federal and state officials established additional governance of
methadone's usage.

Methadone is an opiate "agonist," which means it acts similarly to
morphine, yet it produces little of a euphoric sensation and blocks the
effects of other illicit drugs making it an ideal substance with which to
treat chronic drug abuse. It also has a long half-life, meaning it can fend
off symptoms of withdrawal for significant periods of time. However, the
amount of traces that can remain in the body, i.e. how long it takes for
the body to metabolize methadone, varies from patient to patient.

Today, methadone is used largely to treat addictions to heroin and legally
prescribed Schedule II drugs like Oxycontin, which have recently become a
major focus of press attention.

The drug is additionally cheap and easy to produce making it a pragmatic
safety net for the portion of the drug-addicted population that Yarborough
described as highly susceptible to repeated relapses.

The dirty secret, however, is that some patients, including Chris, contend
methadone withdrawals are worse than those associated with heroin. And
methadone, Chris learned, cannot block Xanax.

Chris had finally turned to the methadone clinics after more than one visit
to inpatient detox centers around the city failed. The detox units with
pleasantly connotative names like Laureate and Valley Hope only exposed him
to other addicts he could get high with after he got out. Following a
diversionary trip to detox he'd taken to avoid jail time for his third DUI,
Chris headed to the clinics."I smoked some crack with this guy, and I
realized I was going to start shooting heroin again," he said. "So I went
to the methadone clinic two days later."

That was four years ago.

The Business End

A doctor named Gary K. Borrell established Oklahoma's early methadone
clinics in the 1980s in Tulsa and Oklahoma City maintaining them until 1998
when he sold them to a businessman named Richard Yanko, according to court
and state incorporation records obtained by Urban Tulsa Weekly.

Yanko has since assumed ownership of the two clinics with his wife Leslie
under a variety of company names. The company now does business in Tulsa
under the name Life Improvement Center, located near 41st and Mingo in East
Tulsa. The Yankos manage clinics in Nevada and Arizona as well.

Two attorneys named Karen Byars and Richard Anderson formed Rightway
Medical in 1999 from the ashes of an administrative fallout at LIC that
involved an LIC security guard and the clinic's director, trusted by Yanko,
who jumped ship to Rightway. The Tulsa location is off 110th East Avenue.
Another location was opened around the same time in Oklahoma City.

Two other clinics exist in the state as well: New Beginnings in Oklahoma
City and the VA Hospital methadone clinic, also in OKC, which treats war
veterans addicted to drugs.

The for-profits became what is today 55 percent of the nation's methadone
clinics.

When patients first enter the clinic, they're given a health exam, and a
doctor, over a series of days, determines the severity of their addiction
and adjusts their methadone dosage accordingly. The process is called a
"peak and trough." The patient receives approximately 10 additional
milligrams a day until they reach a level that enables them to maintain
normalcy.

"It does an excellent job of giving someone back their functionality so
they can address these other areas that have gone to waste in their life,"
said Johnny Mark Kirk, clinic administrator for Tulsa Rightway and a
recovering methamphetamine addict.

Costs to the patient for the program amount to an average of $55 a week
plus additional fees for late payment and dosing and $15 for "arranging for
guest dosing" at other treatment programs. Patients can receive from as low
as two milligrams to as much as 180 milligrams a day. Rates for the patient
remain flat regardless. But, sources says, the cost of methadone to the
clinics can amount to pennies per 100 milligrams.

From there it's pretty much up to the patient how long they remain on
methadone. Urban Tulsa Weekly interviewed two patients who'd both been on
methadone for more than 10 years. Like Chris, the other individual began at
LIC, and following disenchantment with their program, moved to Rightway.

If the patients keep good behavior over a period of time, they obtain
"take-homes," which means they can receive wafers or liquid dosages that
can last them up to a month at a time, according to David Morgan,
Rightway's clinical director in Oklahoma City. A dirty UA can mean a "loss
of privileges," and the patient is forced to return to the clinic early
each day for their dose.

Kirk said consistently dirty UAs, such as a patient continuing to mix
methadone and Xanax, can get you kicked out of the program. He said each
time it occurs, the patient is harangued with a speech asking why they
would threaten their treatment, or they're eventually referred to an
inpatient detox facility.

"If you decide you're not going to quit taking benzos, and you're
continuing to get dirty UAs from them, we're not helping you," Kirk said.
"We try very hard to see any effort and improvement in the patient. As long
as you're trying and things are getting better, we're going to work with you."

But Chris says he rarely didn't show dirty piss and was never punished
beyond his loss of privileges at either clinic, which he didn't care much
about. He added that counseling sessions, considered an integral part of
methadone treatment, often lasted for just a few minutes before he was sent
home. He spoke sarcastically about the "goals" set for his treatment.

Kirk also hesitated to explain that a significant portion of patients can
remain on the program for years at a time, generally, he said, chronic pain
patients struggling with an addiction to pain killers.

OU's Dr. Yarborough said long-term methadone treatments are not necessarily
a terrible thing, although the public tends to cringe at the thought of
indefinite maintenance.

"The government likes to talk about eventual goals of getting people off of
methadone," he said. "If I have a case where someone comes to me and seems
really motivated to get off their methadone, sometimes you can make
suggestions about how to do that slowly. But the first thing I ask them is,
'Why do you want to get off the methadone?'"

Counselor Kirk said patients are regularly encouraged to consider beginning
the process of tapering off methadone. But Chris laughed when asked to
confirm Kirk's statement saying he had attempted at both clinics to lower
his dosages by the week, and not only was the process tediously slow, some
weeks the nurses altogether wouldn't lower his dose claiming it hadn't been
authorized by the clinics' doctors.

And, of course, recovery is technically bad for business.

State regulations require that counselors keep reams of files detailing the
use of admission criteria, projected length of treatment, mental health
specifics, a patient's "assets and liabilities," ongoing care plans and
counseling hours logged, all designed to insure treatment is going as
planned and half-ass addicts aren't just looking for another hook-up.

And all of it's accompanied by a plentiful array of paperwork, which was
made partly available to Urban Tulsa Weekly following a bit of a struggle
with the Oklahoma Department of Mental Health and Substance Abuse Services.

Kirk said admission and maintenance criteria are based largely on an
Addiction Severity Index and outlines set by the American Society for
Addiction Medicine.

The Drug Enforcement Administration regulates virtually every single drop
of methadone that leaves the clinics. Kirk even pointed out bottles turned
upside down to catch the leftovers in small cups. Literally millions of
milligrams of methadone pass through the clinics during a six-month period
with maybe 70 or so milligrams unaccounted for by the end.

Nonetheless, the state still apparently believes both Tulsa clinics have a
difficult time updating their records sufficiently enough to prove their
treatment standards are complete.

The Paper Chase

Every three years the Oklahoma Department of Mental Health and Substance
Abuse Services will re-certify the state's methadone clinics following the
approval of a sampled inspection of patient records.

The clinics are notified in advance of the inspections, but records we
obtained from ODMHSAS showed that advance notice still wasn't enough for
clinics to insure compliance at least during the time that state
bureaucrats were hanging around.

The clinics are given a point score after the records inspection that
should amount to 100 percent, which the clinics must reach before becoming
re-certified.

In 2002, all of LIC's sample records reviewed failed to properly document
ASAM admission criteria, and portions failed to include missed treatment
and counseling sessions, projected lengths of treatment, follow-ups after
discharge and counseling referrals to outside organizations. The files also
failed to adequately indicate whether methadone was even the right
treatment for individual patients.

Due to the deficiencies, the LIC clinics were placed on "conditional
certification," which meant they needed to implement measures to prove the
files would be better maintained in the future before reaching full
certification.

But it wasn't the first time the citations had occurred. LIC was
continually cited for many of the same reasons over a period of two
inspections reaching back to 1993. Following 1998 inspections, Yanko sent
ODMHSAS copies of memos he'd distributed to employees that were intended to
show the clinics had improved on the deficiencies.

Which drug users actually should be eligible for the program became an
issue in 2003 when William Bryan Sargent's mother sued LIC for negligence
after her son died of methadone toxicity. Just two days after he'd begun
receiving treatments at the clinic in Oklahoma City for an addiction to
pills, William overdosed, because an inordinate amount of methadone had
gathered in his liver and his body had failed to properly metabolize it.

Jana Sargent's attorney, Murray Parrish, said the clinics could keep track
of methadone retention levels by observing daily UAs in the earliest phases
of treatment. He said a UA the second day of treatment would have indicated
that too much methadone was filling William's liver.

While LIC claims William was the first death on its watch, a toxicology
expert testifying for Parrish said he'd seen several similar cases in
Texas. After interviewing LIC employees, Parrish said he "perceived
standards to be too low" for entrance into the methadone programs.

Eventually Yanko complained to ODMHSAS that some of the state's regulations
seemed to serve no real purpose and overlapped policies LIC already had in
place. Both LIC and Rightway had been cited for not properly assembling
case review teams of medical specialists that independently analyzed and
authorized treatment plans for patients and their eligibility for entrance
into the programs.

"When a Team has been in place, nearly 100% of its activities have
consisted of rubber-stamping the actions of the professional staff," Yanko
wrote to ODMHSAS in 1999. "Indeed, we know of no other state in the nation
which provides for the redundancy of a case review team."

For the record, Yanko failed to return repeated interview requests. Calls
to LIC clinics in Tulsa and Oklahoma City went unanswered. An LIC clinic
administrator eventually declined comment.

Becky Brooks, a former LIC counselor and now a certified trainer for the
National Alliance of Methadone Advocates, says the peer review teams are no
longer in place. Now the state requires that clinics be certified by an
accrediting body such as the Commission on Accreditation of Rehabilitation
Facilities.

All of the state's for-profit clinics are accredited by CARF. But Brooks
says the standards for CARF accreditation are too low, because the clinics
prepare patients for interviews with accrediting agents rather than
advertising the opportunity for patients to meet with the review team "as
is suggested by best practice guidelines."

Counselor Kirk notes that Rightway received a particularly exceptional
score from CARF in 2003.

"This is an extraordinary accomplishment, as only 3 percent of CARF surveys
result in no recommendations," a CARF letter stated to clinic director
Byars following the accreditation review.

Urban Tulsa Weekly was unable to obtain records of the accreditation and
inspection process conducted for either of the companies by CARF.

As far as inspections go, however, the biggest blow for LIC came in 1997
when federal prosecutors sued the clinic for $50,000 following a DEA
inspection that revealed LIC was not participating in a methadone registry
with adjoining states. The law was designed to prevent patients from
crossing state lines and acquiring methadone illegally from a series of
clinics.

Tulsa Rightway Medical has faired better overall with state inspections in
its notably short existence.

The clinic scored 100 percent on the first shot of its most recent
inspection in 2004. But in 2001, Tulsa Rightway, too, was cited for failing
to document "initial observable conditions" of patients and how long they'd
been addicted to narcotics when they appeared at the clinic for treatment.
The deficiencies improved enough for Rightway to receive the 100 percent
score last year.

The state's certification director for ODMHSAS, Meredith Martin, told us
clinics rarely fail to eventually make certification after deficiencies are
improved upon. We could not reach her for a follow-up interview due to
medical leave she had taken.

Still, while the clinics have enough to worry about under state and federal
scrutiny, the more compelling tales to tell regarding Tulsa's methadone
programs involve their administrative battles inside the state's courtrooms.

From Ashes Rise

When Richard Yanko took on ownership of Life Improvement Center in 1998, he
promoted his trusted employee, Gary Agger, to clinical director of LIC's
Tulsa and Oklahoma City locations.

He updated the facilities' computer and database systems and began paying
for Agger to attend management conferences and workshops to expand his
skills. Yanko later contended in a lawsuit that during the time Agger was
learning how to better-manage a methadone clinic, he was clandestinely
forming a competing clinic, known today as Rightway Medical, with another
LIC employee and the two attorneys, Byars and Anderson.

Yanko complained that the man he invested in to run his own clinic took the
knowledge he acquired, along with the company's proprietary records and
patient files, and proceeded to conduct a "telemarketing campaign" to pull
patients away from Life Improvement Center, all while continuing to work
for LIC.

Yanko then rattled off in court records a list of claims against Rightway's
founders including that Rightway had told LIC patients they would not have
to be "serviced by African Americans," their physicians would not be
contacted if they were found to be mixing benzos with methadone, they would
illegally receive free methadone and extra take-homes and that LIC's
methadone had been slandered as "generic." The narrative of the suit reads
as if the two clinics were merely competing to sell ice cream, not a
narcotic substance designed to treat a powerful drug addiction.

Regardless, Yanko's only legal option was to ask the judge for an
injunction that would bar Rightway from benefiting from the stolen files.
The judge ruled Yanko's evidence was insufficient to prove his trade
secrets and patient lists were misappropriated and that his business would
suffer irreparable harm.

Yanko alleged in an affidavit that Agger continued to deny his intentions
to resign and open a competing clinic, even after being confronted with the
rumor, while still working at LIC. Finally, in June 1999, Agger did resign
to the "shock" of Yanko.

Immediately afterward, Agger expressed interest in buying LIC from Yanko,
according to the suit. Even following Agger's deceptions, Yanko considered
the deal and agreed to turn over sensitive financial information about his
company without first requesting a signed non-disclosure form and an
agreement to return the records. Rightway, Yanko further asserted, never
returned the records and refused his offer of an $800,000 cash deal.

As the story unfolded, more employees left LIC to help form Rightway,
including another counselor and a nurse.

One knowledgeable source said Yanko had simply never expected to face
competition in the for-profit methadone business and would thus do whatever
it took, including embellishing accounts of how his former employees had
established his new competition, to ensure his methadone monopoly. The
source said Rightway had no reason to steal patient files when the patients
were likely to become quickly aware of any alternative providers in the
city, regardless of how the new business was promoted.

Then again, employee shakeups at the state's methadone clinics aren't
uncommon. An LIC security guard who left Yanko to help form Rightway
recently left that company, too, for a job at New Beginnings in Oklahoma
City. He just couldn't get along with Rightway's ownership, a confidential
source said.

Golden Arm City

Dee Dee has been on methadone more than 10 years.

Like Chris, Dee Dee's name has been changed to protect her identity. And
like Chris before he landed in the hospital, she's tired and ashamed of
being on methadone.

"You have to bite a bullet at some point and it takes a while," she said.
"[But] once you get on it, it's very, very hard to get off it."

Dee Dee's tried to escape before. She laughs about the "goals."

"I've set so many goals over the years," she says.

She's gotten as low as 10 milligrams a day before sensing the beginnings of
withdrawal and going back up fearing the full impact. She'd need at least
two weeks to suffer her way to sobriety. But she doubts she could get two
weeks off from her job.

Dee Dee says she's always held a job throughout her entire adult life as a
drug addict. But for more than a decade, the cloud of methadone has
remained--she says it's the worst addiction she's ever had. And, she says,
neither clinic in Tulsa has ever suggested even beginning the process of
withdrawal without her prompting them first.

"The monkey never dies," a dealer says to heroin addict Frank Machine in
the 1955 film The Man with the Golden Arm. "You kick him off your back and
he just hides in the corner waiting his turn."

New developments in the drug industry have at least begun to offer Dee Dee
options. In late 2002, the FDA approved a drug to treat addiction called
buprenorphine. The drug lasts longer and creates even less of a euphoric
sensation than methadone. It also produces a significantly lower degree of
risky respiratory depression.

"The new medications, along with a new law passed in 2000, permit
physicians to use this medication to treat opiate addiction right in their
office," said Nick Reuter, a senior public health analyst for the federal
Substance Abuse and Mental Health Services Administration. "It provides
another alternative to the methadone program-based treatment system."

Rightway Medical has begun to offer buprenorphine at its clinic in Oklahoma
City. Clinic administrator Morgan says the alternative is promising.

"We only started it in January, but it seems to be very effective," he
said. "Patients have stated that it makes them feel more normal."

But it's not cheap. Right now it costs about $110 a week at Rightway. The
Tulsa Rightway clinic will begin offering it soon, counselor Kirk says.

Reuter said SAMHSA doesn't necessarily view the drug as an alternative to
methadone maintenance treatment programs. Rather, he said, the drug's
availability fills a void for 200,000 to 600,000 Americans desiring
substance-based treatment, but unable to access it in their area.

But Reuter said SAMHSA has tried to target physicians with office-based
practices who can make the drug available to patients who might need it,
which suggests a fundamental shift in the way the nation is approaching
drug addiction treatment.

Ten years ago, family physicians may have been much less likely to involve
themselves in treating addiction, but now doctors can and are treating
addicts the way they would any other patient's illness or diseases.
Fourteen doctors in Oklahoma are already licensed to prescribe
buprenorphine, Reuter says.

Dee Dee said over the past 10 years, she's seen the clinics' doctors no
more than once a year, and she said she's still too embarrassed to tell her
private doctor that she's on methadone.

She still worries that people will find out and wonders how long anyone can
take it.

She admits the years have felt like wasted time.

"Sure I can be pissed off about it," she said. "But I walked in there on my
own free will. It's not like there are a lot of options to choose from."

Next Week: Misery Index, Part II. 'Till death do us part.