Few advances in the field of substance abuse elicit such passionate feelings as methadone maintenance, a treatment created at Rockefeller University in 1965. There are approximately 350 methadone maintenance programs throughout the United States. In the five boroughs there are 102 programs, with the total number of patients at approximately 36,000. Yet there are an estimated half a million American heroin addicts, and approximately the same number of "social" or "regular" users. Eighty-two percent of the overall demand for alcohol and drug services is unmet and licensed programs have been operating at close to 100 percent capacity for years.
The History of Methadone Maintenance
First used in Germany during World War II, methadone was brought to the United States after the war. In 1946, Dr. Marie Nyswander began to study the effects of methadone at the United States Public Health Hospital in Lexington, Kentucky. Dr. Nyswander, a psychiatrist with extensive experience treating heroin addicts, served as a physician at the hospital. In 1964, she joined the research team of Dr. Vincent Dole and participated in the initial studies at Rockefeller University.
The research team at Rockefeller University was created by the pressing social and public health problem caused by the heroin epidemic of the 1960s. Studies conducted in that period indicated that between 70 and 90 percent of these chronic addicts would return to opiates within a short time.1 By the late sixties, heroin-related mortality was the leading cause of death for 15 to 35 year olds in New York City, serum hepatitis cases were up, and a record number of heroin addicts were being arrested for drug-related crimes.2
Over 30 years ago, Drs. Vincent Dole and Mary Jeanne Kreek began to experiment with different narcotic drugs to examine the clinical effect on long-term heroin users. The evident failure of morphine as a substitute for heroin indicated the need to find a drug with a long-lasting and stabilizing effect. Methadone, an experimental treatment for chronic heroin addicts, was chosen for two principal reasons: its duration of action and its ability to block a second drug. Methadone had the ability to return people to "normal" activity, allowing them to function in spite of the fact that it was an addictive drug.
In his Implications of Methadone Maintenance for Theories of Narcotic Addiction, Dr. Dole explained, "Our objective at the onset was simply to find a medication that would keep addicts content without causing medical harm and that would be safe and effective for use over long periods in rather stable doses. The goal of social rehabilitation of addicts was not part of the original plan. Merely satisfying addicts, although not an ideal result, seemed better than the existing policy that forced incurable addicts into criminal activity.3
The Good News
Methadone maintenance has been more carefully scrutinized than any other treatment modality. Research indicates that once a proper dosage of between 80 to 120 mg/day is reached, narcotic cravings are relieved, and the methadone serves to block the "high" of other drugs. Equally as important, a regimen of 80 mg/day protects the patient from overdose and respiratory depression if large amounts of narcotics are administered. This protection is strengthened at higher doses of 100 mg/day or more.4
Another important result which makes methadone an effective substitute for heroin is that patients do not feel high from methadone. Therefore, they are able to resume work, socialize, drive, raise families, and conduct their daily lives free from the constant craving for heroin. The medical safety and efficacy of methadone treatment has been reported for the past two decades. There are no known toxic side effects to methadone, even for patients who have received methadone for over 20 years. Moreover, patients do not develop tolerance to methadone over time, so dosages do not have to be increased to continue to have the blockage effect. Providers working in the field of harm reduction emphasize the fact that since methadone is taken orally, the risk of HIV infection from sharing needles is greatly diminished.
A social worker in a support program for methadone patients believes that: "Methadone helps stabilize addicts, and if they are of a mind to use that stabilization to better themselves and work on their recovery from other drug abuse, then methadone is a phenomenal support. But it's up to the individual's to how they use that support or what they do with the stability that methadone provides. For many people, methadone is saving their lives and keeping them out of the underworld of violence and crime."
The Bad News
Many people who are in recovery, who have gone through detoxification, rehabilitation, and ongoing participation in one of the 12-step programs (AA, NA, etc.) see methadone maintenance as the substitution of one drug for another. Methadone remains one of the most stigmatized modalities in substance abuse treatment, and controversy surrounds it to this day. According to Herman Joseph, a research scientist at the New York Office of Alcoholism and Substance Abuse Services (OASAS), "Such stigmatization has resulted in strong community opposition to opening new clinics in many locales (NIMBY -- not in my back yard), despite a need in many areas to stem the tide of HIV and tuberculosis transmission among addicts and the communities at large. Never in the history of medicine has a therapy been so thoroughly evaluated as methadone maintenance for effectiveness and safety and yet subject to such distortion, stigmatization, and regulation."5
Joseph continued, "What makes the stigma even more difficult is the fact that the acquiring of addiction is regarded as an act of willful behavior as opposed to a . . . condition that arouses compassion, such as a congenital deformity of the body or the loss of a limb through an accident or being born retarded. Since addiction is perceived as being self-inflicted, compassion is not forthcoming. According to advocacy groups like NAMA (National Alliance of Methadone Advocates), the stigma attached to methadone treatment is almost as painful, if not more so, as being addicted to heroin. Nationwide, thousands of employed ,socially rehabilitated methadone patients are under more increased surveillance than probationers and parolees ...Therefore, to be accepted in society on equal terms they must remain silent about their status as patients and their accomplishments while maintained on methadone."
Not all providers advocate methadone maintenance, however. Ten percent of methadone patients fail to fulfill their treatment plan; other patients leave because they request to be taken off methadone and follow the abstinence model. These patients are tapered off in dosage; unfortunately, half of them return to methadone treatment. According to Dr. Michael Mullen, Chief of Infectious Disease at Cabrini Hospital and member of the Body Positive Medical Advisory Committee, "There are many questions that we don't have answers for when it comes to methadone. Methadone has its place, especially if you're serious about getting off heroin. Addicts do better in the initial period of heroin withdrawal when they are on methadone."
"However, there have been very few studies concerning methadone and HIV. There are medical implications for the methadone patient who is also HIV-positive, particularly for a patient who has tuberculosis. Rifampin, which is a TB medication, is contraindicated if someone is on methadone maintenance. There are other possible interactions. While it has never been proven that AZT interferes with methadone, addicts are afraid it will lead them back to heroin."
Dr. Mullen added, "There is a certain stigma associated with methadone. Certain groups of addicts look down on methadone and think that those patients are still getting high. Ultimately, abstinence should be the goal of treatment because I don't think people can ever go back to mood-altering substances once they have an addiction problem. It's a daily battle, and I've never met people who, after years of abstinence, were able to return to social use."
Michael McGrath, a former five-year methadone patient, shares the opinion that abstinence should be the goal of treatment. "For me, methadone was just a replacement for another drug, and didn't really focus on the problem itself: addiction. I got on the program because I knew that I could go out in the morning and get my 'wake up,' get straight, without going to the cop man (drug dealer). I had an initial high from methadone, but once the blocking effect kicked in I just started chasing other drugs, cocaine and pills. I've heard about success stories from the methadone clinic, but I've never seen it. Most people I was with in the methadone clinic were involved in the same activities as active addiction."
Eduardo Abrams, also a former methadone patient, echoes many of the sentiments expressed by Michael. "Methadone just became a tool so that I wouldn't be sick, but it didn't address the addiction. I still wanted and needed to get high. I don't think that methadone maintenance is a successful harm reduction strategy for HIV prevention because if an addict on methadone wants to get high, he is still going to get high, on top of the methadone. The longer clean time that addicts have away from being high and numbing their emotions, the better able they are to put the focus on living their lives and accepting responsibility."
Myths About Methadone
This perception that methadone patients are out on the street getting high and selling their methadone on the black market can be explained by reports from the General Accounting Office that many methadone programs are not effectively treating heroin addiction.
A University of Michigan Institute for Social Research national survey of methadone clinics found out that one-half of the programs encouragedpatients to detoxify after only six months in treatment, notwithstanding the abundant evidence that premature detoxification results in a return to heroin use in 80 to 90 percent of cases.6
Equally pervasive is a less-is-more approach to dosage levels . . . study after study over the past two decades has demonstrated that adequate dosing -- typically 60 to 100 milligrams per day and sometimes more -- results in better treatment outcomes, including improved retention of patients in treatment, reduced illicit drug use (of heroin and cocaine) once and lower incidence of HIV.7
One social worker feels, "An underlying problem with methadone maintenance is that people become stabilized, they often substitute other abusive substances. For the patient to be able to deal with cross-addiction, the agency would need to provide counseling from within its own system or in the community that would reinforce harm reduction and recovery, and give patients a better chance to use methadone maintenance as intended -- to support people to become more productive and successful. It would also be esential for the provider to structure limits into their treatment so the patient understands they will not be maintained on methadone if they continue abuse over time. It is necessary for methadone maintenance providers to take responsibility to provide adjunctive support if they are asking patients to overcome an extremely complicated addiction problem that may have existed for many years."
A social worker who has worked with methadone patients thinks that "as methadone helps to stabilize those addicted to heroin, it is a real opportunity for patients to use this stabilization to work on their addiction to other drugs and develop skills to help them return to society. When people do this, they are using 'meth' for the purpose that it was intended, and it is a phenomenal support in their lives. For many, methadone has saved or is saving their lives and is keeping them out of the worlds of violence and crime."
Methadone and HIV
In light of the AIDS epidemic, methadone maintenance becomes an even greater harm reduction strategy. In a prospective study from Philadelphia, the rate of HIV seroconversion was four times higher in heroin addicts on the street compared to patients on methadone maintenance.8 Furthermore, a study conducted in 1994 found that of 3,787 patients entering methadone maintenance treatment, 28.5 percent were HIV-positive. Prevalence studies from the same time found that in New York City less than 10 percent of former heroin addicts who had entered methadone maintenance treatment prior to 1978 were HIV-positive, while at the same time over 50 percent of street intravenous heroin addicts were positive.9
The Medical Maintenance Model
The interaction between intravenous drug abuse and AIDS is a public health issue that requires the development of a continuum of care to meet the needs of addicts who don't usually enter the health care system. This continuum ranges from "low-threshold" clinics, where doses are administered on a daily basis, to full-service clinics providing counseling, primary health care, and family services. Federal regulations require patients to come in to obtain their methadone, as it cannot be filled by prescription. For the approximately 15 to 20 percent of "invisible" methadone patients who maintain jobs, this poses a significant obstacle. Dosages are given each morning at 7:30 a.m.
"At the other end of the spectrum, about 20 to 30 percent of the patients have dual diagnoses with serious mental illness, AIDS and other ailments. These patients could benefit greatly from a day hospital program, but there is no funding available for this. So, after all these patients get their medication and counseling they must leave the premises like other patients, no matter how frail they are," explained Dr. Robert Maslansky, Medical Director of the Bellevue Methadone Maintenance Program (MMTP).
According to Ethan Nadelmann, Director of the Lindesmith Center, a project of the Open Society Institute, "Methadone providers point to studies showing that 'high- threshold' clinical approaches are more effective than 'low-threshold' (e.g. interim program) modalities. But the other half of the picture is that low-threshold programs offering only minimal services besides methadone dispensing are definitely more effective than nothing at all, and may prove more attractive to hard-core heroin users who are unwilling to put up with the requirements imposed by high-threshold programs. For many, these programs can provide a bridge to more comprehensive treatment and other positive life changes."
According to a February 2, 1997 Associated Press article, Attorney General Janet Reno stated that, "Heroin is more plentiful, purer, and less expensive than it was just a few years ago. This is one of the most critical problems we face in fighting narcotics in this country today. If we do not counteract the heroin threat now, we risk repeating the terrible consequences of the 1980s' cocaine and crack epidemic."12 As heroin addiction rates and HIV prevalence increase, it is time to revisit methadone maintenance as a harm reduction strategy.
"There are important developments in methadone treatment taking place in Europe and Australia with their more progressive approaches to medical maintenance [i.e., treatment by primary care physicians and methadone dispensing via local pharmacies]," stated Ethan Nadelmann of the Lindesmith Center. With few exceptions, in the United States federal regulations prohibit pharmacies and general practitioners from prescribing methadone.13
In Belgium and Germany, general practitioners are the
principal means of methadone distribution.14 There are many lessons to be learned from abroad, foremost of which is to place addiction under the sphere of public health instead of law enforcement. The Institute of Medicine reached the following conclusion concerning the methadone debate: "Current policy . . . puts too much emphasis on protecting society from methadone, and not enough on protecting society from the epidemics of addiction, violence, and infectious disease that methadone can reduce."
The time has come to reevaluate what methadone can offer in terms of chemical dependency and HIV prevention. It's worth a second look.
This article was provided by Body Positive. It is a part of the publication Body Positive.