“Methadone made me a prisoner,” said Francine, a former patient of mine, who was on and off methadone for 10 years. “That’s the only way I can sum it up. I couldn’t go anywhere because I had to go to the program six days a week. Even when there was a time I was going three days a week, I was still a prisoner. If you go one day a week, you’re still a prisoner.”
Francine’s “incarceration” had nothing to do with the properties of the drug. In the end, she switched to taking buprenorphine, which is available by prescription, in order to escape the punishing rules and regulations that exist in “methadonia,” a slang term for methadone clinics.
A Proven, Under-Emphasized Response
In case you hadn’t heard, the United States is in the midst of an epidemic of opioid-related deaths. According to the American Society of Addiction Medicine, the Centers for Disease Control and the US Surgeon General, drug overdose is the leading cause of accidental death in the US, with 47,055 lethal drug overdoses in 2014. There were 18,893 overdose deaths related to prescription pain relievers and 10,574 overdose deaths related to heroin in 2014. (It’s important to note, though, that the majority of drug-related deaths involve a combination of drugs, frequently opioids with alcohol or benzodiazepines.)
Heroin use in the US tripled from 2007 to 2014, according to a report from the Drug Enforcement Administration (DEA). It states: “Heroin is available in larger quantities, used by a larger number of people, and is causing an increasing number of overdose deaths.” This dramatic increase is a stunning indictment that the DEA’s decades-long war on drugs is an epic fail, for which drug users continue to pay with their lives.
Localized numbers further illustrate the tragedies. For example, overdoses killed a record 3,050 people in Ohio last year, more than one-third of them involving fentanyl. This year on Staten Island there have been 71 heroin-related overdose deaths; in the Bronx, the other New York epicenter, 146 people died last year. Heroin is cheap and thousands of people who used to buy expensive pain medications (such as oxycodone, or hydrocodone) on the street have switched.
In part because the escalation in heroin use and overdose is concentrated in white communities, the public, politicians and even some prosecutors are advocating a public health approach to the epidemic. In several states and cities, expanding drug treatment, making naloxone and sterile syringes widely available, and empathy for drug users are now the focus, not punishment or prison.
But there is an elephant in the room. There is an obvious, proven response to opioid-related problems. While it’s not exactly unknown or ignored, it is massively underemphasized—and not by accident.
This is to scale up access to methadone, a form of medication-assisted treatment (MAT), which has been proven to reduce opioid-related mortality by more than 70 percent. MAT is the international gold standard for opioid addiction treatment. Making methadone available on demand—rather than absurdly restricted, as it currently is in the US—could end the tragedy of overdose deaths.
But curiously, hardly anyone is talking about that.
Opportunities Willfully Ignored
It isn’t as if there haven’t been opportunities. The Comprehensive Addiction and Recovery Act (CARA), which became law in July, was the perfect opportunity to redesign the delivery of methadone, making it widely available. But no changes to the over-regulated and byzantine system of methadone prescription were included in the legislation. (Buprenorphine, another vital MAT drug, is neither stigmatized nor over-regulated to anything like the same degree.)
This month, US Surgeon General Vivek H. Murthy released the report Facing Addiction in America. It sends a series of mixed messages about MAT. Dr. Murthy affirms that MAT stabilizes drug users’ lives but then asserts, “methadone and buprenorphine have the potential to be misused.” (While true, it’s hardly a factor that should be emphasized in current circumstances.) And the report gives the false impression that a “take-home” supply of methadone is easily available and regular attendance at a clinic is no longer required.
Facing Addiction in America correctly identifies “multiple factors create barriers to widespread use of MAT” that include, “lack of an appropriate infrastructure for providing medications; need for staff training and development; and legislation, policies, and regulations that limit MAT implementation.” But incredibly, the report doesn’t call for removing any of the obstacles and instead recommends “…more research is needed to explore if, when, and how patients can be transitioned from MAT to non-medication status within the context of ‘personalized medicine’….”
How can the Surgeon General think that research into transitioning patients off of methadone is a priority, rather than massively expanding access to the drug, given that there are 78 opioid-related deaths every single day in the US? It’s unethical for Dr. Murthy to release a “landmark” report that recognizes profound problems in the methadone clinic system and not implement reforms to that system which, according to all the evidence, would save lives.
Methadone suffers from massive stigma, hatred even. No drug is more maligned. And this extends throughout the system that is supposed to help people benefit from it—from the doctors who decide which patients get methadone, to the nurses who dole it out, to the counselors who pressure patients to taper off and sadly, even to patients themselves. In my experience working with drug users, there is a fixation on and constant gossip about how many milligrams of methadone a patient is on. Less is always viewed as better, and tapering people off completely is the goal—even though life-long use of methadone is safe and indicated for many patients. The medication is still viewed as “another addiction” by healthcare providers and frontline staff in methadone clinics who by now (it’s 2016!) should understand that methadone is drug treatment.
Deborah Small is the executive director of Break the Chains and a leading voice for harm reduction-based drug treatment. “Methadone is stigmatized primarily because it’s a drug to treat drug users,” she says. “It suffers from the same stigma drug users suffer from, particularly people who use opiates.”
Politically, the War on Drugs scapegoats people who use drugs for social problems. Drug users aren’t seen as human but as “dope fiends,” “addicts” and “junkies.” In many politicians’ and other people’s eyes, no punishment is too harsh for the “criminals” who use illegal drugs, especially heroin. This dehumanization and criminalization is reflected in how methadone clinics are structured.
A Humiliating, Damaging System
The system through which methadone is provided is shaped by the Drug Enforcement Administration (DEA). By design, it entrenches stigma and distrust of patients. All methadone clinics must be approved and inspected by DEA agents. The clinic is assigned a DEA registration number and because methadone is a controlled substance, doctor prescribing practices are monitored. That the drug war dinosaurs at the DEA should have anything to do with the provision of methadone by medical practitioners is a travesty. No non-opioid medications, some which are far more toxic than methadone, have DEA oversight.
The Substance Abuse and Mental Health Services Administration (SAMHSA), which promulgates and enforces federal guidelines for opioid treatment programs, bears major responsibility for refusing to reform a clinic system that resembles prison. It’s not for nothing that methadone is commonly called, “liquid handcuffs, “chemical parole” and a “life sentence.”
Since methadone was first introduced to US patients over 40 years ago, the medication has been held hostage within a shadow clinic structure based on control, surveillance and arbitrary punishment of patients. “It would be difficult to design a more stressful and traumatic system if one tried,” wrote Peter Vanderkloot in his seminal article, Methadone: Medicine, Harm Reduction or Social Control. “First, patients are doled out only the smallest possible supply of a substance that they need like food or oxygen. Then they are placed under constant scrutiny by a hostile and distrustful staff and regularly threatened with loss of access to their medication.”
The coercion in clinics starts with attendance requirements. For the first three months patients must attend clinic six days a week. This is a hardship for anyone who doesn’t live close to a clinic. In rural areas some patients drive for hours to get medicated. Six days a week. For those people, life revolves around getting to and from the clinic, and for many it is a financial hardship, too.
Imagine for a moment if you took your own medication every day, as millions of us do, under these circumstances. Would your current lifestyle even be possible if you had to go to a special clinic, an hour or two away, virtually every day?
After three months, if eight strict criteria are met—for example, no recent “abuse” of drugs, including alcohol; no recent criminal activity; having a stable home environment and relationships—patients are allowed two take-home doses per week.
These criteria to take methadone at home are illogical. Reduction in criminal activities needed to make money to buy heroin is a major benefit of methadone—so shouldn’t it be easier to get, even for those who are involved in criminal activity, most of which is petty in nature? And having an unstable home environment and relationships isn’t limited to people on MAT. But for many, it’s what contributed to their addiction in the first place, and it probably won’t improve after three months of taking methadone.
In these cruel and controlling ways, SAMSHA creates major disincentives for drug users to enter MAT.
Imagine if other medications–Viagra, Ritalin or Valium–were subject to the same criteria. Why can’t methadone be made available as a prescription like these other kinds of drugs, even those that have potentially dangerous side effects?
Instead, patients receive their dose of methadone from a nurse who hands them the liquid medication in a plastic cup through a hole in a Plexiglass window. Then the patient is instructed to either lift their tongue up for inspection or to speak. Why? According to SAMSHA, “…observing a patient take his or her dose and having each of them drink and speak after dosing are fundamental components of diversion control…”
The requirement is humiliating. Small makes this analogy: “Imagine if people had to take their insulin or chemotherapy while a person watched them. Most people would think that was a horrible intrusion.”
Methadone “diversion“ is a phenomenon that has been greatly exaggerated by the DEA. The relatively rare instances of methadone being sold on the street usually involve its being bought by heroin users to stave off withdrawal.
Methadone patients are forced to give “supervised” urine samples to check for illegal drugs. Depending on the clinic, urine specimens can be collected under direct observation (a staff member watches you pee), a one-way mirror, or via a camera in the bathroom. According to SAMHSA rules, “All maintenance patients must receive a minimum of eight toxicology tests per year. The results of toxicological tests are an essential component in making decisions regarding take-home medication privileges.”
Being watched while urinating is degrading. It is a violation of the Fourth Amendment. Vanderkloot rightly concludes, “The entire system is designed around observed ingestion and continual monitoring.”
Consistently having “dirty urine” i.e. use of unapproved drugs, can result in involuntary “administrative withdrawal.” It’s a deliberately vague and bureaucratic phrase that has chilling implications for patients: they are forcibly tapered off methadone.
It happened to my patient Francine: “So, from 100 milligrams they detoxed me in two weeks, which is called a “suicide detox,” down to 10 milligrams. And I couldn’t do it.”
Other infractions of clinic rules that can result in “administrative withdrawal”: nonpayment of fees; disruptive conduct or behavior—including dealing drugs, repeated loitering; violent conduct or threatening behaviors.
Even pregnant women on methadone can’t escape punishment. They can be forcibly withdrawn from methadone and in a case in New Jersey several years ago, a lower court decision held that methadone treatment in pregnant women is child abuse.
A pervasive problem at methadone clinics, one acknowledged by the Surgeon General’s report, is the lack of highly trained, experienced and educated counseling staff. To say they are unprepared to work with a patient population that has exceptionally high rates of complex trauma and chronic mental health needs is an understatement. The certification, education and experience required to work in methadone clinics are minimal. Certified alcohol and substance abuse counselor (CASAC) certifications are usually all that is needed, although some clinics require a BA. Many CASACs have “lived experience” in 12-step abstinence treatment and are hostile to medication-assisted treatment. And counselors can have as little as one year of experience providing individual or group therapy. This is a disaster for patients that wouldn’t be tolerated in other healthcare settings.
We Already Know the Way Forward
Fundamental reforms to deregulate methadone are urgently needed. Fortunately, we don’t have to look far to see how methadone can be restructured to fulfill its original purpose: harm reduction. Below is a list of comprehensive reforms some that are based on recommendations from the Global Commission on Drug Policy. Several countries—including Canada, Portugal and Switzerland—have successfully enacted many of these changes. The implementation of these reforms in the United States is literally a matter of life and death.
1. Eliminate the role of the DEA in all medication-assisted treatment.
2. Abolish methadone clinics and transform them into humane drug treatment centers that operate on the principles of harm reduction.
3. Allow physicians, nurse practitioners and physician assistants to prescribe methadone, heroin and buprenorphine without patient caps or onerous restrictions.
4. Allow patients to pick up prescriptions at the pharmacy.
5. End drug testing of patients on MAT.
6. Deploy MAT vans to neighborhoods that have high rates of prescription opioid and injection drug use and overdose deaths.
7. Open safe injection sites and partner with healthcare providers to offer MAT.
8. Raise the education and experience requirements for substance use counselors and make harm reduction psychotherapy available for all patients.