Methadone Treatment in Narcotic Addiction. Chapter 9

Introduction

Much of the controversy surrounding methadone maintenance treatment reflects the philosophical differences which pervade almost every aspect of addiction treatment. That there are divergent viewpoints is not surprising, since with few exceptions this is true of all areas of medicine. Nor is the lack of consensus undesirable; it would be as inappropriate to apply a "standard regimen for the management of addiction as it would be to insist that all cases of cancer be treated exclusively by surgery or exclusively by radiation.

Some critics of methadone maintenance treatment, however, have avoided the substantive issues and dealt solely with straw men which they themselves have created. The primary example of this tendency to focus on nonissues is the insistence that ancillary services must be made available to patients along with the medication itself. Contrary to the implication of this frequently repeated assertion, no responsible proponent of methadone treatment has ever seriously suggested that programs limit their efforts solely to the administration and dispensing of medication.

The very first paper published by Dole and Nyswander expressed their conviction that ancillary services were an essential component of the treatment regimen: "In our opinion, both the medication and the supporting program are essential.... We believe that methadone has contributed in an essential way to the favorable results, although it is quite clear that giving of medicine has been only part of the program" (120) (lvi) The admonition that ancillary services are indispensable to a successful methadone maintenance program is accepted by all programs; no one has advocated the provision of methadone in a vacuum (lvii). The kinds of services which are needed, however, and the special role, if any, of psychiatric and psychological counseling, are still open to debate.

Psychotherapy as an Ancillary Service

Prior to the introduction of methadone maintenance, the underlying premise upon which almost all addiction treatment rested was that addicts, by definition, were emotionally disturbed individuals whose condition required psychotherapy in one form or another. The rejection of this assumption, one of the most revolutionary aspects of the therapeutic regimen proposed by Dole and Nyswander, was based on empirical evidence rather than on theory: "It must be emphasized that the absence of routine psychiatric treatment did not stem from indifference or lack of clinical resources; all patients [were] seen by qualified psychiatrists on admission and, informally, at frequent intervals thereafter.... The lack of formal psychotherapy in the treatment program reflected the experience of the professional staff that routine psychotherapy was not needed for rehabilitation of the patients that we had stabilized on methadone" (127).

In retrospect, the observations of Dole and Nyswander are not surprising. Since addicts represent an extremely heterogeneous population with respect to age, sex, ethnicity, national origin, educational and social levels, economic status, etc., it would be extraordinary if psychiatric illness were a common bond. It is especially unlikely that there could be a universal causal relationship between two such vague and ill-defined concepts as "addiction" and mental illness." (lviii)

Just as in the general population, there will inevitably be some methadone patients who might benefit from psychotherapy. The policy of the NYC MMTP with respect to psychiatric and psychological services is precisely the same as that which applies to all other ancillary services: in those cases where they are believed to be indicated, they should be made available.

Supportive Social Servies

In addressing the practical problems of employment, education and training, housing and the resolution of outstanding legal cases, most methadone programs have focused primarily not on alleged shortcomings of the patients themselves but rather on external, societal barriers to rehabilitation. The major impediment in overcoming these obstacles is the almost universal discrimination faced by methadone patients. Decades of ineffective efforts to "cure" addiction have lead to frustration, and a consequent reluctance by the general public to accept the concept of "ex-addict" as other than a euphemism for "junkie." Opinions expressed by public officials and the people who staff treatment programs have reinforced this cynicism:

The Federal Food and Drug Administration has decreed that no methadone patient can be routinely trusted with more than a 3-day supply of medication, and to merit even this degree of confidence requires at least 2 years of continuous treatment (130).

The New York State Legislature has legally defined methadone maintenance patients as "addicts" for purposes of criminal certification to the Drug Abuse Control Commission (131). The practical implication of this statute is that the courts, in ordering involuntary commitment, may not distinguish between patients enrolled in methadone maintenance programs and heroin addicts who maintain an illicit, debilitating, antisocial narcotic dependence (lix).

The United States Post Office, in 1972, acknowledged: "We presently make no distinction between heroin and methadone users for purposes of employment" (132) (lx).

The Mount Vernon Housing Authority in Westchester County, New York, justified the exclusion of methadone patients from its facilities by quoting the former Governor of New York, who had concluded: "We have achieved very little permanent rehabilitation [of addicts], and have found no cure" (134). The Appellate Court agreed with the Housing Authority's premise that, since any distinction between methadone patients and heroin addicts is at best temporary, the same discriminatory policy should be applied to both (135).

A physician who directed a methadone maintenance clinic in Washington, D.C., scoffed at the reliability of urine specimens which were collected under the direct observation of "...so-called ex- addict counselors, some of whom were receiving methadone maintenance treatment themselves" (136). (When a program director expresses his conviction that methadone patients, employed as counselors, cannot even be trusted to observe patients urinating, it is not surprising that the public at large refuses to trust them with more essential functions.)

An evaluation of a methadone maintenance program in Philadelphia referred to four counselors as follows: "All four, despite their treatment and 14 months of employment as counselors, were still being maintained with daily doses of methadone. Hence, all four were, in fact, still addicts" (137) (lxi).

"Rehabilitation" is generally used to describe the ultimate goal of patients to be reintegrated into the general community. The indispensable prerequisite, however, is not merely the patient's own readiness, willingness and capability to return to a productive role in society, but society's acceptance of the patient. The experience of the NYC MMTP has consistently been that the latter is by far the greater stumbling block, and the supportive services provided by the Program have been developed accordingly. Despite the Program's efforts, however, it is usually the patient's ability to conceal his or her status as a methadone patient which is the decisive factor in determining whether reintegration will be possible.

Employment, one of the most important factors in ultimate treatment outcome, is a case in point. Together with patient referrals to educational and training programs, major emphasis has been placed on job development, and in this respect there have been few successes in opening up job opportunities with major employers (lxii). Some have refused even to discuss modifying policies which preclude the hiring of methadone patients, while others set certain "conditions" which are impossible for the Program to accept. Thus, some employers demand a firm "guarantee," or "certification," that a patient referred to them for work will not return to drug use, (lxiii) and the Program is asked to "report" any patient who terminates treatment (or has a positive urinalysis or other clinical evidence of difficulty) after being hired. The imposition of such conditions would not only conflict with the Program's policies regarding confidentiality of patient records, but would also be contrary to the "...strong conviction that job performance should be the sole criterion for continued employment. To allow the employer to become involved in the treatment aspects of rehabilitation leads to paternalism. And paternalism is just another form of discrimination" (148).

The development of meaningful and effective supportive social services has been the most difficult challenge faced by methadone maintenance programs. Experience has confirmed and strengthened the premise which has been the keystone of methadone maintenance treatment since its introduction ten years ago: programs must work with their patients in seeking to overcome the many barriers to successful rehabilitation.

Notes

lvi. This view has been consistently expressed by Dole and Nyswander in subsequent papers: "In the treatment of addiction and other chronic diseases, medicines should be prescribed only as part of a larger program of rehabilitation" (121). "The medical procedure - stopping heroin addiction with methadone - is simple, but the social problems of the street addict will continue to disable him unless effective social helps are also given" (122). "In the complex task of rehabilitating an addict, methadone (or any other medication) is only an adjunct.... The main services needed by a methadone program ... are helps in housing, school placement, job training, and employment. Without such help the patient is likely to be trapped in his past, even if he stops using heroin" (123). "...[O]ur programs are usually called 'methadone maintenance programs.' This popular label puts the emphasis on what is merely the medicinal aspect of the treatment. More importantly, the clinics should be rehabilitation programs, not merely dispensaries.... Specifically, the program must help open the way to better jobs and housing for patients, provide opportunities for education, defend patients against injustices" (124).

lvii. Reflecting the popular consensus among those involved in methadone treatment, regulations of the Federal Food and Drug Administration since 1972 have explicitly required that ancillary medical and social services be part of the treatment regimen (125). Nevertheless, methadone maintenance continues to be criticized as a "...new conceptualization of what addiction is and how it is best treated, i.e., with medication rather than rehabilitative therapy" (126).

lviii. Thomas Szasz, a psychiatrist, has cogently argued that both "drug abuse" and "mental illness" do not even exist except as functions of popular morality (128, 129).

lix. Prior to the Legislature's action, the Mental Hygiene Act employed a definition of "addict" which excluded individuals who were physically dependent upon narcotics "...taken under the supervision of a physician in the course of accepted medical practice." The exclusion no longer applies to those whose medical treatment is related to previous drug abuse.

lx. Almost three years later, the Postal Service was ordered by a Federal Court to lift its ban on employing methadone patients (133).

lxi. The assertion that methadone patients are "still addicts" is a widely heard criticism, and the rationale for much of the persistent discrimination. Even in a strictly technical sense, "...the term addiction has been used in so many ways that it can no longer be employed without further qualification or elaboration" (138). As commonly employed, however, the implication of the rubric "addict" goes far beyond physiological phenomena of tolerance and dependence: "Addiction and addict have been used so often that the words have developed a cultural rather than a scientific meaning, connotating disapproval and deprecation" (139). This connotation is in accord with the popular definition of addiction as "The compulsive and uncontrolled use of habit-forming drugs, beyond the period of medical need, or under conditions harmful to society" (140). It also agrees with the criteria of "drug addiction" proposed by the World Health Organization: "(i) an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means; (ii) a tendency to increase the dose; (iii) a psychic and generally a physical dependence on the effects of the drug; and (iv) detrimental effects on the individual and on society" (141). Most other definitions are similar, and stress the harm to the individual and society associated with "addict" drug use (142, 143). Clearly, none of these definitions apply to the methadone maintenance patient.

lxii. One notable exception was the Program's role in persuading the New York City Department of Personnel to adopt the following policy: "No ex-addict, methadone-maintained or drug-free, will be refused employment solely on the basis of his previous addiction ... except where current medical requirements bar such employment" (144). The qualification refers primarily to the uniformed services (fire, police, an sanitation), but even those agencies have recently begun hiring ex-addicts to fill nonuniformed positions (145). Other programs ion the State have not been so fortunate in eliminating conflicting policies of local governmental agencies. The experience of a county-funded methadone program in Syracuse, New York, is not atypical: "...a county department fired an employee when it learned that she was on methadone, apparently without realizing the irony involved in one county agency undermining the efforts of another and, by so doing, forcing a person onto county-funded work relief" (146).

lxiii. With respect to certification, the New York City Commission on Human Rights, following extensive hearings on the question of job discrimination against rehabilitated addicts, noted: "...[T]here is something fundamentally repugnant about certifying an individual as an 'ex-addict.' Most of the drug treatment experts who testified at the hearings were reluctant to endorse a certification process, no matter how constructed. Certification runs not only the risk of stigmatization but also places too much dependence on the judgment of a single individual who may or may not be objective, fair or qualified to make a valid assessment of job readiness (147)."