Methadone Treatment in Narcotic Addiction. Chapter 1

Introduction

Initially, the conceptual impetus as well as the financial support for methadone research came from the Administration of the City of New York. As early as 1959, Mayor Robert Wagner announced that the City would provide funds to major medical centers in New York for addiction treatment research efforts (12). A year later, the Mayor's Advisory Council on Narcotic Addiction recommended that the highest research priority be given to the development of "...a pharmaceutical substitute for heroin which would enable addicts to function" (13). This recommendation was accepted, and in 1962 the New York City Health Research Council (i) actively began to solicit proposals for finding "...a chemical compound that would relieve the need for drugs in addicted persons" (14).

At that time, however, there was little interest in addiction among the academic medical community, and ultimately the Health Research Council invited Dr. Vincent Dole of The Rockefeller University to undertake the research (ii). The initial grant to Dr. Dole was for $100,000. He was joined in this project by Dr. Marie Nyswander, a psychiatrist with many years of frustrating experience trying to rehabilitate narcotic addicts through the use of conventional psychotherapy.

In the course of their early work, Dole and Nyswander prepared to wean two addicts from morphine dependence by transferring them to equivalent, high doses of methadone in a hospital setting. They observed a remarkable transformation: the patients lost their preoccupation with drugs, stopped demanding ever-increasing doses of narcotics, and expressed an interest in leaving the hospital during the day in order to seek employment and schooling opportunities. A similar change was noted among the next four addict-patients placed on methadone. Furthermore, Dole and Nyswander demonstrated that with the administration of methadone, the patients developed an exceedingly high tolerance not only to methadone, but to all other narcotics as well (iii). As a result, the "maintained" patients experienced no euphoria or other central nervous system effects of the medication, and were shown to be pharmacologically unable to achieve a "high" through supplemental use of heroin, morphine, or other drugs of this class.

Theoretical Basis for Methadone Maintenance Treatment

In an attempt to explain the therapeutic effectiveness of methadone treatment in their initial patients, Dole and Nyswander hypothesized that, in addition to possible psychological dependence, repeated opiate use induces a "metabolic change" which is reflected in the physical craving for narcotics. While this craving, or "heroin hunger," can be controlled by the administration of methadone, the underlying metabolic change might be irreversible; therefore, methadone maintenance may be indicated indefinitely for many patients, regardless of their successful social rehabilitation. It is this assumption which has created the most controversy.

Although definitive cellular aberration attributable to narcotic addiction has not been demonstrated, there is much experimental evidence supporting the theory of lasting physical effects:

After withdrawal of narcotic drugs, addicted animals and men continue to show physiological abnormalities that distinguish them from normal controls. Regulation of temperature, metabolism, vasomotor reactions, and other homeostatic functions are abnormal for months after drug withdrawal. Responses to challenge doses of a narcotic drug continue to be abnormal for months, perhaps indefinitely; a specific tolerance to narcotic effects and the addict- type of brain waves can be demonstrated when a narcotic is injected into an animal after a long period of abstinence. To be sure, these findings merely reveal persistent physiological consequences of drug addiction and do not go directly to the problem of what generates the abnormal drive for narcotics in abstinent animals, but the question as to whether an animal or man is restored to physiological normality after withdrawal of the drug can now be answered decisively. The post-addict is not normal. Narcotic drugs leave an imprint on the nervous system, and the abnormal drug-seeking behavior that follows may well have a neurochemical cause (16).

The experimental findings are supported by subjective as well as clinical experience. Addicts report that even after prolonged abstinence they do not respond to narcotics as they did prior to becoming addicted. Tolerance to certain effects (such as nausea) is not extinguished regardless of the duration of the drug-free interval before reexposure, and tolerance to the analgesic, euphoric, and depressant effects develops more rapidly after each successive episode of abstinence.

There are, of course, many factors which determine recidivism. The fact that some ex-addicts remain abstinent without methadone maintenance treatment is not surprising, and is not a persuasive argument negating the theory of a lasting metabolic change (iv). The hypothesis used to explain the effectiveness of treatment, however, is irrelevant to the more fundamental question: Is the therapeutic regimen successful in the treatment of addiction.

The Position of the New York City Administration Regarding Methadone Maintenance (1965-1969)

Based on their encouraging initial results, Dole and Nyswander obtained a grant of $1,400,000 in City funds from Dr. Ray Trussell, who at the time was Commissioner of Hospitals. Trussell also arranged to provide them with inpatient beds at the Manhattan General Hospital, a municipal institution which later became part of the Beth Israel Medical Center.

The first report of methadone maintenance to appear in the medical literature was an article by Dole and Nyswander published in 1965 in the Journal of the American Medical Association (18). Although based on only 22 patients, it had an immediate impact in the political as well as medical arenas. In the mayoral campaign that same year, John Lindsay's platform regarding addiction included support for "...further experimentation with methadone maintenance" (19). Shortly after his election, however, for reasons which were not specified, Lindsay abruptly discontinued financial support of the controversial new methadone programs, (v) and recruited Dr. Efren Ramirez, who had developed a network of therapeutic communities in Puerto Rico, to become the City's Narcotics Coordinator. Soon after his arrival in New York, Ramirez was appointed Commissioner of the newly created Addiction Services Agency in a step heralding the "...refocusing of [the City's] priorities toward the therapeutic community and a commitment to establish more drug-free centers" (20).

A swing back toward methadone maintenance began in 1968: "Lindsay had every reason to assume that his Democratic Party opponent in the mayoralty election in November, 1969, would propose the methadone maintenance approach as an alternative to the City's program. Moreover, the proponents of the methadone approach continued to expand. Initially, the support had come from within the large medical centers of the City. However, the "success" of the program had attracted "good government" people and even some leading members of the black and Puerto Rican communities (vi) - which previously had been almost unanimous in opposition to the program" (21).

The Mayor's renewed interest in methadone treatment was not shared by his top-level administrators: both the Health Services Administrator and the Commissioner of the Addiction Services Agency "...rejected incorporation of a methadone maintenance program into their respective agencies..." (22). Rather than demand the compliance of unwilling City agencies, the Mayor asked the Vera Institute of Justice, a private foundation, to prepare a protocol for a methadone program which would be City-sponsored, but independently operated. The resulting program was the Addiction Research and Treatment Corporation (A.R.T.C.) (vii).

When A.R.T.C. began operations in October, 1969, there were approximately 2000 patients enrolled in existing methadone maintenance programs, and several thousand applicants awaiting admission. The A.R.T.C., however, differed significantly from the early Beth Israel program and others patterned on the Dole-Nyswander protocol in emphasizing maintenance on low dosages of methadone and eventual abstinence. It "... was guided by a strong commitment to a multi- modality approach" (24), and its primary objectives were geared more to research than to treatment. With its emphasis on experimental modifications, the new program represented an attempt to resolve some of the conflicts and controversies generated by the original model, rather than an endorsement by the City Administration of methadone maintenance treatment. The situation was to change radically in the ensuing months.

Notes

i. The Health Research Council was established by Mayor Wagner in 1958 to stimulate research dealing with critical health problems.

ii. Dr. Dole, a physician specializing in metabolic disease research, was at the time a temporary member of the Council, filling in for a colleague who was on sabbatical.

iii. Tolerance is "the ability to endure, without ill effects, the continued or increasing use of a drug" (15). It is a frustrating reality to any physician who has attempted to ease the pain of a victim of terminal cancer, only to see the patient become totally unresponsive to the analgesic effects of narcotics after repeated, frequent use. With respect to methadone itself, it can be readily confirmed that tolerance develops universally to the miotic effect in maintenance patients. What is true of the pain-killing and pupillary actions of narcotics is also true of other properties, including the ability to produce euphoria.

iv. Critics of the metabolic theory have noted that in therapeutic communities, "...these victims of a supposed metabolic defect ably carry out socially responsible and often creative social and interpersonal activities without drugs..." (17).

v. The methadone maintenance programs which have been started at Beth Israel Medical Center, Harlem Hospital, and Bronx State Hospital were kept alive with funds provided by the New York State Narcotic Addiction Control Commission, established in the same year.

vi. a "Committee for Expanded Methadone Treatment" was established in 1968, and included in its ranks Roy Innis, the Associate National Director of the Congress of Racial Equality; Congressmen Charles Rangel and Herman Badillo; State Senator Basil Peterson; Manhattan Borough President Percy Sutton; the co-owner of the Amsterdam News, Clarence Jones; Joseph Monserrat of the Board of Education; and rent- strike leader Jesse Gray.

vii. Although the City's share of the funding was never more than 10% of the program's total budget, with the remainder coming from the National Institute of Mental Health, A.R.T.C. was portrayed as "the City methadone program" (23).