Prescribing Methadone, Pursuing Abstinence
from a lecture delivered at the
International Congress of Toxicology
June 6-7, 1992 Florence, Italy
contributed to DRCNet by
IntroductionIn early June of this year, a New York Times article quoted my distinguished colleague and fellow panelist here in Florence, Professor Herbert Kleber, as referring to a cartoon about Humpty Dumpty. (The cartoon appeared originally in The New Yorker, July 24, 1978.) As every child in the United States knows, Humpty Dumpty was a big egg - one that " sat on a wall and had a great fall." The nursery rhyme culminates in the unhappy observation: "All the King's horses and all the King's men couldn't put Humpty together again." In the cartoon, the King is telling his ministers: "This simply proves to me that I must have more horses and more men!" In the so-called "war against drugs" in America, that pretty well describes the conclusion which has been drawn from our past failures.
New York City has an estimated 250,000 intravenous heroin addicts. The funded capacity of methadone programs available to serve this population is 33,000; the programs are filled. Drug-free residential programs have a capacity of about 6,000; they too are filled. These figures, in a nutshell, summarize the failure to deal with heroin addiction in New York.
New Yorkers take pride in the uniqueness of their City, and in many ways (both good and bad) New York indeed is without parallel. When it comes to inadequacy of addiction treatment capacity, however, New York has plenty of company. A wide gap between the need for addiction treatment and its availability is the rule rather than the exception in major urban centers throughout the world.
>From a humanitarian standpoint, this situation is shameful; from the perspective of societal self-interest, it is suicidal.
Denying treatment to large numbers of individuals who engage in behavior that is potentially lethal to themselves and is associated with staggering costs to the general community is simply insane!
Such harsh criticism applies because we know addiction treatment is effective, and that it can be implemented promptly and on a massive scale. These attributes - demonstrated effectiveness and ability to expand rapidly - apply particularly to methadone maintenance. While all therapeutic efforts which offer help and hope to addicts have a legitimate claim to public support, methadone treatment is in a class by itself.
This recitation of the effectiveness of methadone treatment is not hyperbole; it is supported by the published experience over the past 25 years of programs throughout the world. Also amply documented is the ability to develop methadone maintenance treatment quickly, and on a very large scale. Between 1969 and 1972, New York City increased the number of methadone maintained patients from 1,800 to over 30,000. Beginning in 1975, Hong Kong established a network of methadone clinics which within two years accommodated over 10,000 patients per day. A decade later in the Australian State of New South Wales, the number of patients receiving methadone treatment quadrupled from 800 to almost 3,200 over the course of two years.
Methadone Maintenance: The Persistent Obstacle To AvailabilitySo, what's the problem? Methadone treatment exists. Its benefits are substantial for the individual patient as well as for the society as a whole, and have been documented for decades.
Perhaps most importantly, we know that when a commitment has been made, no obstacle - fiscal, site acquisition or staff recruitment and training - need preclude rapid and massive expansion. So why are heroin addicts, desperate for the help that methadone offers, thwarted in their efforts to gain admission because of the huge disparity between demand for and availability of treatment?
Clearly, one must seek the answer to this puzzle by analyzing the continuing controversy surrounding methadone treatment. But what precisely is the issue that is in dispute? Superficially, one might think that the focus of the debate is simple and clear-cut: Methadone - Yes or No? If that indeed were the case, however, the battle would be over and the "pro" voices would have carried the day. Methadone maintenance exists in Europe, Australia, Asia and South America, in addition to almost all of the 50 states in America. In recent years, presumably because of the onset of the closely related scourge of AIDS, even those countries which previously had refused adamantly to permit so-called "substitution treatment" of heroin addiction have relented.
Germany is a case in point: In a period of less than five years, methadone treatment programs have been initiated in eight States.
Obviously, therefore, the challenge to methadone maintenance advocates is not the introduction of this form of treatment. Nor is there any serious threat of reversal of past gains in this regard; there are few demands that existing methadone programs be closed. In New York City, for example, even the most intemperate critics have not suggested that 33,000 former hard-core heroin addicts, now stabilized on methadone, be returned to the streets to resume their deadly habits of shooting dope.
So what is the problem? Why is methadone treatment both permitted and provided, but under such constraints that only a very small segment of the population that could be benefited is given access to it? As recently as last year, I postulated that the problem lay in misunderstanding of basic pharmacology, leading to the erroneous contention that methadone patients get high from the medication. (1) With some embarrassment, I now have to acknowledge that I view this as a secondary obstacle to the acceptance of methadone maintenance treatment and its delivery on the scale which is required. The primary explanation seems to me to be the rejection of the concept underlying methadone maintenance treatment by the very people who support it and who provide it - and the irrational, counter-productive policies and practices which are the consequence of that rejection.
To return to the fundamental problem of lack of treatment for those who want it and need it : Tens of thousands - in New York City, hundreds of thousands - of addicts in major urban centers around the world lack access to treatment which is known to be highly successful in overcoming personally and socially destructive self-administration of heroin. I have suggested that this situation reflects rejection of the underlying concept of methadone maintenance treatment even by those who support and provide it. But what exactly is the "concept" that is so tough for people to swallow? What was it that Dr. Dole and Dr. Nyswander originally proposed which today, 27 years later, is still anathema to the supporters of methadone maintenance no less than to its overt opponents?
Fitting Square Pegs Into Round Holes: Methadone Maintenance Within The Abstinence ParadigmThe seminal contribution of Dole and Nyswander was not the demonstration that methadone, in constant daily doses, can allow many long-term, criminal, recidivist heroin addicts to lead healthy and productive lives. Rather, it was their revolutionary proposition that there is a physiological component of addiction that might contribute to its etiology, but that certainly is a factor in its perpetuation.
Dole and Nyswander postulated that repeated exposure to exogenous opiates could permanently alter the body's homeostasis, and that methadone might correct this physiological abnormality while at the same time "blocking" the acute effects of short-acting narcotics such as heroin. Their hypothesis was remarkably prescient; not until many years later, with the discovery of the endorphines, could skeptics be given a plausible scientific basis for this theory.
As yet, of course, there is no proof that addiction indeed is a "metabolic disease;" the concept, then as now, has been based largely on empiricism and common sense. Thus, if willful, defiant, anti-social hedonism accounted for the development and/or perpetuation of addiction, it would be impossible to explain why so many addicts seek voluntarily to enroll and remain in methadone programs; even more baffling would be the dramatic, favorable impact on their lives which this treatment can have.
The corollary is equally persuasive: If addiction were due primarily to a character flaw and a deficit in will-power, entering a drug-free program would, by definition, be evidence that "the problem" had already been largely overcome even before treatment commenced, and the results of such programs should be excellent. In fact, however, only a very small proportion of clients who begin drug-free treatment complete it, and an even smaller proportion subsequently are able to remain abstinent.
This is the reality even for patients admitted voluntarily, despite the motivation inherent in their application and admission, and despite the skill and compassion of staff (and, often, loved ones) who devote their lives to providing help and support.
Dole and Nyswander were remarkably restrained in their advocacy of methadone treatment even in the earlier years, when federal authorities in America threatened an absolute prohibition against the prescribing of methadone. Based on their hypothesis that addiction is a disease which, in many individuals, can not be overcome by willpower and psychosocial support alone, they suggested that some heroin addicts will require medication - methadone - to enable them to lead normal lives, free of illicit drug use and all the devastating consequences of such use.
Note that I attribute to Dole and Nyswander the qualifiers "many individuals," and "some heroin addicts." The fact is that they never claimed that methadone is a sine qua non for recovery of all individuals, nor that it need be a life-long treatment for every heroin addict. By not insisting that methadone maintenance is a universally applicable and necessary treatment, did they perhaps weaken their thesis that heroin addiction is a "metabolic disease?" Not at all!
There are a great many serious, physical illnesses which can be prevented, and/or whose signs and symptoms can be eliminated, by appropriate changes in lifestyle alone, without medication: asthma, hypertension, cardiac disease, gout, diabetes, peptic ulcer, colitis, a variety of cancers (for instance, of the lung and the skin), orthopaedic ailments - the list is endless. The caring, competent, holistically oriented health professional does everything possible to encourage and facilitate those behavioral changes which will prevent, mitigate the signs and symptoms of, and on occasion even cure these diseases. However, it would be professionally and ethically unacceptable (and ridiculous!) if physicians refused to prescribe medication to patients who will not or can not comply with the behavioral change prescribed, or whose disease persists and progresses despite their very best efforts.
Nevertheless, the paradigm of abstinence as the be-all and end-all of addiction treatment continues to dominate. Fifteen years ago, in an article entitled "The Irrelevance of Success," I wrote:
" the most destructive impact on methadone maintenance treatment has come from the seemingly more moderate critics who tolerate the use of methadone, but with certain qualifications . . . [Endorsement] has amounted to no more than the grudging approval to utilize methadone, but only within a therapeutic framework diametrically opposed to that which formed its original foundation. Today, the utilization of methadone represents only a modification of the drug-free approach, and a total repudiation of methadone maintenance treatment as employed so successfully by Dole and Nyswander." (5)
Nothing has changed in the past fifteen years. The rationale for "maintenance" treatment of addicts continues to be anathema, even to the majority of its self-proclaimed supporters. They continue to focus on a drug-free end-stage of treatment, and reject the premise that for many addicts this is an unachievable, unrealistic and irrelevant objective. Policies and practices which otherwise are incomprehensible take on a certain logic if one attributes to methadone programs the view that heroin addiction can and should be overcome without reliance on medication.
>From this perspective, both the medication (methadone) and those who need it are viewed pejoratively. This in turn leads programs (and regulatory authorities that govern those programs) to establish hurdles to discourage or reject applicants for enrollment in maintenance treatment, including severe limitation on availability of such treatment; to rely on low dosages of medication, despite evidence that such dosages are sub-optimal and potentially lethal; to set limits on the duration of methadone treatment, despite the fact that relapse is the rule rather than the exception when treatment (any treatment) is stopped; and to refuse to permit methadone administration without a strong "supportive services" component to deal with the psychological and social problems which they attribute to all addicts, and which they obviously believe are the basis for the patients' need for a "crutch." In sum, methadone is viewed as a regressive step, to be tolerated only in the hope that it will be followed by two steps forward in pursuit of the ultimate, universal objective of complete and permanent abstinence.
ConclusionThe experience of the past several decades demonstrates conclusively that drug-free treatment is simply not enough - not nearly enough! Stubbornly clinging to the paradigm of abstinence as the only acceptable therapeutic orientation, regardless how broad the spectrum of treatment options contained under that philosophical umbrella, condemns the vast majority of heroin addicts to continued suffering and, all too often, to death. At the same time, for society at large it perpetuates the incalculable costs associated with continued denial of help to those who want it, need it, and can be benefited by it.
It is high time that methadone maintenance not only be permitted and provided, but that its underlying rationale be accepted as well. Methadone treatment is not a sign of resignation or an acknowledgment of defeat; it is not an expedient to which one turns because it is cheaper or easier than other modalities; and its raison d'etre most certainly is not the expectation that it might help achieve a goal of abstinence.
I began this presentation with the assertion that the enormous gap between demand and need for addiction treatment on the one hand, and its availability on the other, is insane. I also referred to a cartoon to illustrate the inability of policy makers in my country - and in most other countries - to learn from their past failures by altering their fundamental approach to dealing with the plague of drug addiction. I will end on the same note, but in a more serious vein. A recent text on management practices defined insanity as follows : "The definition of insanity is continuing to do the same things and expecting different results." (6)
The results to date of our "war on drugs" have been woefully inadequate. More of the same is indeed insanity! Changes are imperative, and none is more vital than a commitment to ensure immediate availability to treatment of all types - and to methadone treatment in particular - to all those willing to accept it. This commitment can be met - but not if we persist in the view that nothing short of total abstinence is an acceptable therapeutic goal. The bottom line is straightforward: Addiction is a disease; it must be treated as such!
Bibliography1. Newman, RG: What's so special about methadone maintenance? Drug and Alcohol Review, 10:225-232, 1991. (back)
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