Methadone Treatment in Narcotic Addiction. Introduction

The Past and the Present

The most recent wave of concern regarding narcotic addiction in the United States culminated in early 1972 when drug abuse was proclaimed the major domestic crisis facing the nation (1). The alleged changes in the century-old problem of drug addiction which gave rise to this intense concern were as follows:

• The increase in the 1960's of the absolute number of addicted individuals
• The spread of the problem from urban ghettos to smaller communities and the middle and upper classes
• The rise in narcotic use among adolescent and preadolescent youths
• The increase of crime, attributed in large part to the growing addict population
• The reports of widespread narcotic use by American military forces and a growing concern over the impact of thousands of addicted soldiers returning to this country

In fact, each of these developments had played a similar role fifty years earlier in precipitating public alarm over addiction. In 1916 "...an estimate purported to establish that there were 200,000 highly dangerous drug fiends roaming the streets of New York City..." and within a few years this figure had increased to 300,000. The New York City Commissioner of Health in 1919 told the press that drug addiction "...is born in the underworld and is the twin brother of every crime in the great categories of violence." By 1920 it was reported that "...there were 1.5 million 'victims of the drug habit' in the United States, that no part of the country was without its quota of addicts, and that the problem was ballooning everywhere.... It was authoritatively reported and widely believed that drug abuse had shifted its point of incidence and overnight had become a great threat to young people; 70% of known addicts were discovered to be under twenty-five years of age; children in the New York public school system were allegedly turning up in their classrooms completely stoned." The problem was no longer confined to "criminal classes," but extended to all levels of society. Simultaneously, "...it was revealed that drug peddlers were concentrating their efforts on military camps,... that new addicts were being found in alarming numbers among young soldiers," and there were "press rumors about addicts in the armed forces and 'dope fiends' coming home from overseas to menace the community" (2).

Although the focus of public concern was identical in both eras, the response of the government was markedly different. Beginning in the early 1920's, drug addiction was, for all practical purposes, removed from the purview of the medical profession and delegated to the law enforcement agencies. In 1922, a Congressman described Federal policy in managing drug dependence:

It seems to me that the untutored narcotics agents of this great Government... might have been better employed than in taking sides in a medical controversy involving the broad subject of what will or will not constitute the proper medication in the treatment of addiction. Yet this was done, and I am sorry to say is now being done by our Government, and will continue to be done until the end of time unless some protesting voice is raised against undue interference by lawyers, policemen and detectives in the practice of medicine, and furtherance of its research and study (3).

Since the government felt that addiction could be eliminated through vigorous law enforcement measures, and that addicts could be "cured" if simply cut off from their supply of drugs, the prescribing of narcotics for addiction treatment and research was effectively outlawed. The medical profession, in general, appears to have shared the government's orientation: in 1921, a member of the American Medical Association's Committee on Narcotic Drugs attacked the notion that "...drug addiction is a disease which the specialist must be allowed to treat, which pretended treatment consists in supplying its victims with the drug which has caused their physical and moral debauchery..." (4).

When narcotic addiction once again emerged as a major national concern in the early 1960's, a policy of "more of the same" promised little political advantage; the public, given to demanding quick and easy solutions even to the most complex problems, would hardly have been likely to endorse continued reliance on the law enforcement approach which, after all, had failed to prevent the resurgence of addiction in the first place. It was precisely at this time of maximum receptivity for change that Dr. Vincent Dole and Dr. Marie Nyswander reported their encouraging initial experience with methadone maintenance treatment. Although the conclusions drawn by those involved in the early research were restrained, the media immediately heralded it as the long- awaited "medical breakthrough," labeling methadone a "Cinderella drug" (5) which could be economically applied to hundreds of thousands of addicts and, in short order, solve the narcotic addiction problem. Balancing the enthusiasm of the press, however, was the severe criticism of maintenance treatment voiced by the medical establishment and law enforcement advocates who clung to the notion that administering narcotics to addicts was unethical, immoral, and ineffective.

The response at the Federal and local levels of government was to cater to both parties in the controversy. Thus, most governmental agencies involved in funding addiction treatment programs encouraged a "balanced approach," carefully expanding drug-free modalities to at least the same extent as chemotherapeutic programs. Nationally, it was repeatedly emphasized that "...the effort to make maintenance programs available should not obscure the need to expand other approaches" (6), and the Special Action Office for Drug Abuse Prevention presented data to confirm its multimodality orientation: "...between June 1971, and March 1973, the number of Federally funded patients in methadone treatment doubled. During that same period the number of patients in non-methadone programs increased five-fold" (7). At the State level, the New York Drug Abuse Control Commission in 1973-1974 allocated 2600 "slots" for methadone maintenance out of a total capacity of 13,741 (8). And in New York City, where the total number of patients in addiction programs increased by more than 400% between 1970 and 1972, the proportion of patients in methadone maintenance facilities remained unchanged at approximately 55-60% (9).

Not even the most enthusiastic advocates of methadone maintenance could take issue with the premise that exclusive reliance on a particular modality would be inappropriate. From the outset, however, numerous conditions were imposed on methadone maintenance as the price of even limited endorsement by those agencies concerned with funding and regulating addiction treatment programs. By the end of 1974, restrictions on methadone dosage, the duration of treatment, and other aspects of the treatment regimen had markedly altered not only the procedures of methadone programs, but their underlying philosophical orientation as well. Although the label "methadone maintenance" has continued to be applied, the programs today bear more similarity to their drug-free counterparts than to the early programs which employed the Dole-Nyswander model.

Beyond the modifications imposed on methadone maintenance programs, there has been a more fundamental change in the role of all addiction treatment programs. As a result of the widespread publicity given the massive "war on addiction," and the implication that the tremendous investment of money and personnel would eradicate the problem, the expectations of the general public were unrealistic from the outset. Later claims that "the corner has been turned," made by national and local leaders as early as 1973, seemed to justify these high hopes. Thus, when it became necessary to concede that these pronouncements of success were premature and that, nationwide, "...conditions [with respect to heroin addiction] have been gradually worsening since early 1974" (10), cynicism replaced confidence. By this time the state of the economy had overshadowed crime and addiction as the major focus of public concern, and hastened a return to the punitive approach which, though more costly in financial as well as human terms, appeared simpler and less controversial than medical management.

In retrospect, treatment advocates have mostly themselves to blame for the rapid swing of the pendulum back to a law-enforcement emphasis. Proponents of specific treatment approaches rarely missed an opportunity to make exaggerated claims for their own modality and to vilify publicly other therapeutic efforts. To preserve their own dwindling credibility, public methadone programs joined in the attack on private facilities. Drug-free program staff members were vocal participants in community efforts to keep out (or drive out) maintenance clinics, and program directors spent more time trying to discredit the evaluation studies of others than in assessing candidly their own effectiveness. Clinical experience was ignored, and philosophical principles were sacrificed to accommodate the rapidly changing priorities of funding agencies: drug-free programs which had vociferously damned methadone maintenance agreed to provide "temporary" maintenance when "methadone money" was all that was available; maintenance programs readily acceded to the wishes of regulatory agencies and adopted detoxification as a universally applicable objective of treatment; and both drug-free and chemotherapeutic programs, which were designed to treat narcotic addicts, hastened to redefine their mission when attention (and dollars) began to concentrate on the "soft-drug" user and the alcoholic, even though there remain "...several hundred thousand daily chronic users of heroin not currently in treatment" (11).

The Future

Although addiction and the response to addiction are dynamic processes greatly influenced by complex and unpredictable societal factors, two "truths" exist: heroin addiction will continue to be a major medical and social problem in this country for many years to come, and there will be a persistent polarization of views regarding how best to deal with it. The intent of this book is not to achieve consensus regarding the many difficult issues which exist, but rather to facilitate a reasoned debate by bringing into focus fundamental, substantive questions. At the same time, it provides one perspective of the issues, and describes the results when this perspective is translated into program policies and procedures in the large-scale treatment of addicts.