By Ella Nilsen

Sentinel Staff

Few people are on the road at 5:30 a.m. But drive past the Keene Metro Treatment Center on Route 10 in Swanzey any day of the week, and you’ll see cars pulling into the parking lot and people meandering to the back entrance of the building.

Here, they pay $17 a day, are given their methadone doses and see counselors.

Early morning is the busiest time for methadone clinics. People from across the region drive to the clinic daily, some before they go to work.

Keene Metro is staffed by a program director, a medical director, two nurses and three to four counselors.

It serves about 220 clients, according to statistics Program Director Carrie Lemay shared at a recent community forum on heroin. Based on the most recent data from the N.H. Department of Health and Human Services, 81 of those are on Medicaid. Many other clients pay for their treatment out of pocket, but a spouse of a former client said the clinic accepted private insurance.

Medicaid — a federal insurance program for low-income people that’s funded by state and federal taxes — reimburses the clinic $10.50 per patient, per day. Medicaid also reimburses clients for their mileage to and from the clinic, based on the shortest route on Mapquest.

Keene Metro, which opened in 2006, appears to have started without a Medicaid option; then-Program Director Donna Higgins told Swanzey Planning Board members all clients would be private-pay.

According to Swanzey Planning Board documents from that year, Colonial Management Group officials said there would be a staff-to-client ratio of 1 to 40, and said there would be about four clients in the building at any given time.

Keene Metro director Lemay said she couldn’t talk to a Sentinel reporter for this story and Colonial Management officials did not return multiple calls and emails for comment.

A potential for impairment

At the beginning of methadone treatment, clients are generally started out on doses of 20 milligrams, according to Dr. Nels A. Kloster, a Brattleboro-based physician who specializes in addiction medicine. From there, the dose is supposed to be raised gradually, until the patient reaches what Kloster calls the “Goldilocks” range: “not too hot, not too cold.”

The dose a patient receives depends on how severely he or she is addicted, which can vary widely from individual to individual, said Kloster, who also serves as the medical director for Brattleboro’s Habit OPCO methadone clinic.

A dose should be high enough so the patient won’t feel sick, but low enough so he or she can’t get high or nod off. The standard dose for severely addicted people ranges between 80 milligrams to 120 milligrams, Kloster said. A 2002 brief on methadone by the Centers for Disease Control and Prevention had the standard ranging from 60 to 120 milligrams.

But problems with dosing can occur if patients aren’t being honest with staff about their tolerance, Kloster said.

“A lot of people can play the system so they have their dose out of the Goldilocks range, so they fall asleep,” he said. “If people are playing a game with treatment and trying to get high all the time, things start to fall apart.”

Doctors, nurses and counselors at methadone clinics must be vigilant and make sure patients are not getting too much of the drug, Kloster added.

A day in the life

At Keene Metro, former counselor Christopher Rossey saw patients’ doses range from 40 to 200 milligrams, he said.

During the time Rossey worked at Keene Metro, there were times when the staff-to-patient ratio was closer to 1 to 50, he said, higher than what was proposed before the center opened.

Being a counselor at Keene Metro meant long hours and many clients to look after, said Rossey, who worked at the clinic from October 2008 until December 2012.

“Four years, two months,” he said in a recent interview. “Longer than most people.”

But despite the long hours and responsibility, Rossey still praised Keene Metro and Colonial Management Group.

“I think the company really did the best they could,” he said, adding staff was dealing with a large number of addicted patients. “You’re talking about an area that is rural … percentage-wise probably has a high rate of opiate use.”

The Monadnock Region has seen a spike in opiate use in recent years.

Out of the N.H. Attorney General’s Drug Task force teams, the one covering western counties including Cheshire, Sullivan and parts of Hillsborough is the most active, according to Keene Police Chief Kenneth J. Meola.

Approximately 95 percent of the cases the western division investigates are opiate-related, Meola said.

Overall, Rossey said he believes Keene Metro Treatment Center is effective at helping patients, saying that during his time the clinic did really well at having patients “take ownership of their treatment.”

One of three counselors (the clinic hired a fourth during Rossey’s last year-and-a-half), he typically managed a caseload of 50 clients, although it could be more, he said. By New Hampshire law, he was required to provide eight hours of counseling per month to each new client for the first six months. Required counseling hours decrease every six months a patient is in the program.

The first three months of treatment put more of a focus on individual counseling, Rossey said. After that, it was more case management, which included checking to see if clients were applying for jobs, he added.

Rossey said he thinks the clinic should provide more counseling to clients, especially after one increases or decreases a methadone dose, to see how he or she responds to the drug.

Each day at work was extremely busy, Rossey remembered.

“I would show up at 5 a.m. and aside from maybe 30 minutes in the afternoon, your feet are on the pavement; you’re always moving, always talking to somebody,” he said.

And with so many patients to see, Rossey said he had to work hard to keep up with the load.

“It was hard; it was a stretch,” he said.

Staff turnover was frequent. Rossey said the clinic’s program director changed twice while he was there. At one point, staff was without a program director for six months, while interim directors from the company’s regional staff filled in, he said.

But Rossey said patients’ doses weren’t raised indiscriminately at Keene Metro and he never saw a patient nodding off at the clinic.

Counselors first had to decide whether a higher dose would benefit the patient emotionally and help him or her avoid discomfort, he said. They then had to put in a request for the patient, and staff would verify it.

If there was a question of a patient still using other drugs during treatment, a nurse would assess him or her at “potentially any time,” Rossey said.

“In my experience, every time that was discovered, there was a high attention to providing urine drug screens; there was a counseling intervention.”

A lack of transparency

One way Rossey said he believes the clinic could improve is by being more transparent.

“More engagement in the community,” Rossey said. “Really take down those walls and get out there.”

When a Sentinel reporter went to Keene Metro in the spring, staff told her she could not talk to patients in the clinic’s parking lot. Pointing to the federal Health Insurance Portability and Accountability Act (HIPAA), staff told her she had to leave the property.

Keene Metro’s Program Director Carrie Lemay recently spoke at a community forum on heroin and prescription drug abuse, held on Sept. 1 at Keene High School.

At that forum, Lemay said methadone does not affect clients’ ability to drive or give them withdrawal symptoms.

“It’s just incredible the lives they have begun to live again,” Lemay said of Keene Metro clients. “Yes, unfortunately it’s another drug. And if they have to come daily for the rest of their lives, that’s what they’re going to have to do ...”

Lemay also said members of the public were welcome to come to the clinic and see it for themselves.

“I have no problem ever having anyone come to the clinic,” she said. “It’s very homey. ... I’d be happy to just tell you it’s a really, really good place to be right now. It makes me proud to be a part of it.”

But when the same Sentinel reporter approached Lemay after the forum and asked if she could visit the clinic, Lemay said no, and added she could not talk to the media.

A way to check

At Habit OPCO in Brattleboro, Kloster said he and his staff monitor new methadone patients very closely, sometimes asking them to stay at the clinic for a few extra hours so they can check doses and make sure patients aren’t getting sleepy when their dosage peaks.

Habit OPCO sees about 175 patients with three counselors. The clinic also works with the Brattleboro Retreat to provide some counseling services.

If a patient is falling asleep in the waiting room, staff will put him or her on a lower dose, he said.

Habit OPCO clinics have their own protocol, which differs from the standards used at clinics owned by Colonial Management Group, Kloster said.

“The Metro clinics, I’ve seen their protocol and it’s much more aggressive than the protocols we use,” he said. “Their average dose is significantly higher than our average dose is.”

Kloster said some of the clients at his clinic have transferred from Keene Metro, where their doses were too high, in his opinion.

“It’s much more rapid than I would be comfortable with,” he said.