In modern history, few things have caused such a sharp spike in US deaths as drug overdoses.
“The heroin epidemic the country is suffering through, and the subsequent media coverage about the fight to conqueror this epidemic has opened my eyes tot he way people really view addiction…” Read More Below:
But our antiquated conceptions of addicts prevent us from doing so.
When I was 22 years old, I was treated for an addiction to opioids. In the five years since, I wake up each morning and scan my news filters to read about some of the 78 people who die each day from overdose. Which depressed Rust Belt city was hit today?
The opioid crisis is one of few in public health that, despite all efforts, continues to worsen. Nearly 2 million people in the United States are addicted to painkillers and an additional 450,000 are addicted to heroin. Fortunately, we have a proven way of lowering the death rate and easing the ills of addiction: medication-assisted treatments like methadone and buprenorphine. Unfortunately, thanks to a moral and policy-driven opposition to these treatment techniques, we’re not using it…[Read More]
“This is the first time I’ve ever been in here,” she says of Red Emma’s—her first time, despite spending almost every morning in this stretch of Maryland Avenue. Here’s the routine: around 6 a.m., Sanders goes to Institutes for Behavior Resources at 2104 Maryland Avenue for a dose of methadone and support group meetings. Then it’s off to Maryland Avenue Adult Day Care Center, a wide windowless building next door to Red Emma’s, where she gets help with her medications and doctor appointments and joins dozens of older white, black, and Asian members among the workout equipment, game room, cafeteria, and arts and crafts stations. (Sanders receives a monthly $1,200 “widow’s pension” from the U.S. Army; her husband, a Vietnam veteran, died in 2008. She says the clinic and the day care center are both covered by Medicaid.)
I ask Sanders what she’d like in her coffee. “Sugar,” she says with a smile. “Lots and lots of sugar.” Sanders says she’s grown to expect hostility from local businesses but here no one bats an eye as she squeezes in among the crowd seated by the windows overlooking North Avenue. Other places have been less welcoming. “The first thing they think is you’re here to shoplift,” she says. “They’ll say, ‘That’s why we don’t like you methadone people, get the hell out of here. Don’t stand around or we’ll lock you up.'”
Sanders started using heroin when she was 19 or 20 and living in Park Heights. She liked to party, and dope was everywhere. It was an occasional thing, but then her nose would run and her body would ache. “Everybody say, ‘Oh, that’s not a cold you have,’ you know what I mean?” she says. “Before I knew it, I had a habit.”
Until recently, she was living in Park Heights and taking two buses each way to Charles North. There are no methadone clinics in Park Heights—yet. Residents are fighting the opening of a clinic next to a day care center right now, but state legislation to block methadone clinics within 500 feet of child care centers looks unlikely to pass.
In February, Sanders moved in with her boyfriend, 54-year-old Moses McNeil, at the 20-story J. Van Story Branch, Sr. Apartments, a public housing tower at the corner of 20th Street and Maryland Avenue, right around the corner from her clinic.
It was on this stretch of Maryland Avenue, with a cluster of methadone clinics in a half-mile radius, that I first met Sanders in late January. On the morning of my visit, pedestrians jaywalked wantonly, petty arguments filled the air with Baltimore’s slurred opioid cadence, and a huddle formed around someone whose rapid hand movements resembled those of a blackjack dealer. Mornings here are never pretty, but that morning was exceptional in its messiness: a blizzard had left mounds of sooty snow and impassible sidewalks. Three middle-aged pedestrians in dark coats—Dee Jones, Sharon Johnson, and Sam Taylor—were walking south in the road’s one passable lane when a passing car gunned its engine and honked.
“Why you honking your horn?” shouted Jones, whose bright red cap and tote bag were the only spots of color around. “You see somebody you know?”
In the 2100 block, a soft-spoken security guard in a light brown uniform confronted a group of women standing on the sidewalk.
“Ladies, you gotta go in,” she said. “You can’t smoke out front. Put it out.”
The group broke up.
Like Jones, Johnson, and Taylor, Sanders and McNeil were there to visit a methadone clinic. Nearly 19,000 Baltimoreans used heroin in the past year, according to a city task force. Methadone maintenance programs help people quit heroin by substituting prescribed doses of a synthetic opiate that minimizes withdrawal symptoms and reduces cravings. A movement to treat addiction as a public health issue rather than a criminal justice issue has grown over the years. That treatment has to take place somewhere, though, and many methadone patients must come to the clinic every day to have their medicine dispensed. (There are strict rules regarding “take home” doses.) Wherever clinics have proposed opening in city neighborhoods—including, in recent years, Hampden, Hollins Market, Harwood, and Park Heights—calls for treatment have been subsumed by the din of residents and local businesses decrying the crime and grime they say follows the clinics. It is one of Baltimore’s defining civic conflicts.
In Charles North, there are two clinics in the 2100 block of Maryland Avenue alone. There’s another half a mile away. “There’s the trash, you’ve got throngs of people hanging out on the sidewalks, it’s not uncommon to see people passed out on neighbors’ stoops,” says Kelly Cross, who lives on the 2300 block of Maryland Avenue. Cross serves as the president of the Old Goucher Community Association and is running for the Baltimore City Council in the 12th District.
“The police acknowledge it,” he says. “The police all say, ‘We wish there was something we could do about it, but this is what happens when you have all the clinics here.'”
“It’s a bad idea to put them here in these locations with businesses and residents,” says a Baltimore city police officer one morning in the 2100 block of Maryland Avenue. (He asked to remain anonymous.) “Instead of getting methadone and leaving, they hang around all day. There’s a lot of buying and selling pills, constantly. They’re involved in prostitution and other crimes. Sometimes the street is cluttered with people, up and down like zombies—you know what they look like.”
In 2014, 192 city residents died of heroin overdoses. Critics of Baltimore’s treatment landscape say too many methadone clinics are concentrated in too few neighborhoods, with “saturation” in places like Charles North and large “treatment deserts” in west and northeast Baltimore (see map online at www.citypaper.com ).
Is there a way for neighborhoods and clinics to get along? And will Baltimore ever have clinics everywhere it needs them? Activists in Charles North think they have some answers, and they are appealing to City Hall and the State House for help.
In 2014, 12th District City Councilman Carl Stokes heard about a methadone clinic planning to open near Greenmount Avenue, about 10 blocks from the two clinics in the 2100 block of Maryland Avenue. Stokes and 14th District Councilwoman Mary Pat Clarke submitted a bill that would rezone 428 East 25th Street and a property next door so that use as a methadone clinic would require approval by the Board of Municipal and Zoning Appeals.
The city Law Department sent a letter warning that passage of the bill could attract civil lawsuits that would “inevitably run into the millions of dollars.” Two years earlier, a federal court had ordered the city to stop forcing small residential drug treatment programs to get “conditional ordinances” requiring a full council vote. That burden singled out people recovering from substance abuse, the court argued, a class protected under the Americans with Disabilities Act.
“It is clear from case law across the country,” read the letter from Chief Solicitor Elena R. DiPietro, “that the current scenario at the very least puts the City at great risk of violating the ADA should passage of the legislation prevent the opening of a methadone clinic on the subject property.”
Stokes says that solicitor’s recommendation that the bill not get a hearing “basically killed the legislation.”
By the time Stokes’ bill died, the Central Baltimore Partnership, a community development organization, had formed a “Saturation of Metropolitan Services Agencies” task force to deal with the problems it saw clustered around methadone clinics. The Central Baltimore Partnership asked a Charles North Community Association board member named Alan Mlinarchik to chair it. Mlinarchik, 57, lives in the Glen Arm section of Baltimore County but became involved in Charles North in 2009 when he bought a building at the corner of St. Paul and 21st streets. That’s two blocks east of the clinics on Maryland Avenue, and two blocks west of a state parole and probation office.
“I call this the boulevard of broken dreams right here,” Mlinarchik says. “You can sit here and just watch people trudging back and forth.”
Early on, Mlinarchik says, the task force supported legislation that would have allowed the state to deny licenses to methadone clinics based on the concentration of existing clinics in a given area. However, the ADA eventually colored the task force’s public strategy, Mlinarchik says, and the task force declined to back Stokes’ 2014 bill.
“We stood back,” Mlinarchik says. “We saw early on that zoning isn’t the way to do this. Every case where a municipality tries to use zoning, they get sued and they lose. Zoning is problematic because it says, ‘We’re going to separate clinics from other facilities, zone them out of existence, or prevent them from opening.’ That is discriminatory. Our argument is that we need to not just solve the problem of concentration but solve the problem of treatment deserts.”
In person and at a February 29 task force meeting in a dining hall at St. Mark’s Church in Charles North, Mlinarchik returns over and over to the message that the effort against clinic “saturation” is as much about the patients as it is about the community. In many neighborhoods with great need, he argues, there is little treatment, and where there is too much treatment, predators descend on methadone patients, trying to sell them other drugs. “They wade through this every day,” he said at the meeting. “We’ve heard from them. It makes it hard for them to recover.”
Mlinarchik’s professed concern for patients doesn’t mean, however, that he feels completely shackled by the ADA. “There is room to make decisions like this about the siting of medical facilities, specifically clinics, if it is in the interest of the protected class,” he says. “If you’re not hanging out with the people who are using, you are less likely to use. What we have in concentrated areas is the exact opposite of that.”
More decentralized treatment options, Mlinarchik argues, will lead to better treatment. “What happens when the interests of the patient diverge from the interests of the clinic?” he asks. “Where should the ADA come down? Our answer is the patient.”
Wanda Sanders and Moses McNeil know very well the challenges for those in recovery on the streets near their clinic, including people selling pills. “You see people nodding and they going all the way down to the ground, that’s not methadone,” says Sanders, who says she’s seen two people get hit by cars after walking into the street and going into a nod. “That’s methadone mixed with something else, the prescription drugs that doctors are prescribing to people: Clonidine, Klonopin, Xanax/alprazolam—’bars,’ which they call them out on the street.”
Sanders says methadone alone makes you feel normal, not high. The mixture of prescription drugs is called a cocktail, and it approximates the high of heroin. She’s tried the cocktail before—just to see what it was like, she says. “Man, it was horrible,” she says. “Who would want to be that comatose?” (There were 54 methadone overdoses in Baltimore City in 2014, including methadone prescribed for pain, not just opioid treatment. There were 22 benzodiazepine overdoses—Klonopin is a benzodiazepine, as is Xanax/alprazolam. In Maryland, more than half of benzodiazepine overdoses were in combination with prescription opioids, and almost one in five prescription opioid deaths were in combination with a benzodiazepine. )
Methadone alone is powerful enough, though, that even a day without it can start to trigger withdrawal, Sanders says. And so every day, she and McNeil make their way to the clinic, trying like so many other patients to ignore the fracas on the street.
“Some people really do the right thing,” Sanders says, “then some people don’t want to do the right thing.”
“We try to do the right thing,” says McNeil. “We stay together.”
“We come and go about our business,” Sanders says. “If you don’t, then [the clinic] will write you up, and they’ll give you a sanction for that. We’re not supposed to be on the property in front of the program or even on the corner hanging around, period.”
Sanders and McNeil met at Turning Point, a “walk-in” east Baltimore clinic that claims to serve over 2,100 methadone patients a day and tries to get new patients admitted in just hours. Federal guidelines require all methadone clinics to provide counseling, and Turning Point has a mental health clinic and a psychiatric nurse practitioner, but Sanders and McNeil regard it as a “gas and go” clinic. Turning Point Clinic founder Rev. Milton Williams did not respond to requests fror an interview.
“Ain’t gotta take no groups at all,” McNeil says of these kinds of clinics.
“You go get medicated and leave,” says Sanders.
Institutes for Behavior Resources, Sanders says, is not a “gas and go.” She has attended the clinic for four years, and she says the group sessions there, not just the methadone, help her and McNeil stay clean because they can talk about their problems.
“There are meetings throughout the whole day,” Sanders says.
“Till they’re getting ready to close,” adds McNeil.
“They try to keep everybody busy,” Sanders says, “so they don’t have to hang out anywhere in the neighborhood.”
Vickie Walters is a social worker and executive director of R.E.A.C.H. Health Services, the opioid treatment program at Institutes for Behavior Resources. On a tour of the program’s six-story building at 2104 Maryland Avenue, she points out the office of a “nurse care manager.”
“She might be out with a patient,” Walters says. “She’ll accompany patients sometimes to appointments.” The clinic also has a full-time nurse practitioner and reproductive health services, and it is part of the state’s “health home” program, which means it coordinates the treatment of patients’ substance use disorders with their overall health needs.
As Walters and I round a corner, we cross paths with a tall man. “Hey, Darrell,” she says.
Darrell Hodge, 59, works for the clinic as a peer recovery specialist. “I was just going downstairs, I’ve got some people there,” Hodge says, and we enter a conference room and meet several more men who are there for an “anti-stigma” group meeting.
“I never thought a methadone maintenance program was for me,” says one of the men. “I only wanted to go in the back door.”
Another man says he felt ostracized at Narcotics Anonymous meetings. “If you’re on methadone, they say you’re not ‘clean’,” he says.
“It’s bad enough that you have to deal with stigmatizing yourself and family and friends that stigmatize you,” Hodge says. “Some of the places you go for help, they stigmatize you, which can be discouraging. It makes it difficult to overcome.”
While critics of methadone clinics—like the Central Baltimore Partnership’s task force—say they have the interests of methadone patients at heart, the staff at Institutes for Behavior Resources believe those efforts increase the stigma and thereby make recovery more difficult. Both Walters and the clinic’s medical director, Yngvild Olsen, have testified in Annapolis against bills that could create more hurdles for those seeking a license to open a methadone clinic.
Last year, they opposed a bill from Sen. Joan Carter Conway (D-District 43, Baltimore City) that would have required the state’s licensing process to include a zip code-level assessment of existing opioid treatment slots and “the number of individuals in need” of treatment—in other words, an assessment of whether or not the zip code is “saturated” the way critics claim Charles North is.
When it comes to the inability of clinics and their neighbors to find a way to coexist, the feeling of being singled out is a major sticking point for the clinics. “It just strikes me you wouldn’t require that of a clinic setting to treat heart disease or diabetes,” says Institutes for Behavior Resources president Steven Hursh. “You wouldn’t say, ‘Are there enough people in your community who need orthopedic services?’ Applying a standard that is very specific to this particular disorder as if somehow it needs to be regulated to a greater extent—that’s the stigma that pervades the perception of this disorder and the people who provide treatment for it.”
Hursh and Walters say they are already extensively regulated, more so than other kinds of treatment. “We’re singled out in that respect, as well,” Hursh says.
“Today we actually have an auditor from Behavioral Health System Baltimore looking at charts,” says Walters. “Last Tuesday, we had an auditor from [the state’s] Behavioral Health Administration looking at charts and policies. Two months before that, we had someone from [the state’s] Office of Health Care Quality looking at charts and policies, then in a month from this week, the CARF [Commission on Accreditation of Rehabilitation Facilities] people will spend two days with us. The DEA [federal Drug Enforcement Administration] can pop in any time.”
It is activity outside the building, however, that generates complaints. Institutes for Behavior Resources shares a security guard with Man Alive, the clinic across the street, and they allow police to look at footage from their security cameras. The clinic also has a “diversion plan”—a federal requirement—to keep their methadone off the street.
Walters says all patients who have earned “take-home” doses get random callbacks. “If on a Monday they picked up 28 doses,” Walters says, “they may get a callback on Tuesday to bring back 26 doses.”
Federal guidelines do not stipulate when it is appropriate to kick patients out of the program, although the guidelines say “standard practice” provides for situations like violence, drug dealing, and “repeated loitering.”
“If a patient assaults another patient, they can’t stay here,” says Walters. Dealing drugs can lead to removal at Institutes for Behavior Resources, too.
“Sometimes we can see it on camera,” says Yngvild Olsen. “If it appears as if this is what is happening, we say, ‘You can’t stay here, you’re a threat to other folks and their recovery.’ The selling part, that’s where we draw the line.”
“If they’re buying,” however, says Walters, “that’s a symptom of their disorder. We’ll increase their level of care.”
That is in keeping with the federal guidelines, which suggest keeping patients in treatment with “intensified counseling” and mental health evaluations even after instances of drug dealing or loitering. But this fails to satisfy neighbors who don’t want those symptoms playing out blocks away from the clinic.
“We’re not asking for a policing effort on the part of clinics,” says Mlinarchik of the Central Baltimore Partnership’s Saturation of Metropolitan Service Agencies task force. “We’re asking for, as part of the therapeutic process, if you see somebody in your program standing on the corner buying or selling, you can go say to them, ‘This is not part of the program—this is problematic for your participation in the program.'”
Mlinarchik says he has compassion for those with substance use disorders. “But I think the solution is not to simply say, ‘We know you’re addicted and so anything you do is okay’,” he says. “There’s gotta be that mix of compassion and determination to get people out of the habits.”
Anti-loitering policies may look good on paper, Mlinarchik says, but “we’ve been told flat out by some providers, ‘We will never enforce them, we will never kick someone out of a program because that means we’ve given up on them.'”
Mlinarchik says he’s helping build a coalition of people who believe methadone and other opiate medications are “not the answer.” Their answer is group therapy and 12-step programs, he says, “not simply moving from illegal to legal substances.” I asked Mlinarchik if it was his task force’s position that meetings and 12-step programs are better than medication. He said it was not. “But we’re working with this group,” he said. “In the Venn diagram of what they’re doing and what we’re doing, the intersection is, ‘The current system ain’t working.'”
I asked Mlinarchik whether he thought a coalition that sounds almost anti-maintenance might antagonize or stigmatize methadone patients. “Well,” he answered, “we don’t want to stigmatize them, and that’s why I say we don’t have a complete overlap with the goals of this group. I won’t say we’re partnering with them. We’ve had discussions, because what we agree is, the current system is not ideal.”
Last summer, the Mayor’s Heroin Treatment and Prevention Task Force published a template for a “Good Neighbor Agreement” between clinics and communities. Institutes for Behavior Resources and the Central Business Partnership were already negotiating such an agreement a year before that. Those negotiations fell apart, and they have yet to sign one—despite the fact that Mlinarchik and Walters were both on the mayoral task force that drew up the template. During a February meeting with Walters, medical director Yngvild Olsen, and president Steven Hursh at the Institutes for Behavior Resources offices, I asked about the negotiations.
“It was not a ‘good neighbor agreement,'” said Walters. “It was very one-sided. It was like, ‘You will, you will, you will.'”
Walters says Institutes for Behavior Resources staff attended community meetings until about 12 or 18 months ago. “It became pretty clear that we were not wanted in this community,” she said. “It’s disheartening when you come to the table when we do want to be good neighbors and to get a sense that’s not something that can happen because revitalization and growth somehow means that we can’t be here.”
I asked Walters, Hursh, and Olsen whether they thought it was just a cut and dried “not in my backyard issue” for the critics of the clinics.
“I think that’s part of it,” said Walters. “I think they’re very savvy, they do present this in the light that they care about folks that come in our doors, and they don’t want them accosted by drug dealers and people trying to sell them other medications when they are trying to get recovery. But I can’t help but think that has a lot to do with it.”
The two sides don’t even agree on what’s happening in their backyards. Olsen says that studies in Baltimore City show that crime decreases around opioid treatment programs. An often-cited 2012 study of Baltimore by University of Maryland School of Medicine researchers in the journal Addiction found no differences between areas around clinics and the rest of the city when it comes to what the FBI calls “Part I” crimes, which include homicide, rape, aggravated assault, robbery, and arson. A January 2016 study led by a researcher at Johns Hopkins Bloomberg School of Public Health concludes that “violent crime associated with drug treatment centers is similar to that associated with liquor stores and is less frequent than that associated with convenience stores and corner stores.”
Critics of the clinics say they’re more concerned with nuisance crimes like drug dealing, which weren’t part of that study, and they do see a link between clinics and crime. Mlinarchik points to a 2004 investigation of five Washington, D.C. methadone clinics by the federal Government Accountability Office, which found that “patients frequently must navigate their way through a virtual bazaar of illegal drug dealing when they enter and exit the facilities.” Peter Duvall, a neighborhood revitalization manager for Strong City Baltimore (formerly Greater Homewood Community Corporation), crunched some numbers from records of district court cases archived by the Charles Village Community Benefits District and found that the sale of benzodiazepines—often part of the street “cocktail”—was the number one reason for drug arrests. Of the 48 drug arrests chronicled by the benefits district in the first ten months of 2014, Duvall says 44 took place within two blocks of opioid treatment clinics.
Mlinarchik says the Central Business Partnership is on good terms with Man Alive, the clinic across the street from Institutes for Behavior Research. “We’ve had lots of good productive conversations with them,” he says, and both sides have signed a “good neighbor agreement.” After an acrimonious start with Concerted Care Group, the clinic that opened near 25th Street and Greenmount Avenue in 2014, Mlinarchik believes they are starting to develop a better relationship with the community.
Wherever the relationships between existing methadone clinics and their communities are headed, the state’s Department of Mental Health and Hygiene is taking new steps to influence the location of new clinics.
In March 2015, the Maryland State Senate voted unanimously to pass Sen. Joan Carter Conway’s bill to assess methadone treatment “saturation” as part of the clinic licensing process. The Central Baltimore Partnership called it a “monumental” achievement. However, the bill never got a hearing in the House of Delegates. That summer, the Central Baltimore Partnership began meeting with Department of Health and Mental Hygiene (DHMH) and Delegate Peter Hammen, chair of the House Health and Government Operations Committee, about ways to address community concerns at the regulatory level.
As regulators continued working, however, legislators took another shot. This February, Del. Mary Washington (D-District 43, Baltimore City) introduced a similar bill, saying she was disappointed in DHMH’s progress. (Sen. Conway sponsored a cross-filed version of the bill.) At a March 11 House committee hearing, no one besides Del. Washington testified in favor of the bill. (The Central Business Partnership, says Mlinarchik, was “keeping its powder dry on the legislative front.”) In testimony against the bill, Barbara Bazron, executive director of DHMH’s Behavioral Health Administration, addressed community concerns.
“I’d like to emphasize the fact that we do not have zoning authority,” Bazron said, “so we are not in a position to say that a program cannot locate in a particular area. However, we can have the conversation and we can certainly present information that will inform the decision of the provider.”
DHMH acknowledges community concerns about the concentration of clinics in agency documents. In the effort to influence the location of clinics, the state agency plans to give more leverage to local addiction agencies like Behavioral Health System Baltimore, giving them data so they can “meet with prospective providers and direct them to areas of need.”
The chairmen of the committees handling Sen. Conway’s bill and Del. Washington’s bill have indicated that they will not move the bills forward. For now, changes in Baltimore’s methadone treatment landscape will rely primarily on any influence that state regulators and the city addiction agency can wield outside the shadow of the Americans with Disabilities Act. And while the state and city work on a way to steer clinics to where they’re most needed, the Central Baltimore Partnership has begun recruiting community associations all across Baltimore for a coalition to advocate for a citywide “master plan” for locating treatment facilities.
Now that Wanda Sanders is living at the corner of 20th Street and Maryland Avenue, she doesn’t have to worry about whether or not a clinic will be opening in her old stomping grounds of Park Heights. But moving closer to a methadone clinic hasn’t solved her biggest problem. What she really wants is to get off methadone completely.
“I’ve been on methadone on and off I’d say for about 25 years,” she says. “If I knew then what I know now, I would have gone cold turkey on heroin. I would never have gotten on methadone at all.”
Sanders believes methadone aggravates her many health problems. But the idea of never taking methadone again is daunting. Sanders has gone three days without methadone before, and that was hard enough.
“After that third day, I’m hightailing it down here, haha!” she says.
A change of scene might help. She says she and her boyfriend, Moses McNeil, are planning to get married and move to North Carolina, perhaps as soon as this summer.
North Carolina is over 300 miles away. But it’s a much longer road from 75 to 0 milligrams.
“I want to be off of it really bad,” Sanders says of methadone. “But I’m going to get there.”
an audience that included the U.S. surgeon general, a U.S. senator and top health officials from the city and state listened Friday as Charles Jones illustrated the reason they had gathered Friday at Chase Brexton Health Services in Baltimore.
Jones told them about coming to the center and each time being asked to draw a picture of himself.
“I always drew a picture of me with weights on my shoulder,” said Jones, 54, of arriving at the clinic to attempt, once again, to break a heroin addiction that began 26 years ago. “The last picture I drew, the weight wasn’t off my shoulder, but I could lift it. Chase Brexton, the program, it gives me hope.”
Lauding Jones for sharing his “powerful story,” Dr. Vivek H. Murthy, the surgeon general, announced $94 million in new federal funding for the kind of comprehensive, medication-assisted treatment nationwide that has made the West Baltimore man optimistic about his recovery. Murthy said the money will help about 124,000 new patients receive drug addiction treatment.
Chase Brexton, whose main clinic is in Midtown Belvedere, is one of five centers in Maryland that will share nearly $1.8 million of the funding intended to combat an alarming spike in recent years of overdose deaths caused by heroin and other opioid drugs, such as OxyContin and Percocet.
“The bottom line is this: Addressing the opioid epidemic is a public health priority of the highest order,” Murthy said. “A key part of that is supporting treatment. A key part of that is also making sure we change how this country thinks about addiction. We must help people understand that addiction is not a moral failing, but it’s a chronic illness that we have to treat with urgency, with skill and with compassion.”
Considering addiction as something in the mainstream rather than on the fringes of society has been a running theme in recent years as opioid-overdose deaths have cut a swath not just through inner cities, but suburban and rural areas as well.
In Maryland, 527 people died of heroin-related causes in the first nine months of last year — the most recent statistics available, and more than triple the number who died during the same period in 2010. In 2014, the last full year for which data is available, 578 deaths were attributed to heroin and 329 to prescription opioids.
Much as his predecessors have issued reports on public health issues such as smoking, Murthy said he will release one later this year on substance abuse and addiction. It will be the first time the office has issued a report on the topic.
“This is our opportunity to bring together the best possible science on prevention, treatment and recovery,” Murthy said after the announcement. “And it’s also our opportunity to reframe how the country thinks about addiction — as a chronic illness.”
The money announced Friday is coming from Affordable Care Act funding and is part of the Obama administration’s effort to improve access to medication-assisted treatment, which many believe offers the best chance of recovery, combining as it does behavioral therapy and drugs such as methadone and suboxone that help reduce cravings and withdrawal symptoms.
Health and Human Services officials said research shows that a “whole patient” approach in which drug users receive primary care as well as addiction treatment is successful.
Jones said he previously tried to quit without medication but now takes suboxone, which helps tamp down the craving for heroin. That, combined with therapy and the support of clinic staff makes him feel that he has turned a corner.
“I was just not really liking the person I was. I wasn’t raised to be addicted to drugs … or to be incarcerated because of my drug addiction,” Jones said.
“A couple weeks ago, I completed the first part of my program, and we had a little celebration,” he said. “One of the things that was most touching to me was my therapist, my primary care provider, my addictions counselor — they all attended the ceremony.”
CEO Richard Larison said the $300,000 that Chase Brexton will receive from Health and Human Services will allow an expansion of addiction services to its clinic in Glen Burnie, one of its five locations. Larison said some of the most frequent users of emergency services in Anne Arundel County are opioid users who might be better served in a clinic setting.
“Instead of going continually to the emergency room, they could get connected to comprehensive primary care and addiction services,” Larison said. “We think we can start to make a difference in what it is that’s going on. That’s where the money is going to be used.”
Among the officials attending the announcement were city and state leaders in the forefront of combating Maryland’s opioid problem — Dr. Leana Wen, Baltimore’s health commissioner; Lt. Gov. Boyd K. Rutherford, who headed Gov. Larry Hogan’s heroin task force; and Van T. Mitchell, Maryland’s secretary of health and mental hygiene.
Sen. Barbara A. Mikulski, representing the state’s congressional delegation, said Murthy had picked the right location to announce the new funds.
“We here in Baltimore have had a hardscrabble time with drugs for a long time,” she said. “Baltimore has been trying to lead this way … to look at it as a public health problem.”
Mikulski referred to the 94-1 Senate vote Thursday passing the Comprehensive Addiction and Recovery Act authorizing, though not allocating, funding to fight opioid abuse. She noted that it was the first time in months that congressional lawmakers had put aside partisan politics to address a national problem.
In February, President Barack Obama proposed $1.1 billion in new funding to address heroin and opioid abuse as part of the final budget of his presidency.
A total of 271 health centers in 45 states, the District of Columbia and Puerto Rico, are receiving part of the new federal funding that Murthy announced Friday. The other centers in Maryland are: Baltimore Medical System ($406,250) and Total Health Care ($325,000), in Baltimore; The Community Clinic ($378,604) in Silver Spring; and Greater Baden Medical Services ($379,167) in Brandywine.
Wen called the investment “a huge step in the right direction.”
While she has worked to expand access to the overdose-reversing drug naloxone, Wen said the key is to treat the underlying addiction.
A round-the-clock crisis and referral line that the city launched in October (410-433-5175) gets more than 1,000 calls a week, she said.
“Ultimately,” Wen said, “that person needs to be connected to long-term treatment.”
As the largest independent city in America, Baltimore, Maryland, has a lot of peculiarities and a lot of history. From the Battle of Baltimore during the War of 1812 that prompted Francis Scott Key to write the National Anthem, to the odd way in which the locals pronounce the “O” (“Owe say can you see…”) Baltimore has always been an engaging city. Edgar Allan Poe rests peacefully there as his woeful poetry lingers on, but the current state of Poe’s beloved Baltimore would disturb even him.
One of the reasons for an increase of overdoses in Baltimore is that the drugs are of a much purer quality than the national average, according to the DEA.
Though once nicknamed “Charm City” for the artsy and vibrant culture, Baltimore’s eclectic neighborhoods are now peppered with vacant and burned-out houses. Gritty portrayals of the city, like in HBO’s The Wire are all-too-accurate as they depict drive-by shootings and gangs running the neighborhoods. No one is refuting Baltimore’s dangerous reputation. “Bodymore, Murdaland” had the fifth highest murder rate in the nation as of last year, but it is now being plagued by a very different epidemic: heroin.
With an estimated 60,000 addicts among its streets, the city of Baltimore is being consumed by a devastating drug known for destroying the lives of its users, and those left to pick up the pieces. This number suggests that one in 10 Baltimore residents are addicted to heroin, a statistic that reflects Americans’ overwhelming shift from prescription drugs to the cheaper alternative.
While some remember the ’90s as being “heroin chic,” this drug was then considered much too unorthodox for some, and too impractical for others. Instead, opiates like OxyContin and Percocet were an especially popular choice for people in rural areas of the United States to get high. Known as “hillbilly heroin,” these pills were easy to acquire, and prices were fairly manageable for working class Americans who suffered from addiction problems. Today, however, these pills typically sell within the $50-60 range and many users, unable to afford the surge in prices, turn to heroin.
As prescription drug addiction continues to rise in America, where patients are routinely overprescribed narcotics, opiate dependency has led many to try heroin and even adopt it as their drug of choice. Buying a $20 bag of “dope” (sometimes of a relatively pure consistency) makes a lot more sense to drug users who often spend three times as much per pill.
And with the number of both heroin consumers and dealers growing every year, lower income neighborhoods, like many found in Baltimore, are particularly vulnerable to high drug activity. The city’s overall poverty rate is just above 25%, leading a large amount of its citizens to enter the heroin business and cash in on this new trend.
By sitting firmly in the middle of the East Coast, the geography of Maryland itself makes the state an easy target—a quick stop for drug dealers shipping their product up and down the coast. Most of Baltimore’s heroin enters the city this way, but the famous Port of Baltimore serves as a particularly convenient pathway for international drug smuggling.
The Port of Baltimore was established in 1706 as a port of entry for the tobacco trade with England. It was originally designed to accommodate the largest of shipping vessels, but today these are often stuffed with massive loads of illegal narcotics. For instance, in 2013, custom agents seized 128 pounds of cocaine that was shipped to the Baltimore port from Panama and China.
Fresh off the boat, these drugs are funneled right onto city streets by the thousands of dealers eager to make a profit, and the city’s war on heroin rages on.
As Baltimore’s addict population continues to grow, the media has taken notice.
The National Geographic documentary series Drugs Inc. recently aired an episode entitled, “The High Wire” that highlights Baltimore’s heroin problem. Showing junkies shooting up on the streets in broad daylight and drug dealers peddling at Lexington Market just a few feet from police, this show emphasizes the fact that a greater police presence does not seem to offer much of a solution.
Some, however, say that the National Geographic program sensationalizes the issue and does not accurately reflect Baltimore’s problems with drugs. In a Baltimore Sun article, David Zurawik disagrees with the number “60,000” saying:
“Second, the 60,000 number has never come close to being confirmed. The Sun tried to do so twice—in 2005 and, again, in July—and concluded that ‘it likely emerged from a blend of best guesses and misunderstandings’ dating back to at least 1986.”
However, a report by the Drug Enforcement Agency in the year 2000 stated that Baltimore had the highest per capita rate for heroin use in the entire country, and 15 years later, this still rings true.
With statewide overdose deaths attributed to heroin increasing by 88%, Governor Larry Hogan labeled it a “State of Emergency” in response, saying:
“Every state on the East Coast has declared a state of emergency except Maryland — and Maryland has the worst problem,” Hogan said.
To date, Maryland has not yet declared a “State of Emergency” and it is not clear why. Massachusetts and New Jersey have already done so, with Governor Christie organizing a special task force to address the problem.
In the meantime, Hogan’s speech has drawn a lot of public attention to the issue, and the state has followed Christie’s lead on assembling a special task force, to be led by Maryland Lieutenant Governor Boyd Rutherford. Additionally, recent efforts to prevent heroin distribution in Maryland include joining a six-state coalition to target a supply line of the drug along the East Coast, as New York and New Jersey provide nearly a quarter of the heroin found in Baltimore.
Many of the proposed solutions, including attempts to arrest more dealers, center around the idea of prevention. Lately, however, the bigger concern is the shocking number of overdose deaths in Maryland, and Baltimore, in particular. In 2013 alone, the city experienced over 300 fatal heroin overdoses, and an even higher number of emergency room visits.
One of the reasons for an increase of overdoses in Baltimore is that the drugs, most commonly originating from South America, are of a much purer quality than the national average, according to the DEA. Buyers consider themselves lucky to be given “raw” clean dope and reputable dealers make a point to cut the drugs with very little else, if at all.
Some dealers, however, maximize their profits by cutting the powder with substances like Fentanyl—a synthetic opiate that is approximately 15 times more potent than heroin. Users have no way of knowing what they are snorting, smoking or shooting into their arms, and many suffer the fatal consequences.
Thankfully, though, Maryland police have recently been required to carry the lifesaving medication, naloxone—a drug that can reverse the effects of an overdose. Quincy, Massachusetts was the first place in the United States to carry naloxone and it reportedly saved 230 lives in just four years.
Yet, even with the newly implemented law requiring this tool, many addicts fear being arrested more than the idea of death itself and are therefore reluctant to call for help. Although ingesting a substance is not necessarily cause for arrest, many know from personal experience that anything resembling heroin paraphernalia or drug residue means serious trouble in the eyes of the law. The much debated War on Drugs is not inspiring people to seek help for their addictions or even save their own lives as America has been conditioned to view addicts as criminals first and disease sufferers second.
One medicine that is far more commonly given to heroin users is the controversial drug methadone, and some clinics in Baltimore hand it out to scores of addicts amidst their personal horrors of withdrawal. As opiate-addicted patients eagerly wait for their medicine, their dependence on heroin lessens as their dependence on methadone increases. While the severity of addiction prevents a lot of these recipients from ever weaning off of opiates entirely, methadone has proven extremely beneficial, just in terms of harm reduction. Addicts that were previously nodding out at work and subsequently fired can suddenly find themselves able to live something resembling a normal life. Suburban women, now considered the “new face of heroin,” can come one step closer to overcoming their addiction, and stop having to smuggle Baltimore street drugs in their minivans.
Other substitutions for heroin like Suboxone, the orange strips that dissolve synthetic opiates into your bloodstream, are also considered beneficial in treating heroin addiction. Baltimore physicians are prescribing more Suboxone than ever before, and many drug abuse clinics report on the success that this treatment can provide for struggling patients. Still, a large percentage of people are unable to ever quit these alternative drugs, and clinics administering them are routinely questioned—often leaving these facilities short on necessary funding.
Aside from the chemical dependency aspect of addiction, researchers are also focusing on improving mental health care for addicts. Treatment centers like Baltimore’s Glass Health Programs describe therapy as an essential tool for recovery, in addition to offering medication assistance.
Whereas Maryland was once able to rely on organizations like AA and NA to provide recovering addicts with this type of service, the state’s current crisis reflects the growing need for more mental health centers focusing on substance abuse and recovery. Although Maryland’s task force plans to address the problem as a state-wide concern, Baltimore still remains the biggest obstacle in fighting Maryland’s heroin epidemic. As public opinion remains divided on how to aid the heroin capital of the United States, many are left wondering: what more can be done?
Julia Beatty is a student and freelance writer in NYC. You can follow her on Twitter @juliabeatty1.
Please read our comment policy. – The Fix
Methadone, as a treatment for opiate addiction, is one of the greatest medical discoveries of the 20th Century. Discovered by Dr. Vincent Dole, Dr. Marie Nyswander, and Dr. Mary Jeanne Kreek at The Rockefeller University in the 1960s, it has been approved by the World Health Organization, and it is used throughout the planet as a front-line treatment against the scourge of heroin addiction. While life-saving, it remains tragically misunderstood.
In 1988, Dr. Dole was awarded the Albert Lasker Award – also known as the American Nobel Prize – for the creation of Methadone Maintenance.
“The practical success of maintenance in rehabilitation of tens of thousands of addicts, now especially important as a measure of limiting the spread of acquired immunodeficiency syndrome, has been documented….”
“Then, as now, it was clear that narcotic addiction could not be eliminated simply by prohibition, however severe the penalties. For a chronic user, the need for narcotic is inelastic. With tens of thousands of such persons as a market, limiting supply without reducing demand increases the price of illicit drugs to the point that black marketers are willing to take the necessary risks. The net result is a highly profitable business for the drug sellers, corruption of government officials, infiltration of legitimate business with laundered money, increase in crime committed by addicts to support their expensive habits, filling of jails, and deaths from injection of contaminated drugs of uncertain potency. The clear lesson to be learned from repeated failures of past policy is that demand must be reduced by effective treatment.
The epidemic of narcotic use has not been extinguished by prohibition, civil commitment, jailing, or other punishments. …”
[In the original studies] “A remarkably different result was seen when, in the course of the scheduled testing, methadone was administered. The fluctuation in clinical state became less and then disappeared. Doses became stable. The patients seemed normal. Most remarkably, their interests shifted from the usual obsessive preoccupation with timing and dose of narcotic to more ordinary topics (Dole, Nyswander & Kreek, 1966).”
“The treatment is corrective, normalizing neurological and endocrinologic processes in patients whose endogenous ligand-receptor function has been deranged by long-term use of powerful narcotic drugs. …With long-term administration of narcotics, the modulating system is downregulated. The receptors become insensitive both to narcotic drugs and to their natural ligands. A new stability is achieved if methadone is given in an adequate daily dose, but at the price of continued dependence on the medication.”
“Objectively measurable physiological disturbances persist after detoxification from heroin or any other narcotic that has been used for a long time.”
“None of these theoretical speculations should divert attention from the fact that methadone maintenance is an available treatment for otherwise intractable addicts. It is effective under a wide variety of conditions provided that an adequate, constant daily dose is given. Like digitalis, methadone can be lifesaving. …
Apart from theory, the most striking fact is the physiological normality of maintenance patients. Persons who have taken a constant daily dose over a period of months to years are indistinguishable from normal peers. Despite a daily dose that would induce a coma in a naive patient, the patients are normally alert and functional; they live active lives, hold responsible jobs, succeed in school, care for families, have normal sexual activity and normal children, and have no greater incidence of psychopathology or general medical problems than their drug-free peers. Surprisingly, considering the constant input of narcotic, they have a normal response to painful stimuli, including specifically the warning symptoms of surgical emergencies.” – Dr. Vincent Dole (1988)
For more information, please go to:
Yes, guest dosing is possible when on methadone.
Here, we review the planning required and answer your questions about using guest services while on methadone. Then, we invite your questions about traveling while on methadone at the end.
Methadone and your travel plans
People in addiction recovery that receive opiate substitution therapy must be very organized while taking methadone. Missing doses can result in withdrawal symptoms, increased cravings, and/or relapse. So what happens when you go on vacation and travel while taking methadone?
Thankfully, many certified methadone clinics and dosing centers in America accept patients needing to guest dose. Protocols have been established for communication between your home program and a clinic that is near your vacation spot. But what kind of planning do you need to do? How much does guest dosing typically cost? And how do you follow up AFTER your vacation?
What you need to do to continue methadone therapy
AMS of Delaware, a health care provider located in Rehoboth Beach, Delaware, welcomes visiting or transitioning clients into the area. Their methadone guest dosing services have been in place for years to ensure that you can keep on a stable path to recovery. Today, we speak with Richard Ruby, the National Operations Coordinator at Addiction Medical Solutions, LLC.. In this interview, we talk about what you need to do to get methadone therapy while traveling and what options clinics offer.
If you have any additional questions about traveling while on methadone or want to leave a comment about medication assisted treatment for opiate addiction, please message us in the comments section at the bottom of the page. We try to respond to all questions with a personal, prompt reply.
ADDICTION BLOG: Roughly how many methadone clinics in the U.S. currently operate guest dosing services?
AMS OF DELAWARE: Every medication assisted treatment facility has the ability to offer guest dosing services to referring agencies. A rough estimate would be 250 + centers across the U.S.
ADDICTION BLOG: Where can methadone users usually find guest dosing clinics? Are guest dosing services usually set up in many cities or do clinics tend to offer these services near popular tourist destinations, for example?
AMS OF DELAWARE: Virtually every medication assisted treatment facility is fully equipped and capable of accepting guest dosing referrals, not just in high traffic vacation areas either. Clinical staff and patients alike can find guest dosing facilities through theFederal Tx Locator or by using medication specific, Buprenorphine Treatment Locator reserved for those patient taking Suboxone.
ADDICTION BLOG: What percentage of methadone users do you think currently use this option?
AMS OF DELAWARE: Rough estimate would be approximately 55% of patients use guest dosing options during vacation, however, requirements for coordination of care vary from state to state as the sole discretion belongs to the receiving facility once the last dose of medication is verified from referring agency.
Some programs require upwards of 2 to 3 weeks to accommodate for guest dosing requests whereby, AMS of Delaware, a member of Addiction Medical Solutions, LLC is able to accommodate in 24 hours or less for this purpose which makes vacation stress-free and convenient.
ADDICTION BLOG: What kinds of documents does someone taking methadone need to prepare in order to receive methadone while traveling?
AMS OF DELAWARE: Documents include:
- A Signed Consent
- A 30 day medication dosing history
- Proposed dates for guest dosing
**** NOTE HERE that one federal requirement is proof of valid identification upon time of arrival to any guest dosing facility. Furthermore, the majority of programs require mandatory locked storage containers for safeguard/security of health sustaining medication.
ADDICTION BLOG: Can a person travel internationally and receive methadone in another country?
AMS OF DELAWARE: One wants to be extremely careful traveling into international waters and in/out of certain countries whereby methadone is strictly prohibited even with a valid doctor’s order.
ADDICTION BLOG: Who IS NOT ELIGIBLE for guest dosing services and why? Ex. People going through induction.
AMS OF DELAWARE: In general, referral agencies frown upon accepting new patients within the first 90 days of treatment. However, Addiction Medical Solutions is capable of medically monitoring these cases with distribution of one medically observed dose of medication per day, again discretion lies with receiving agency to accept or decline requests. A few programs are unable to dispense odd number doses as their medication is prepacked through independent providers.
ADDICTION BLOG: How much does this service typically cost in clinics around the country? What is the range?
AMS OF DELAWARE: Most programs charge anywhere between $20 to $30 fees for one time registration plus $20 to $25 dollars per dose of medication.
ADDICTION BLOG: What happens if someone misses a dose of methadone while on the road?
AMS OF DELAWARE: Methadone has a half life of 48 hours, therefore for a patient who normally doses at 100mg daily, they would still have approx 50mg in their system the next day. Although missing a dose may be moderately uncomfortable, its not unbearable and will not provoke withdrawal.
ADDICTION BLOG: What about weekend dosing when clinics are closed (Sunday, for example)?
AMS OF DELAWARE: Generally, it’s understood that if the receiving program is closed for normal operations on Sunday, than a take home dose would be issued to cover for Sunday unless strictly instructed otherwise by the referring agency.
ADDICTION BLOG: Should people traveling out of town schedule an appointment with their hometown methadone clinic physician BEFORE leaving?
AMS OF DELAWARE: Yes.
Patients interested in guest dosing should always make an appointment with their counselor to make pre-arrangements minimum of two (2) weeks prior to departure for vacation. Plus, they should be well informed on pricing for guest dosing programs. In addition, they need to know the hours of the guest clinic’s operations and be informed about any other special instructions.
ADDICTION BLOG: What should happen when a traveler returns to their hometown methadone clinic? Do they needs to schedule an appointment with their physician AFTER travel, for example?
AMS OF DELAWARE: Absolutely not.
All the patient has to do is to turn in the empty take home bottles. Their home program makes a phone call to the referral agency to verify the date and last dose of medication received by the patient.
ADDICTION BLOG: Is there anything else you would like to share with our readers?
AMS OF DELAWARE: LIFE IS STRESSFUL ENOUGH. HOWEVER, GUEST DOSING DOES NOT HAVE TO BE; At least this is the viewpoint of Addiction Medical Solutions, LLC and its affiliate programs.
You can visit amsdelaware.com or www.addictionmedicalsolutions.com for further information or to find links to federal/state resources regarding addiction.
Photo credit: Jenifer Correa
Author: Dr. Fabricio Alarcon, MD, FACP
AMS of Delaware, LLC Medical Director
Chronic opiate/opioid use has been associated with weight gain. Medical literature links opiate use and development of a preference for sweet-tasting foods. The preference for sugary foods can lead to increased consumption of such foods potentially resulting in weight gain.
In fact, several studies have shown that chronic opiate use increases sugar intake. There are many reasons why this can happen. Let’s review some of them.
When patients start an opiate addiction/dependence treatment program, the cravings for sugary foods can be worse. One possible reason is that, during the induction phase, patients might be using the effects of sugar on the brain to stimulate production of dopamine to help them feel better and deal with the cravings. Consuming simple carbohydrates and sugar, for most people is also considered a pleasurable activity. As with any other pleasurable activity, it will stimulate your brain to produce and release dopamine. The more dopamine you produce, the more pleasure you experience.
Consuming simple carbohydrates or sugar will also stimulate the production of insulin in the pancreas, which will then go to the brain and release a chemical called Serotonin, which participates in feelings of well-being, energy, stress management, sleep, and overall helps people feel better.
Consumption of sugar has also been linked to increased pain tolerance, by increasing the production of an endogenous opiate called beta-endorphin, which helps attenuate pain sensation.
Weight gain is less of a problem when addiction therapy incorporates an opiate antagonist like Naloxone, which is often combined with Buprenorphine, found in a generic form and also in the following combination brand name medicines: Suboxone, Zubsolv, Bunavail. Naloxone acts in your hunger center (known as “hypothalamus”) and can have appetite-suppressing effects. It also acts in your brain’s pleasure and reward system (known as the “mesolimbic system”), by increasing the sensitivity and number of dopamine receptors. Dopamine effect on the mesolimbic system gives people pleasure. The higher the Dopamine effect, the higher the pleasure people experience. This effect helps people that suffer from addiction by making them feel they do not need to consume more and more of the addictive substance to achieve pleasure. This effect will then also help with cravings.
We, at Addiction Medical Solutions, want to make sure we offer our patients additional tools to help their journey and prevent some of the obstacles they may encounter, such as undesirable weight gain caused by the medications we might use to treat addiction.
Attached is some information that might be helpful to control the consumption of carbohydrates and hopefully prevent any undesirable weight gain.
Simple Ways to Control Carbohydrate Intake and Help Prevent Weight Gain
Consume no more than 130 grams of Carbohydrates each day. Keep track of food labels.
Eat 5 times a day (Breakfast, Snack, Lunch, Snack, and Dinner)
Eat in two to three hour intervals
Do not use Sugar
If you absolutely need to add sweetness, use a sugar substitute such as Stevia.
Avoid high carbohydrate, high glycemic index/load foods:
Especially avoid breads, pasta, rice, potatoes, sweets, sodas, fruit juices, energy drinks. Do not eat more than 20 grams of sugar (5 teaspoons) per day. Do not eat more than 10 grams of sugar (2 teaspoons) in one serving.
Do not eat foods where the sugar content is more than half the total amount of carbohydrates per serving.
No fruits for the first few weeks of your low carbohydrate diet plan.
Favor foods that are good sources of protein
Eggs, lean meats, and fish, legumes, soy, nuts
Favor Non-starchy Vegetables (see list below)
Drink at least 8- 8 ounce glasses of water each day
Read all nutritional labels for Total Carbohydrates
A friendly Website for Checking Nutritional Facts is:
Calorieking.com (This website offers free insight into nutritional labels for various types of foods)
It’s very important when starting out on a new way of eating to plan your food ahead of time. This really cannot be emphasized enough. Try to plan at least a week’s worth of menus, and have food on hand a few days ahead of time. Then you won’t be caught wondering what to eat and fall for the easy quick high carbohydrate food.
Some useful information about food groups:
Vegetables — Try to eat lots of non-starchy vegetables — at least three to five cups per day.
Protein Foods — The next runner up is typically protein foods. Large amounts of protein are found in eggs, meats and fish. Many people find that protein helps keep them satisfied longer. Eating protein also helps stimulate your metabolism.
The next groups are in random order and can be “ranked” depending on the individual:
Low-Sugar Fruit — Most people who cut carbs eat one serving of low-sugar fruit per day. Avoid fruit juice, which can lack the fiber and some of the nutrients of the whole fruit and raises blood sugar much more.
Nuts and Seeds — Nuts and seeds have lots of nutrients and, in some ways, can substitute for starchier foods. Nut flours can be used to make some baked goods. Among the seeds, flax seeds are especially healthful and low in carbohydrates; they can also be used in baking. The combination of fiber, protein, and healthy fat in nuts and seeds makes them satisfying, and they have many of the nutrients of the more starchy grains, such as wheat.
Fats — Although reducing carbohydrates usually means increasing fats, it is a common misconception that low-carbohydrate diets are loaded with saturated fats. Monounsaturated fats, especially olive oil, should be emphasized as a source of fat. The essential fats in foods, such as omega-3s found in fatty fish, are even more important.
Dairy Products — The amount of dairy you eat or drink will partly be determined by your sensitivity to carbohydrates. Milk has quite a bit of sugar, so we suggest using a product called “Unsweetened Almond Milk”.
Diary products in which the whey is removed (such as strained yogurt, cottage cheese, or other cheeses) have less sugar. If you don’t eat a lot of dairy, make sure you are getting calcium in other ways.
Legumes — Beans and other legumes, such as lentils and peas, have quite a lot of carbohydrate. But this is a type of carb that is either digested slowly or not digested in the small intestine at all (resistant starch). Therefore, in moderation, they are excellent choices for people who don’t process sugar well. They are also a good source of protein.
Whole grains — Whole grains, such as brown rice and barley, are tolerated by some people as a part of a moderately low-carbohydrate diet. Their starch is broken down into glucose more slowly than refined grains and flour. A serving of grains is about half a cup. Whole grain pasta should be cooked “al dente” (slightly firm), as the more you cook it, the faster it is broken down. If pasta is a “must have” in your diet, then inquire about low-carb high-protein alternatives, and we can discuss some options with you.
Sugary and starchy foods – These are foods which are rapidly converted into glucose, raise insulin levels and promote fat accumulation. Therefore, AVOID them.
- Foods made with a lot of sugar (candy, soft drinks, etc.)
- Foods made with a lot of flour (cakes, cookies, crackers, etc.)
- Fruit juices
- High-sugar fruits (dried and tropical fruits have the highest amount of sugar)
- Some condiments, such as barbecue sauce, some ketchup brands, and salad dressings (check labels)Starchy and non-starchy vegetables: look for low-starch/non-starchy vegetablesGreen VegetablesLow-starch green vegetables include spinach, turnip greens, beet greens, kale, mustard greens, amaranth greens, lettuce, broccoli, green beans, cabbage, cucumbers, peas, green peppers, Brussels sprouts, artichokes, leeks, scallions and zucchini.
Yellow and Orange Vegetables
Although many of the high-starch vegetables, such as pumpkin and sweet potatoes, reside in the yellow-orange family, some low-starchmembers also exist. They include yellow and orange peppers, yellow squash, carrots, yellow tomatoes and rutabagas.
Red and Purple Vegetables
Most vegetables in this category are considered low-starch: tomatoes, red peppers, red cabbage, radishes, rhubarb head the list of red vegetables with few carbohydrates. More blue or purple fruits exist than vegetables, but eggplant fits into this healthy group. Even though you might find beets listed in non-starchy vegetable lists, we do not recommend them as part of a low carbohydrate diet due to their high glycemic index.
Low-starch white vegetables include jicama, onions, cauliflower, turnips and mushrooms.
High-Starch Veggies: try to avoid
If you keep a strict eye on your carbs and starches, certain vegetables should be on your “watch” list. High-starch vegetables include potatoes, sweet potatoes, yams, parsnips, corn, mixed vegetable dishes like succotash, pumpkins, and other winter squash varieties.