Not the Picture of Health: Women on Methadone

Introduction

Previous research indicates that women heroin addicts suffer more from health and dental problems than do male addicts, and more than both men and women in the general population (Mondanaro 1981. Beschner & Thompson 1981; Finnegan 1979. Stryker 1974; Flaherty, Bencivengo & Olson 1978; Andersen 1977; Draizen, Gillespie & Eisenbud 1975; Santen er al. 1975. Gossop, Stem & Connell 1974; Brown er al. 1972; Stoffer 1968). Women addicts who voluntarily enter treatment often do so because they are pregnant, afraid of being incarcerated or are suffering from increasing health problems. Thus, health problems related to the heroin lifestyle can be instrumental in an addict's decision to seek treatment. Methadone maintenance, currently the predominant form of treatment for chronic heroin addiction, brings with it its own array of client-perceived health problems.

This article contains a discussion of the health of women on methadone maintenance. The methadone experience is a process, with each stage having unique aspects. Thus, unlike other. more static analyses, the present findings define each problem and its particular management within the context of the methadone career. Given this framework, a woman's health problems are described as a process, looking at the initial stages on methadone. Next, the later stages, after the woman has stabilized, are focused on. Finally, an examination is made of a common result of health problems: disillusionment with the methadone experience. The article concludes with the authors' concerns as researchers, and some suggestions are made.

The data presented are a product of a two-year ethnographic study of 100 women on methadone conducted in the San Francisco Bay Area from 1980-1982 (NIDA Grant No. 2 R01 DA 02442). The authors conducted extensive field work in methadone maintenance clinics and completed open-ended in-depth interviews with each of the respondents. The "grounded theory" method (Glaser & Strauss 1970) was used in the gathering and analysis of data. The perspective of women on methadone, rather than professionals in the field, is central to this analysis.(1)

Health in the Initial Stages of Methadone Maintenance

Orally administered methadone is very different from intravenously administered heroin. Although it is an analgesic and a synthetic opiate, it does not produce the exact effects of heroin in either a physiological of psychoactive sense. Therefore, the woman on methadone experiences physical and emotional changes in the initial stages of maintenance. She attributes these changes to the shift from heroin to methadone. A common result of these changes is the use of substances (a form of self medication) in addition to methadone. The following details these health changes and the ways they are managed.

Physical Changes

When women first get on methadone. they often experience a number of what have been loosely called side effects. These include weight gain, weight loss, amenorrhea, acne, hoarseness, sweating, constipation, leg cramps, muscle spasms, hair loss, bladder infections, nervousness, arthritis, anxiety, memory loss, body aches, emotionality, nonemotionality, and lethargy (Goldsmith et al. 1984; Schecter 1978, Bazell 1973; Chambers. Brill & Langrod 1973; Kreek 1973; Yaffee, Strelinger & Prarwatikar 1973; Bloom & Butcher 197 1; Goldstein 1971 ; Langrod, Lowinson & Joseph 1971; Wieland & Yunger 1971). The physical symptoms vary from individual to individual with regard to both presence and intensity. Some women experience few symptoms, others many. It is impossible to determine the exact cause of these physiological symptoms or even their relationship to methadone (Kreek 1979). Women's perceptions of symptoms are rooted in their own experiences as well as descriptions they have heard from other methadone or active heroin users. Thus, a folklore has been developed around the methadone experience (see Goldsmith et al. 1984 for a discussion of this issue). One observant woman noted that nearly everything, and its opposite, has been attributed to methadone. She pointed out that ". . . diarrhea, constipation, loss of sexual appetite, nymphomania, gaining weight, losing weight, sweating, not sweating ... every physical effect that you could possibly think of was on this list [of methadone's possible side effects] because that's what people complained of. In other words, they [the clinic] polled people on methadone over years and everybody had something wrong with them so they all attribute it to methadone."

Perhaps the most common physical change that women attribute to methadone is weight fluctuation. Some women talked about losing weight when they first got on methadone. One woman attributed weight loss to stomach problems: "When I first got on methadone. I lost a lot of weight because my stomach wasn't used to methadone's poison. My stomach wasn't used to having such a strong chemical in me and I lost a lot of weight. Then when my body stabilized and got used to it, I gained a lot of weight. Then when I was on methadone about a year and I was used to it, then I started to lose weight again and I didn't like that."

Far more was heard about weight gain than loss. Many women noted that they had gained excessive amounts of weight shortly after they had gotten on methadone. However, almost in the same breath, most women who complained of weight gain also noted that while they were on the heroin treadmill they were constantly running around and ate very little. The lack of such activity while on methadone may account for weight gain. As one woman who gained 50 pounds put it, "I also think it's the lifestyle. Running around all day and looking for dope and not eating. When I did eat, I'd go to cafes-and there are certain cafes where dope fiends hang out. I'd go there and buy something to eat and nibble on it and put it down and run out. I got out of the habit of really eating. Now I spend a lot of time cooking for my husband. And I eat it." Another woman said, "The only reason they gain weight is because they're not spending all their time running around. They have time to sit back and eat when they're not sick. When you're sick, you don't want to eat anything.

Dental problems are another common complaint among women in the initial stages of methadone maintenance. Many women say that their teeth are in very bad shape. Some suspect a chemical imbalance brought on by methadone that may account for dental problems. A more likely answer is that being in the heroin lifestyle for an extended period (during which regular trips to the dentist are not the norm) affects the teeth, and problems only manifest themselves years later when the addict is coincidentally on methadone.

Lethargy and drowsiness are common problems for women in the initial stages of methadone. Many women spoke of falling asleep in the middle of the day and not being able to control it. One woman provided this example: "One thing that I hated about it is how tired it makes you. I like to fall asleep at night naturally. But when you're on methadone, four in the afternoon if you're reading the paper, you read the same line eight times until Finally you fall asleep. I didn't like that." Many women argued that it had been their experience that side effects, especially lethargy, are more frequent on large doses of methadone. Because large doses are more likely to produce these effects in the initial stages of methadone maintenance, this could account for the frequency of these symptoms during this period. Ironically, while the large dose is preventing a woman from getting high on heroin, it can also impede her completion of productive tasks.

Emotional Changes

When women first get on methadone, they frequently complain of emotional instability. Although getting out of the chaotic heroin lifestyle can be a terrific relief, many claim that methadone itself causes irritability, nervousness, and general tension. Some women want to continue to get high when they first get on methadone maintenance, and desire some sort of psychoactive experience. Consequently, they opt for large doses of methadone. Ultimately, when they lower their dose level, they often experience depression (if not withdrawal sickness). One woman started on methadone at 95 mg, a high dose. At first she wanted to keep getting high. but then changed her orientation. As she described it, "I had a heroin state of mind. I was on 95, but I was getting too loaded so I dropped my dose to 45. But I did go through some emotional ups and downs. At first the ups are real high and the downs are really down. But then gradually the ups and downs start evening out until it feels straight. And that's where I am now, straight a lot. Oh. I have suicidal thoughts and stuff like that, when the ups are really ups, and the downs . . . in that valley I have suicidal thoughts."

The irritability that many women claimed was caused by methadone can have serious consequences. One woman, for example, talked about the irritability experienced by both her husband and herself that was eroding their relationship. She believed that they both needed "sedation, " but that it was a double-edged sword, because the methadone itself caused the irritability, which was intense. She stated that "as long as it's that day-today rat race, he really needs methadone and I do. too, because I would be taking pills or something else. It sedates you so much. At the same time it's sedating you. your nerves become raw-you are on edge. It doesn't take anything to set you off. Consequently, we have violent arguments."

Some women are so emotionally unstable that rather than causing emotional ups and downs, methadone controls these mood changes. One woman, for example, felt that she was constantly on the verge of a nervous breakdown. She used both methadone and tranquilizers to preserve, as she said, her sanity: "No, I don't feel like I'm in charge of my life, because I have to have medication to maintain my sanity. Methadone is in charge of my life now. " This was found to be a common problem. Whether methadone causes emotional instability or it is used as a result is irrelevant. Many women experienced severe emotional turmoil and used not only methadone but other drugs to attempt to bring this under control. Thus. the use of drugs other than methadone occurs among women when they first get on a methadone program. This phenomenon is detailed below.

In an earlier study of women heroin addicts (Rosenbaum 1981 b), it was found that there was little preferred use of substances other than heroin. The women in the present study bear out this original finding. While addicted to heroin, few used other substances (except marijuana) regularly. Yet when initially on methadone maintenance. many women became what they called "garbage heads," and began to use a variety of psychoactive substances in addition to methadone.

The motivation for the use of psychoactive substances in addition to methadone is problematic. Some women claimed that they were seeking a way to get high even to test the notion that methadone blocks the effects of heroin. One woman used heroin for this purpose: "I wanted to see if this 'blockade' stuff was true, so I shot some heroin. It was like sand through the hourglass----here one moment and then away. I wanted to find some way of altering my feelings. You know, if you're depressed and things are going bad it's a way of changing that reality for that moment." Another woman claimed that after an individual gets on methadone maintenance her life changes very, little. She was, consequently, still looking for some way to get high:

The interesting thing was when I first went on the methadone program I was still involved with drugs. I was still using and it was still part of my life. In fact, frequently, I would be on a low dose of methadone and using a lot of heroin and going through heroin withdrawal. It was mostly a reward system. Nothing had changed about my life but methadone. I am certain from what I see down there now, comparing people's lifestyles, if you take a person with an addict lifestyle and you remove the dope and you substitute the methadone, nothing much is going to change about their life and, in fact, nothing much changed about mine.

Other women claimed that the use of substances in addition to methadone was a form of self-medication (see also Goldsmith et al. 1984). Methadone, they claimed, does not handle pain in the same way as heroin; thus, any number of ailments become evident after cessation of heroin use. As one woman described it, "Addiction is physical, mental and spiritual. After that [heroin addiction] you've got to take care of your illness and what's wrong with you. That's another thing you've got to fight with them [clinic staff]. That was the worst time that I had with this program and they am wrong. They are very wrong. After you leave drugs you find that you've got illnesses, arthritis, tumors, whatever-you got it-heart trouble. You don't notice these things on drugs. Heroin is a painkiller. Once you're hooked on methadone, it doesn't do anything for the pain."

Little distinction can be made between the desire to get high and self-medication. After an individual has been addicted for a long period of time the two motivations fuse into one. Getting high is considered self-medication and preferred medications often cause the individual to experience euphoria. Thus, when one looks at multiple drug use in women on methadone maintenance it is important to acknowledge that the use of psychoactive substances other than (or an increased dose of) methadone produced a euphoric effect for the purpose of assuaging pain physical or emotional. It has been argued that heroin alleviates both physical and mental suffering (Sobky 1981). Many clients felt that methadone does not have the same effect, and as a consequence other substances were seen by some women as necessary to produce the painkilling effect of heroin. This is a health rather than a behavioral issue. Whereas multiple drug users are often accused by clinic staff of simply wanting to get high, they are more often simply attempting to regain the effects of heroin to alleviate their psychological suffering and pain. The motivation is medicinal, the effect is often euphoric.

Three substances were found to be used most often in combination with methadone to produce a pain alleviating state: alcohol, opiates other than methadone (usually heroin), and diazepam (Valium). They were used primarily to moderate the physical and emotional effects detailed earlier. Several other researchers have found that alcohol is a popularly used substance by individuals on methadone maintenance (Goldsmith et al. 1984; Preble & Miller 1977; Bazell 1973, Babst, Chambers & Warren 197 1 ). In the present study, far less alcohol abuse was found than had been expected, which was perhaps due to an all-female sample. Many women clearly did not prefer alcohol as a supplementary drug to methadone.

The use of heroin as a supplement to methadone is fairly common in the initial stages of methadone maintenance (Chambers & Taylor 1973). As noted. some women used heroin to see if it would work-if the blockade was really effective. Most were disappointed. in as much as the blockade was at least somewhat effective. Additionally, many addicts had become attached to injecting heroin and missed that ritual. Some used heroin in order to return to injecting.

Diazepam was found to be the most widespread drug used during the initial stages of maintenance by the women in the study population (see also Goldsmith et al. 1984; Bigelow et al. 1976; Woody et al. 1975). Many women had even become dependent on diazepam. routinely taking doses in excess of 30 mg several times daily (in addition to methadone). Diazepam seems to provide a soothing effect for women on methadone maintenance. It alleviates the nervousness they often feel. One woman described her diazepam use as follows:

I have no desire to use heroin. The only thing that I've felt that I wanted since I've been on methadone has been Valium. When H. [her daughter] was raped, I went through some heavy changes with that. Valium is a really nice thing to me every once in awhile when I take it. It's not like a heroin thing. I don't crave it and I don't take it all the time. But if I get under a whole lot of anxiety, that's what I think of now. Now that I've been on methadone for awhile, I know that there are people out them taking Valium daily-tons of it-with their methadone. I don't understand what that is, but the Valium came to me naturally. I had taken it before when my mother died and that was the first thing I thought of when H. was raped. I couldn't sleep. I was shaking constantly. I was crying all the time. I thought, "I'll go and try some Valium." And that helped me out.

Finally, additional methadone is often used as a form of self-medication (Goldsmith et al. 1984). Sometimes this happens within the clinic and often outside. If a woman is feeling excess pressure or tension, she may request that the nurse on duty give her an additional 5-10 mg on a given day. If she feels that she needs more than the ceiling provided by the additional dose, she may buy diverted methadone on the street. She may prefer buying it outside the clinic if she does not want to raise her dose permanently by 20-30 mg. She may simply want, on a one-shot occasion, to use methadone to excess. By keeping the clinic-prescribed dose at a low level and using excess methadone only occasionally, the woman has mom control of her excesses than she would have on a permanently high dose.

In the initial stages of methadone maintenance, women often experience numerous health problems. Some arc physiological side effects commonly associated with methadone. Others are emotional problems of anxiety, nervousness and irritability. The use of substances other than methadone occurs in order to replace the painkilling effects of heroin.

During the stabilization phase on methadone. women often reported problems with dose level, a buffering sensation. and loss of sexuality. The following provides a description of these problems and a look at the way women manage them.

Finding a Dose

The physiological nature of stabilization is finding a dose that suits the individual: a dose level at which a woman can function without being sick from withdrawal, or without experiencing intense side effects from over-medication. Stabilization is a leveling-out period and may take several months. Earlier, the emotional ups and downs of the initial stages on methadone were discussed. Once one is stabilized, or accustomed to methadone, the ups and downs tend to be eliminated. As one woman described it. "It's [methadone is] easier on your system, because of the slowness with which it acts. With heroin. your body is going like this [she indicated up and down] all the time. As soon as you hit this peak. you're on the way down. You are up and down like that all day."

Many women, however, talked about getting an initial jolt from methadone and then leveling out at a point that made them function optimally. Again, this woman pointed out, "When you use heroin, after initially being loaded, which lasts a very few minutes, you hit a high energy level where you can do whatever you had to do and just feel good. That's the level that methadone keeps me at."

For most women, once they are stabilized, or have arrived at a dose suitable for them, they simply feel normal. Many spoke of the first hour of so after dosing as being rather benign. Then the methadone "kicks in" and its effects are felt. At this point, users seem to be "up." One woman stated that "when it first starts to come on, it feels kind of nice for a half hour and then I get chatty after I drink it. A half an hour after I drink it, I'd get chatty for about an hour and a half. And that's about it. Then I'm normal. "

Being Buffered

In addition to being a substance that made them feel normal, methadone was regarded by many women as providing an emotional buffer against stressful situations without causing them to feel high. According to one woman, "It's not euphoric. It's just that things don't bother you. Like bad things can happen and it just doesn't get to you like it would somebody else. You're just not overtaken by grief. "

The same woman, who is the mother of a four-year-old boy, also claimed that methadone's buffer makes parenting easier: "Plus, I'll tell you, coping with children, I'm so glad for methadone. Sometimes you wonder how people do it straight. And he's a damned good baby. Oh, my God, is he a good baby! I think one of the reasons for that is----I hate to say it-but we were always feeling good [because of the methadone]. We were lucky. We never hurt really bad. So we were always feeling good and paying attention to him." Occasionally, the buffering effect of methadone is used in order to avert a trying situation. In one clinic that was studied, clients were given the liberty to drop or raise their doses by 5-10 mg on any given day without permission from the clinic physician. Many clients noted that if they were having a problem, they would temporarily raise their dose for the purpose of creating a bigger cushion. One reason for this was to guard against potential heroin use. One woman stated that 111 was on 60 mg and then I was going through some troubles at home when my old man was dealing really heavily. It was very tempting, and so I just went up on my methadone instead of starting to fix again. "

Some women complained about methadone's buffering qualities. They claimed that it saturated them and created a screen between them and reality. One woman complained that with heroin she could never get enough, although with methadone there was always too much: "When I was on methadone, I just wanted to get off, because it was enough already! It seemed like the whole time I was on heroin I never had enough. You can never have enough! But with methadone, you're just over-saturated with it. It's always too much."

Sexual Problems

One cost of stabilization on methadone for women is the diminishment of sexual desire. This, accompanied by reduced sexual function on the part of methadone maintained men (Buffum 1982), often results in sexual inactivity for couples on methadone.

Studies of the effects of methadone on sexuality have focused on methadone-maintained men, with dysfunction reported to occur in 20 to 35 percent of those studied (Goldsmith et al. 1984; Chambers, Brill & Langrod 1973; Kreek 1973; Cushman 1972; Wieland & Yunger 1971). It has been postulated that men who experience altered sexual function while addicted to heroin are at greater risk of experiencing sexual problems while on methadone maintenance (Hanbury, Cohen & Stimmel 1977). Some investigators found evidence that sexual disturbances in both men and women are often related to dose level (Crowley & Simpson 1978; Yaffee. Strelinger & Prarwatikar 1973). Impotence is said to be a more persistent problem among patients treated with higher doses (Goldstein & Judson 1973; Goldstein 1971).

Naturally, there is a wide variability in sexual patterns (just as in the non-addicted population) but a certainty is that regular orgasm-producing sex is not common among men and women on methadone maintenance. Several men and women claimed that men cannot achieve an erection and even when they can, they cannot reach orgasm. As one woman stated, "Methadone and sex is nothing. Women maybe can do it, but men cannot. " One man claimed that men cannot even get enjoyment out of sex while on methadone. He said "both heroin and methadone make it more difficult for a man to come, but with a heroin hard-on you can still get enjoyment out of it [even without climax]. With methadone, you don't."

Women on methadone often claimed that having sex is a lot of work and requires a fantastic output of energy. As one woman (who is the partner of the man quoted above) related, "And with methadone, as far as sex is concerned, the women experience the same goddamn thing. I could be making love for hours and hours, too, and it becomes a job. When you can't come you become so frustrated with yourself. It's just that I know it's [sex is] going to be such a bummer for me, why even go into it?" Some women claimed that sexuality is affected by the timing of the methadone dose. When it first "comes on, " the body is too saturated to achieve an orgasm, but when it begins to leave the system and the individual is experiencing withdrawal, the body's sensitivity can simultaneously make it easier to achieve orgasm, but also make any touching intolerable. According to one woman:

Methadone interferes with sex, because if you don't feel good, you don't want to be touched because your skin feels like it's crawling. But at the same time, when you're sick, that's when all the sensitive parts of your body get aroused. All the parts of your body get really, really sensitive when you're sick, and in fact, if you can get past that icky feeling and just get into sex at that time, it's really good because you don't have the methadone blanking all your nerves.... If you try to get into it when you're sick, it's almost impossible, and then if you just drink your methadone, you can't reach a climax-it takes forever. It might take you a couple of hours having sex. You finally will, and then your methadone is worn out of you.

There are two major explanations by women for the lack of sexuality in their lives after being stabilized on methadone: dose level and negative prior experiences with sex. Women often claimed that on larger doses of methadone they feel more anesthetized, and hence have a more difficult time with sexual activity (Crowley & Simpson 1978). Some women claimed that when they lower their dose they are again able to enjoy sex. The following is an example: "I've always been active sexually. I've always had a healthy sex life and enjoyed it. I'm pretty aware of myself as a woman and have never really had too many problems having an orgasm, but when I was on a high dose they were much less intense, much shorter and with less feeling. Everything was less feeling. That was one thing that I didn't like. When my dose was much lower, I really started to recognize how it does deaden your senses."

Many of the women that were interviewed had experienced sexual violence at an early age, including father or father-figure incest and rape (see also Cuskey, Berger & Densen-Gerber 1977; Densen-Gerber, Hutchinson & Levine 1977; Mondanaro 1976). Several of the women had also been prostitutes while they were addicted to heroin. Each of these experiences might predispose a woman to avoid sexual activity. In addition to methadone dose level and its buffering effect, a past history of sexual trauma may strongly contribute to a woman's lack of sexual desire and ability to achieve orgasm. As one woman described it, "I don't know if it's the methadone or the lifestyle or what, but I know my husband blames methadone for causing problems in marriages. He blames the methadone program for his first marriage separation. I don't know what it is, whether it's that I worked on the streets, but I have lost all sexual urges. I don't know if it's him or not, because I have no urge to find out. He can go see anybody else."

Few women in the stabilization phase seemed to be particularly concerned about their lack of sexuality. As another woman said, "Oh boy, it's [our sex life is] nothing now. If they wanted to make a movie about it, you could bring your grandmother. We don't consider it a problem. It doesn't interfere with our marriage. Neither one of us is upset by it." One woman, interestingly enough, remarked that it was beneficial that sex between her and her husband was nearly nonexistent, because while other couples tired of each other, they would not:

In the very, very beginning, using heroin is like an aphrodisiac-only in the beginning. Then, like half the time we just fall out. It's the same with methadone. I mean, even if we wanted to, that's it for the evening. In our case, we're not all fucked out after all these years like so many couples are. After the first two years, they're all fucked out and then they don't even know each other, and then they're ending up divorcing. We can discuss things. We have a fantastic rapport. There is so much more than sex that we have. It's so beautiful!

In the previous section, an exploration was made into how the use of substances other than methadone (and increased doses of methadone) is often the result of a women's experiencing a number of physical and emotional problems that she connects with methadone. In later stages. particularly during stabilization, the use of other drugs is largely related to the desire to regain control of drug use (see Goldsmith et al. 1984).

After the individual has progressed out of the initial stages of methadone maintenance-in which she appreciates the control placed on her by the program-she begins to feel that she is regaining strength and self-control. This is due in part to her having experienced many months without the chaos of the heroin lifestyle. In short. the individual's life has straightened out considerably and she begins to feel that she does not need as much control as she did in the initial stages of life on methadone. One area in which she can attempt to regain control is drug use.

Some women have complained that in the initial stages of methadone maintenance, they were frustrated because they had no control over methadone's effects. In as much as these effects are long lasting, only one dose is taken, usually in the morning. (Some addicts split their dose between morning and evening, but this is rare.) The methadone takes about an hour to "kick in," and then the woman is "up" for a couple of hours. After this, often she becomes a little sleepy and sometimes begins to feel mildly "sick" when the methadone begins to subside. If the woman does not care to feel sleepy at noon or chatty in the morning, there is little she can do about it. This inability to control the side effects of methadone is a source of some dissatisfaction in the stabilization phase, and many women attempt to regain control through the use of other substances.

Another rationale for the use of substances other than methadone is the notion that the stabilization phase of life on methadone is actually the stage at which the individual is "hooked." Many women claimed that after three months on methadone, they knew they were strongly addicted to it. This can be interpreted by the individual as a license to use a host of other drugs. What has she got to lose? As one woman put it, "I used more drugs when I was on methadone than I do now. My attitude was, I'm already hooked on the methadone, like a dog. So what difference does it make now?"

The most popular substances currently used by women in the stabilization phase are alcohol, diazepam, cocaine, and to a somewhat lesser degree, heroin (Hunt et al. 1982; Preble & Miller 1977; Bigelow et al. 1976; Woody et al. 1975; Bazell 1973; Eiswirth, Smith & Wesson 1972, Gearing 1970). Occasionally, a double habit will result from the persistent use of one of these drugs in combination with methadone. As one woman described it, "When you take Valium with the methadone, or if you take it and you're on methadone ... it bothers the methadone in your system. It just doesn't react right. You'll get sick and apparently the methadone won't hold you. If you stop taking Valium, you feel like you're methadone sick, but you're not. You're really Valium sick. It's just a mess. That's why I'm detoxing off them [Valium]." In sum, women use substances other than methadone during stabilization in order to attempt to regain control and/or because they feel addicted to methadone and have nothing to lose.

As a result of the above-described health problems. women often become disillusioned with methadone maintenance. They are concerned about the immediate side effects of methadone, long-range health problems, and aging.

Immediate Side Effects

Earlier, some of the health problems that women routinely associate with methadone use were described. They are often referred to as side effects, and include weight gain, heavy perspiration, drowsiness and loss of sexual appetite. As noted, the exact cause of these symptoms is open to speculation. It is simply not possible at this point to be certain that methadone itself causes the side effects, what dosage of methadone exacerbates the situation, what role an individual's previous addiction to heroin and its concomitant health problems play, or to what extent the use of other drugs affects these symptoms. Nonetheless, it is these problems, which the women believe are methadone's side effects, that cause them to become disillusioned with life on methadone.

Another major source of discontentment with methadone is a woman's tiring of using drugs in order to feel normal. In order to get on a methadone maintenance program. a woman must have been addicted to heroin for at least two years. Forty-three (43) percent of the women that were interviewed had been addicted for eight years or more. Women often forget what it is like to be drug-free, to feel normal without the aid of opiates. Many women longed for this feeling, which they could barely remember or only imagine. As one woman lamented:

I would like to have a baby and I don't want it to be hooked. I just want to live a normal, regular life without drugs. Really, if you think about it, for over half my life I've taken drugs. I really can't remember what it feels like to be normal, to feel normal. I can't remember ... I know everybody has to have an escape from reality every once in awhile, but just waking up and not knowing I have to get drugs or going to bed at night and knowing I'm not going to wake up sick, that would be a relief in itself.

Long-term Effects

Part of the desire to be drug-free is the fear of long-term addiction to methadone and its physiological effects (Hunt et al. 1985-1986. Goldsmith et al. 1984; Langrod, Lowinson & Alksne 1977). Women fear that methadone will saturate the bone marrow, causing painful joint problems, or that their teeth will rot; that they will suffer permanent memory loss or age prematurely. The fear of long-term maintenance is fueled by the mystery surrounding the drug and the folklore that has developed among clients concerning negative long-term effects (see also Goldsmith et al. 1984). Again, it should be reiterated that widespread use of methadone as a maintenance drug (as opposed to a detoxification substance) is a relatively new phenomenon. It is impossible to determine what the long-term effects of 15 or 20 years of methadone addiction might be. Many women worry about this, and it is often a source of disillusionment.

Finally, some women in the study population expressed concern about methadone's ability to mask disease symptoms. They feared that perhaps a chronic illness might have gone undetected and they may be seriously ill. According to one woman:

Another thing that's important, one thing that's wrong with it, is you don't know if you're fucking dying there or not, because you have the feeling of well-being. You don't know. I could have 40 different things wrong with me and I wouldn't even know it. Because, when people come down and they're clean, you've never seen anything like it. They ache, and things that have been wrong with them all the whole time come out, you know, like all the natural things that you should feel. Well, that's a feeling. true, but all the pains that were suppressed during that time, and that's what I'm not too thrilled about. 'Cause I could be dying and wouldn't know it!

Aging

Most women on methadone maintenance express a fear of, and an aversion to, growing old on methadone. These women were generally in their thirties (the mean age of the study population was 31). They have taken stock of their situation and have come to the realization that they are "not getting any younger" and need to establish some productive direction in their lives before they have exhausted their resources, one of which is their youth. Many discover, at around age 30, that they cannot physically keep up with the heroin lifestyle, because their hustling capabilities are declining. They are able to see down the road and realize that while they can use their bodies (through shoplifting or prostitution) to earn a living now, this will not be possible in just 10 short years or so. Furthermore, like many other women in their thirties, they feel the need to straighten out their lives socially while they still have options. They want a permanent satisfying job, a home, children and a husband or steady boyfriend. They differ from conventional women because they have opiate addiction to deal with before it is possible to "take care of business. " Thus, for the same reasons that women get on methadone maintenance. they become frustrated. If being on methadone has not helped them to achieve the goals established when getting on. many women begin to see getting off as the key to attaining these goals.

As middle and old age approach, many women begin to feel a greater pressure to conform to conventional social standards of success. Their fear of growing old is exacerbated by their uncertainty about the role played by methadone in the aging process, which they believe may speed up or intensify it. For example, there was a 50-year-old woman at one of the clinics who had been on methadone maintenance for 13 years. She had a number of health problems (that may or may not have been related to methadone) and was emotionally unstable. She served as an example to the younger women at the clinic of what not to become. As one woman put it, "I'm 31 now, and I'm getting scared. I don't want to turn out like M. I have to get my life together-get a job. I'd even like to have a baby. And I can't see staying on methadone much longer. I'm already realizing that my health is different-my teeth are bad, my skin ... what would happen to me if I stayed on methadone for another five or six or 10 years?"

Whether she is still in the initial months on methadone maintenance, has reached the stabilization stage, or is moving toward the end of her career, the woman on methadone maintenance is not the picture of health. Regardless of the root of her health problems, she tries to manage them in each stage, often self-medicating with a variety of substances. The use of these substances both compound her problems and offer her temporary relief. The end result is disillusionment with being on methadone maintenance.

In response to this disillusionment, women often become depressed. Some try to get off methadone, often prematurely. Some become resigned to life on methadone. Most Importantly, this depression, early attempts at detoxification (that often prove unsuccessful) and hopeless resignation impede the process of rehabilitation. Women on methadone maintenance often seem to be in an endless holding pattern----out of the heroin world, but unable to make the full transition into the conventional world.

As the evidence presented in this article attests, a woman's health problems while on methadone maintenance make a significant contribution to her sense of disillusionment. These research observations lead one to believe that, although she often correlates her health problems directly to methadone itself, the woman on methadone suffers from numerous health problems not just because she is on methadone maintenance, but because her basic health regimen is so poor. Over 90 percent of the women interviewed were heavy cigarette smokers. They consumed a great deal of junk food, with diets high in sugar, fat, salt and caffeine. Less than five percent had a regular exercise routine. It is a fair assumption that anyone-maintained on methadone or not-following such a routine would not be the picture of health. If an examination of the total health routine was conducted, perhaps more could be done for and with the woman on methadone maintenance.

Some clinics have a policy of distributing health information to detoxifying clients in which they often make dietary and exercise recommendations. Perhaps clients just getting into programs could be instructed in basic nutrition and fitness. The disproportionate number of women to men in methadone maintenance programs (many have about 50% women, while the percentage of female heroin users is nowhere near that great) indicates that they are able to request help (Rosenbaum 1981a). Women do not seem to be as easily deterred by methadone's negative reputation among addicts as are men (Hunt er al. 1985-1986). Perhaps these women would also be responsive to clinic- initiated health care suggestions.

With regard to the unique problems of women, some get on methadone maintenance because they are pregnant. Others become pregnant while on maintenance. Their menstrual cycles. too, seem to be affected by drug use in general. Special programs for pregnant women at some clinics have been extremely helpful for women and their babies. Researchers and clinicians constantly attest to the marked differences between babies born to mothers addicted to heroin and those who have been part of pregnant women's programs in methadone maintenance clinics (Suffet et al. 1981; Green et al. 1980, Finnegan 1975). Programs designed to meet the special needs of mothers and their children should be supported and expanded.

The connection between the health problems experienced by women and their use of illicit substances should be acknowledged. Women do not appear to use drugs in a vacuum, but instead do so at particular junctures in their careers. By recognizing these junctures and structuring appropriate therapeutic interventions. perhaps clinicians can better serve the woman on methadone.

Regaining one's health can make the crucial difference between discouragement and depression on the one hand, and the positive physical and emotional states necessary to forge a fulfilling and productive life. The institution of programs and policies that would enable clients to become educated and informed about health matters would. it would seem, be a worthy goal for any program associated with the treatment of addiction.

1. It should be noted that this description is general; that some women had no health problems that they attributed to methadone. Because this analysis is qualitative, no concrete statistics can be offered. However, the data strongly suggest that health problems are a major concern. (Back)

* Institute for Scientific Analysis. 2410 Lombard Street. San Francisco. California 94171.

The authors wish to thank Lynne Jackson and Jerome E. Beck for their valuable editorial assistance.

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