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Watch your thoughts; they become words.  Watch your words; they become actions; Watch your actions; they become habits. Watch your habits; they become character. Watch your character; it becomes your destiny.  - Frank Outlaw

I would like to welcome all of you to "The Director's View."  - - -It has been a long time since I have shared with all of you, but it was never my intention you would have to wait ...as long as you did but life happens to me, as it does to you. I know we all have been experiencing some difficult times in our life lately and I am not immune to them, as some of you seem to think.

I have been through some of the most agonizing moments of my entire life the last few months.There were times I wasn't sure I could continue on from one day to the next but I did find the strength.  I would like to thank all of you who was there for me.  I would like to thank all of you who prayed for me during the time I needed you. Life is finally beginning to turn around for me, but seriously, every day is still a challenge for me.

I was traumatized through the events which occurred and I promise, I will share all of it with you later but it is still too fresh on my mind presently.  I am sure many of you may have experienced similar situations and we do need to talk about them. I believe healing comes from sharing with others and allowing others to help you.

I want to thank all of you for visiting "Medical Assisted Treatment of America."  I want to extend a very special welcome to all the visitors from other countries and there are many. Many of you would be surprised to know how many other ones  are visiting with us and exactly which ones they are. I know I was... 

If you haven't met me or corresponded with me, I would like to introduce myself to you. -- My name is Deborah Shrira and I am a methadone patient just like many of you.  Methadone did save my life and yes, it is the reason I constructed  "Medical
Assisted Treatment of America."  Yes, I wanted to share with all of you about the difference methadone made in my life. If it had not been for methadone, I would not be here with you celebrating Easter.  I do not take lightly what it did for me in my life and I am not saying it is for everyone but if you have tried everything else and nothing has worked, then it is time to give it a try.    

I want, not only to welcome all of the new visitors to "The Director's View," but to wish all of you a"Happy Easter." I hope as all of you enjoy today with your families and have Easter Egg Hunts, you will not forget about the true meaning behind why we celebrate Easter. I ask each of you to take some time and reflect on what Easter is all about.  Would you do this just for me?

Most know I am from Georgia and we had something really important occur. The State Legislature of Georgia declared March 2, 2009 as..... Methadone Treatment Awareness Day!!! Can you believe it? It is certainly a start, don't you all agree?  I would like to share it with all of you.

09 LC 94 0176
House Resolution 124
By:  Representatives Benfield of the 85th, Neal of the 1st, Drenner of the 86th, Gardner of the 57th, and Morgan of the 39th

A Resolution

Declaring March 2, 2009, as Methadone Treatment Awareness Day at the state capitol; and for other purposes.

WHEREAS, opiate addiction continues to increase at an alarming rate with more than one million people currently addicted; and

WHEREAS, untreated opiate addiction has devastating financial ramifications for families, healthcare systems, and judicial systems, costing billions of dollars annually; and   

WHEREAS, untreated opiate addiction destroys the fabric of families upon which our society is founded; and

WHEREAS, methadone treatment has been proven to be the most effective treatment for opiate addiction, with beneficial outcomes of decreasing drug use, lowering crime rates, decreasing medical care costs, and decreasing the further spread of HIV, AIDS, and hepatitis; and

WHEREAS, methadone treatment facilities employ healthcare professionals dedicated to helping their patients rehabilitate their lives to become productive members of society; and  

WHEREAS, methadone treatment patients, families, friends, medical professionals, and others interested in the concerns of the opiate addicted population of Georgia will be present at the capitol on March 2, 2009, to speak with elected officials in order to increase their understanding of opiate addiction and its treatment.

NOW, THEREFORE, BE IT RESOLVED BY THE HOUSE OF REPRESENTATIVES that the members of this body recognize March 2, 2009, as Methadone Treatment Awareness Day at the state capitol and commend the outstanding professionals dedicated to treating patients with opiate addictions.

BE IT FURTHER RESOLVED that the Clerk of the House of Representatives is authorized and directed to transmit an appropriate copy of this resolution to the Opioid Treatment Providers of Georgia, Inc.


I can still hardly believe it is true.  I am very proud of Georgia because I know how many lives methadone has saved and one being mine. It deserves to be recognized and the many outstanding professionals dedicated to treating patients with opiate addictions.

What do oxycodone, hydrocodone, diazepam, alprazolam, temazepam, and doxylamine have in common? These drugs were found in Heath Ledger’s body when he died in January 2008—two prescription opioids, three prescription benzodiazepines, and an over-the-counter sleep-aid. All six drugs can suppress the central nervous system and cause respiratory depression. According to the New York City medical examiner, their cumulative effects killed the 28-year-old actor.

Heath Ledger’s death brought to mind the death of Anna Nicole Smith, in February 2007, with nine drugs in her system—three opioids (morphine, hydromorphone, and methadone) and two benzodiazepines (flurazepam and diazepam). Why would people do this to themselves?

Reference: AT Forum Volume 18, #2-Spring 2009  Publisher: Sue Emerson

I just wanted to add Nicole Smith's death was due to the combination of another medication, chloral hydrate.  It was not mentioned in A T Forum's list of drugs and it was the most potent of all especially if mixed with other drugs. Some of you may know it by the name of Placidyl®.  

Anna Nicole Smith accidentally overdosed on at least nine prescription drugs — including a powerful sleep syrup she was known to swig out of the bottle — after a miserable last few days in which she endured stomach flu, a 105-degree fever, pungent sweating and an infection on her buttocks from repeated injections.In a detailed autopsy report released Monday, a medical examiner noted the former Playboy playmate refused to go to a hospital three days before her Feb. 8 death. She chose to ride out her illness in a hotel suite littered with pill bottles, soda cans, SlimFast, nicotine gum and an open box of Tamiflu tablets.

Broward County Medical Examiner Dr. Joshua Perper found that in the days leading up to her death, Smith, 39, had been taking large amounts of the seldom prescribed sedative chloral hydrate, which also contributed to the 1962 overdose death of Smith’s idol, Marilyn Monroe.

Police found no apparent signs of foul play, and the medical examiner also ruled Smith’s death probably was not a suicide because people who take their own lives typically use much more lethal drugs than chloral hydrate.

Rather, he said, Smith might have been simply unaware that the sedative could be fatal in combination with multiple other prescriptions she was taking in normal doses for anxiety, depression and insomnia.

Contributing factors included her weakened condition from a stomach flu and fever brought on by a pus-filled infection on her buttocks from repeated injection of other drugs.

She may have taken the dosages she was accustomed to but succumbed because she was already weakened,” Perper said in his report. “Miss Smith has a long history of prescription drug abuse and self-medicated in the past.”The recommended dose of chloral hydrate is one to two teaspoons before bed. Smith often took two tablespoons, and she sometimes drank directly from the bottle, the report said.

A statement issued by lawyers for Howard K. Stern, Smith’s companion, who was with her before her death, said Smith’s physician and Stern urged her to get emergency treatment but that she refused because “she did not want the media frenzy that follows her.”.

Reference: Anna Nicole Smith Died of Accidental Overdose
                  Updated 1:26 p.m. ET, Tues., March. 27, 2007 Associated Press

 It's time to give the article
 some thought.  We will be
 the ones paying for them
 if they are made mandatory?
 How about some feedback?
 How many of you have the 
 insurance to pay? Most of us
 have problems even paying
 for our methadone, am I not

Five of the CSAT Expert Panel participants released the field review document in the online Annals of Internal Medicine before review and feedback from the field, the process CSAT has followed in all previous consensus publications. (CSAT sent the guidelines out for field review in January 2009.)

Annals Version 1. The CSAT Consensus Guidelines were first published December 1, 2008, in the Clinical Guidelines section of the online Annals of Internal Medicine. (Print publication was scheduled for January 2, 2009.) The article was titled “QTc Interval Screening in Methadone Treatment: The CSAT Consensus Guidelines.” The title indicated that the authors were writing on behalf of the CSAT Expert Panel—when in fact at least two panel members were not even aware that the article was being developed.

The published QTc screening guidelines included:

Inform patients about the risk of arrhythmia when starting methadone treatment.

* Ask patients about any history of structural heart disease, arrhythmia, and syncope.

Obtain ECGs for all patients; measure the QTc interval pretreatment, again within 30 days, then annually; additionally, if methadone dosage > 100 mg/d, or if syncope or seizures develop.

If the QTc interval is > 450 ms but <. 500 ms, discuss the potential risks and benefits with patients, and monitor them more often; if the QTc interval is > 500 ms, consider: discontinuing or lowering the dose; eliminating contributing factors, such as drugs that promote hypokalemia; or using alternative therapy.

Be aware of interactions between methadone and other drugs that prolong the QT interval or slow methadone elimination.

Several days after it appeared online, the Annals article was pulled, at CSAT’s request. It was also removed from the January print edition.

Annals Versions 2 and 3. On January 20 the article resurfaced on the Annals website, with print publication now scheduled for March 17. Missing from the title were “The CSAT Consensus Guidelines,” and the authorship designation “for the Center for Substance Abuse Treatment Cardiac Expert Panel”—thus making the panel independent from the article’s authors. But the article still listed the Expert Panel members by name, and still cited CSAT as the panel’s convener and as a funding source.

The third version deleted, at their request, the names of two CSAT Contributing Panel members who had not been asked for permission to be listed.

Editorial Response. In early February a related editorial appeared on the Annals website. The editorial, published in the March Annals print edition, criticized the panel’s lack of scientific basis for its recommendations, lack of explanations for its decisions, and lack of a literature review to plan the data-gathering process.

Detailing the substantial harm routine ECG screening could cause, the editorial commented, “For the typical person who begins methadone treatment, the risk for death from torsade de pointes is likely to be substantially lower than that from competing causes of mortality associated with untreated opioid addiction.” Thus, the title of the editorial: “First Do No Harm . . . Reduction?”OTP Clinicians Respond to Screening Guidelines

In January, shortly after the first online draft was published, Mark W. Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), fielded questions and concerns about the published guidelines. Some practitioners thought the recommendations were final and required implementation. Others asked if CSAT had approved the guidelines, and why they hadn’t gone through normal federal channels, instead of being published first in a peer-reviewed journal.

In letters and Web postings, clinicians strongly disagreed with the proposed guidelines—calling them unnecessary, costly, and impractical; based on a disconnect with “the reality of clinical practice”;—“beyond the ability of most methadone providers to implement”; and no substitute for the provider-patient relationship—”Serial [ECGs] cannot replace an informed patient.” One reader suggested the authors were “inadequate and biased.”

Some readers mentioned practical problems: “Medi-Cal has told us …they won’t authorize serial screening EKGs.” Several cited the rarity of methadone-associated problems: from 1969 to 2002 only “43 cases of methadone-associated TdP and 16 cases of QTc prolongation [were] reported [to the FDA’s MedWatch Program].”

After substantial field review, AATOD has released guidelines that differ substantially from those published in the Annals of Internal Medicine:

“Consider a baseline and follow-up 12-lead ECG for patients with ‘a history of arrhythmia, prolonged QTc, a family history of premature death, and/or other significant arrhythmia risk factors’ on admission or for suspected arrhythmia risks in ongoing methadone maintained patients."

“Refer for cardiac consultation cases of cardiac conditions affecting heart rhythm, unexplained syncope, or seizures or s significant increase in QTc from baseline."

The guidelines also recommend that OTPs develop a Comprehensive Cardiac Arrhythmia Risk Management Plan that includes ‘”the type, threshold and frequency [of arrhythmias] for screening and monitoring.”

AATOD believes that these safeguards, individualized induction practices, and informed and appropriate monitoring and follow-up offer the best protection for patient safety. AATOD further believes, “Prospective clinical trials are needed before routine ECG screening can be endorsed.”

For the complete AATOD recommendations, visit http://www.aatod.org/qtc.html

ECG screening will be a featured topic at the AATOD Conference, April 25 through 29 in New York City. A discussion, “What to Do About QT: Assessing and Reducing Cardiac Risk in the OTP,” will be held Tuesday, April 28, from 10:30 to noon. Speakers include three authors of the Annals article. Audience comments will be incorporated into CSAT’s field review process.

American Association for the Treatment of Opioid Dependence (AATOD) Conference
April 25-29, 2009

New York, New York

Contact: 856-423-3091 or http://AATOD.org

Certain methadone patients—especially those who are on high doses or taking other drugs that impact QTc levels—face some risks when taking methadone. But if mandatory ECG screening is established, some OTPs will not have the resources to comply. Already some programs have considered limiting methadone doses to 100 mg/day.

Some programs will pass along the compliance costs, either by raising fees or by requiring patients to obtain an ECG from a primary physician and return the results to the OTP. Insurance and malpractice costs will rise. There is a need to find some way of balancing the risks of TdP and enabling patients to access MAT without creating additional barriers and increasing the stigma associated with methadone maintenance treatment.

In most cases of hepatitis C virus (HCV), the virus is transmitted through contact with infected blood, usually through the sharing of needles and other drug injection instruments. However, for up to 20 percent of HCV infections, the method of transmission is unknown.

Researchers have suggested that for some of these cases, HCV may be transmitted through the nose via the use of contaminated drug-sniffing implements. To test this hypothesis, investigators tested mucus samples from 38 intranasal drug users with chronic, active HCV infection for the presence of blood and HCV. They also asked participants to snort air through a straw in a way that would mimic their normal drug-sniffing behavior to determine whether sniffing implements became contaminated. The straws were then tested for blood and HCV.

The investigators found trace amounts of blood in 74 percent of mucus samples and on 8 percent of the straws used for sniffing. In addition, they detected HCV in 13 percent of mucus samples and on 5 percent of the straws. Only 8 percent of the samples contained both HCV and trace amounts of blood. Participants had a high rate of nasal inflammation and other nasal problems, including nosebleeds and damage to the inside of the nose from drug use, which may have contributed to the passage of blood and HCV from the nose. These results lend support to the hypothesis that HCV can be transmitted through shared use of contaminated sniffing implements, stated the authors.

Reference: Aaron S, McMahon JM, Milano D, Torres L, Clatts M, Tortu S, Mildvan D, Simm M. Intranasal transmission of hepatitis C virus: Virological and clinical evidence. Clin Infect Dis. 2008;47(7):931–934.

Source: National Institute on Drug Abuse (NIDA) News Scan #60 – March 24, 2009

The West Virginia Gazette reported on March 21 that there is a proposed bill in the West Virginia House of Delegates that would tax nine Opioid Treatment Programs (OTPs) $1 for each dose of methadone that they dispense. Projected yearly tax revenues are estimated at $1.5 million. The tax revenues would fund prevention, early intervention, and recovery programs for opioid-dependent people.

One OTP regional director called the proposed tax “discriminatory” citing that “the legislation wouldn’t tax people who get methadone for pain treatment. Nor would it tax other medications used in opioid addiction treatment.” Supporters of the tax say the state is looking for a more versatile approach to addiction recovery including increasing the number of beds for long-term recovery. The article can be accessed at: http://wvgazette.com/News/200903210417

Source: West Virginia Gazette – March 21, 2009

From The Editor:  I must say I do believe they are discriminating against methadone but since most all of their Methadone Maintenance Treatment Facilities are owned and operated by CRC Healthcare, I'm all for it.  I receive complaints every day from patients
attending CRC-Owned Methadone Maintenance Treatment Facilities and they can't all be lying when they come from different states. I believe they have sown bad seeds and now hopefully they will begin to reap what they have sown.    

We have opened up a new methadone forum.  I am extending a special invitation to all the patients attending methadone maintenance treatment to join with us. We will be discussing among other issues what's happening in your treatment facilities. We want to know if you are treated with dignity and respect? We are interested in compiling a list of the problems you are having at the ones you attend. We need your input and we need you to join with us for change. You can join us by clicking on the URL and it will take you to the new forum: Methadone: A Flicker of Light In The Dark .


I realize I haven't been adding much new information lately and as I mentioned before I have been dealing with my own problems which are indirectly connected with methadone and "Rate Your Program."  Twice I had to temporarily remove "Rate Your Program..." I think most of you can imagine why...because some of the treatment facilities didn't like the remarks made by some of you.  We are making some progress but if I had not taken it down I would not have received my methadone... I apologize for being as weak as I was but without the methadone, I wouldn't be any good to anyone. It is back up now and I am encouraging all of you to continue to post.

I have transferred to another treatment facility and I feel confident it is going to work out for me. I will tell you more about the new facility I am at later because I definitely want to recognize it because it has earned my respect. If you are attending one you feel should be recognized then we want to hear about it.  We want to take the time to recognize all the treatment facilities treating us like human beings with dignity and respect. We want them to know how much we appreciate them therefore, I am asking all of you to write me if you think yours is worthy and if there are any special people there you would like me to mention their good deeds. I will be trying to make an effort each month to update you on what is happening and maybe even adding some new articles.

Please send me an e-mail with your name and phone number if possible and tell me about your treatment facility. Please include the name and address of it and if there are any special people you would like for me to mention and tell me why they should be
recognized. I will not only publish what you wrote about them but send them a special thank you card form "Medical Assisted Treatment of America."  If you really appreciate them ..take the time to let me know and include your name and address and we will send you a gift card for dinner if we should choose to publish yours. They are few and far between but I am sure there are some very good ones available and I for one would like to recognize them.

I have been diligently working on a new methadone website.   If you like this one, then you will love the one I am working on. I haven't had any one to help me but I will get it finished before the end of the year. It will have alot of amenities you don't have on this one.  I really had no idea of how to build a website when I started on this one and I had to get it up in a hurry but I am taking my time on the new one and I know what I am doing for a change. It is another reason I stopped adding news and updated articles but I feel like I am going to have to keep you updated to some extent while I finish the new one.

I do have some wonderful people working with me and they try to keep your e-mails answered and I have Moderators on both forums available for you and of course, we still answer calls twenty-four hours, every day of the year. If you can't afford to give us a call then you can let them know or send me an e-mail with your name and phone number and the best time to call and we will call at our own expense.  You always have access to us if you really need to talk with someone because we do understand there are times you need human contact.

I know I must bring all of this to an end but I just wanted all of you to know why you haven't heard from me. I wanted to update you on what is happening here and to let you know we are all working as much as we ever did to make things easier for you.   I am closing for now and will include our phone numbers and e-mail address. Please let me hear from all of you and if we haven't answered your e-mail then just hang on  for we are running behind but I promise you we will answer.

I want to leave you with one thought: Think on it.


"You will become as small as your controlling desire; as great as your dominant aspiration."  James Allen    

We can be reached at:   Office   (770) 428-0871   (Cellular)  770-527-9119

All feedback is appreciated. If you need to reach me, send your e-mail to:


If you need for us to give you a telephone call because you can't afford to call then send your requests to. If it is Urgent then type urgent on the subject line.


Have A Happy Easter!   

Editor:  Deborah Shrira                             Dated:  April 2009