Fitting Square Pegs Into Round Holes: Methadone Maintenance Within The Abstinence Paradigm
The seminal contribution of Dole and Nyswander was not the demonstration
that methadone, in constant daily doses, can allow many long-term,
criminal, recidivist heroin addicts to lead healthy and productive
lives. Rather, it was their revolutionary proposition that there
is a physiological component of addiction that might contribute
to its etiology, but that certainly is a factor in its perpetuation.
Dole and Nyswander postulated that repeated exposure to exogenous
opiates could permanently alter the body's homeostasis, and that
methadone might correct this physiological abnormality while at
the same time "blocking" the acute effects of short-acting
narcotics such as heroin. Their hypothesis was remarkably prescient;
not until many years later, with the discovery of the endorphines,
could skeptics be given a plausible scientific basis for this
theory.
As yet, of course, there is no proof that addiction indeed is
a "metabolic disease;" the concept, then as now, has
been based largely on empiricism and common sense. Thus, if willful,
defiant, anti-social hedonism accounted for the development and/or
perpetuation of addiction, it would be impossible to explain why
so many addicts seek voluntarily to enroll and remain in methadone
programs; even more baffling would be the dramatic, favorable
impact on their lives which this treatment can have.
The corollary is equally persuasive: If addiction were due primarily
to a character flaw and a deficit in will-power, entering a drug-free
program would, by definition, be evidence that "the problem"
had already been largely overcome even before treatment commenced,
and the results of such programs should be excellent. In fact,
however, only a very small proportion of clients who begin drug-free
treatment complete it, and an even smaller proportion subsequently
are able to remain abstinent.
This is the reality even for patients admitted voluntarily, despite
the motivation inherent in their application and admission, and
despite the skill and compassion of staff (and, often, loved ones)
who devote their lives to providing help and support.
Dole and Nyswander were remarkably restrained in their advocacy
of methadone treatment even in the earlier years, when federal
authorities in America threatened an absolute prohibition against
the prescribing of methadone. Based on their hypothesis that addiction
is a disease which, in many individuals, can not be overcome by
willpower and psychosocial support alone, they suggested that
some heroin addicts will require medication - methadone - to enable
them to lead normal lives, free of illicit drug use and all the
devastating consequences of such use.
Note that I attribute to Dole and Nyswander the qualifiers "many
individuals," and "some heroin addicts." The fact
is that they never claimed that methadone is a sine qua non for
recovery of all individuals, nor that it need be a life-long treatment
for every heroin addict. By not insisting that methadone maintenance
is a universally applicable and necessary treatment, did they
perhaps weaken their thesis that heroin addiction is a "metabolic
disease?" Not at all!
There are a great many serious, physical illnesses which can be
prevented, and/or whose signs and symptoms can be eliminated,
by appropriate changes in lifestyle alone, without medication:
asthma, hypertension, cardiac disease, gout, diabetes, peptic
ulcer, colitis, a variety of cancers (for instance, of the lung
and the skin), orthopaedic ailments - the list is endless. The
caring, competent, holistically oriented health professional does
everything possible to encourage and facilitate those behavioral
changes which will prevent, mitigate the signs and symptoms of,
and on occasion even cure these diseases. However, it would be
professionally and ethically unacceptable (and ridiculous!) if
physicians refused to prescribe medication to patients who will
not or can not comply with the behavioral change prescribed, or
whose disease persists and progresses despite their very best
efforts.
Nevertheless, the paradigm of abstinence as the be-all and end-all
of addiction treatment continues to dominate. Fifteen years ago,
in an article entitled "The Irrelevance of Success,"
I wrote:
"…the most destructive impact on methadone maintenance
treatment has come from the seemingly more moderate critics who
tolerate the use of methadone, but with certain qualifications
. . . [Endorsement] has amounted to no more than the grudging
approval to utilize methadone, but only within a therapeutic framework
diametrically opposed to that which formed its original foundation.
Today, the utilization of methadone represents only a modification
of the drug-free approach, and a total repudiation of methadone
maintenance treatment as employed so successfully by Dole and
Nyswander." (5)
Nothing has changed in the past fifteen years. The rationale for
"maintenance" treatment of addicts continues to be anathema,
even to the majority of its self-proclaimed supporters. They continue
to focus on a drug-free end-stage of treatment, and reject the
premise that for many addicts this is an unachievable, unrealistic
and irrelevant objective. Policies and practices which otherwise
are incomprehensible take on a certain logic if one attributes
to methadone programs the view that heroin addiction can and should
be overcome without reliance on medication.
From this perspective, both the medication (methadone) and those
who need it are viewed pejoratively. This in turn leads programs
(and regulatory authorities that govern those programs) to establish
hurdles to discourage or reject applicants for enrollment in maintenance
treatment, including severe limitation on availability of such
treatment; to rely on low dosages of medication, despite evidence
that such dosages are sub-optimal and potentially lethal; to set
limits on the duration of methadone treatment, despite the fact
that relapse is the rule rather than the exception when treatment
(any treatment) is stopped; and to refuse to permit methadone
administration without a strong "supportive services"
component to deal with the psychological and social problems which
they attribute to all addicts, and which they obviously believe
are the basis for the patients' need for a "crutch."
In sum, methadone is viewed as a regressive step, to be tolerated
only in the hope that it will be followed by two steps forward
in pursuit of the ultimate, universal objective of complete and
permanent abstinence.
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