Two stories on methadone

English: Methadone structure, animation

First,

DEATHS among drug users have hit a record high in Scotland, increasing by a fifth in 2011, the latest government figures reveal.

Last year 584 people died from drug use, which means that drugs now account for one in every 100 deaths in Scotland.

The heroin substitute, methadone, was at the heart of the increase, with almost half of the drugs-related deaths involving the prescription drug.

Second,

How I Learned to Stop Worrying and Love Methadone

Just like ex-junkie Russell Brand, I used to believe that “maintenance” was as bad—if not worse—than active addiction. Here’s how I came to understand how fatally wrong I was.

I have no quarrel with any addict receiving methadone maintenance, IF they’ve been provided with accurate information and quality drug-free treatment.

I wish that, rather than describing methadone as, “the most effective treatment for opioid addiction,” they would be more specific about what they mean by effective:

…study after study shows that when methadone prescribing increases, addict deaths drop. It is superior to abstinence-only treatment in terms of fighting HIV and overdoses, and many studies find it superior in cutting crime.

Those things are important, but methadone is not the only way to achieve those goals and they’re not the only things that are important.

Of course, as we’ve pointed out many times, there is one group of opiate addicts that are not treated with opiate maintenance. Doctors are not treated with opiate maintenance and they have terrific outcomes.

Are we really denying addicted doctors “the most effective treatment for opioid addiction”?

Of course not. We’ve decided that, for them, we’re going to aim a little higher than reducing overdose risk, crime and HIV.

9 Comments

Filed under Controversies, Dawn Farm, Harm Reduction, Policy, Research, Treatment

9 responses to “Two stories on methadone

  1. A very insightful post, as usual. Thanks, Jason.

  2. Tom

    I appreciate your willingness to evolve in your thinking about methadone. I also appreciate your healthy skepticism.

    I admit I am one that says that methadone is “the single most effective treatment for opiate dependence.” Part of the reason I phrase it this way is to help cut through the stigma (and misinformation) around methadone. The stigma is part of what keeps many people who might benefit from the option from even considering methadone. l continue to think that it is an accurate statement, although I certainly don’t advocate a “methadone fits all” approach. Methadone is not the most effective or “best” treatment for every single individual who is opiate dependent.

    Thanks for helping to bring the conversation forward, and thanks for a “smart” blog!

    p.s. would you consider adding my site recoveryhelpdesk.com to your blog roll?

    • Thanks for the kind words. I’m interested to hear how you reconcile the fact that opiate addicted heath professionals get one treatment, while other opiate addicts, particularly poor ones, get methadone. What are your thoughts on this disparity?

  3. Tom

    The most obvious difference is that health professionals have more money and better health insurance than people with low income, so they have more options. That’s part of it.

    Also, methadone tends to be a less ideal treatment match for the average health professional. Most people don’t choose medication-assisted treatment unless they have already tried residential and outpatient treatment options multiple times without successfully achieving sustained sobriety. I’m guessing that most doctors are able to keep their addiction secret –until it isn’t a secret anymore. Then they begin treatment and succeed (if they hadn’t, they would have lost their medical license), so they never get to the point that opiate replacement therapy is the best option.

    How do doctors tend to succeed without the need for opiate replacement therapy? My guess is they tend to have less complex addiction profiles. In other words, they are less likely to have addiction complicated by other factors like major mental health issues, homelessness, criminal justice involvement and other issues common among low income people living with addiction.

    The clients I work with tend to have become addicted by age 16. By that time, they had already experienced significant trauma. Most share a common cluster of issues including anxiety/PTSD, ADD/ADHD, depression, anger and grief/loss issues. Many did not complete high school. Many have spent time in prison. Many are homeless or marginally housed.

    They never made it out of high school, and would never make it through medical school. The doctors did. And the reason they were able to make it through medical school is the same reason they are more likely to achieve sustained sobriety without opiate replacement therapy. They probably didn’t become addicted until much later. And they have more strengths and resources, and fewer barriers.

    Abstinence-based treatments have their own risks. Even with access to the exact same treatment as doctors, I think methadone would be a better option for someone who:

    Has been to rehab 5 times (kicked out 3 times), used while in rehab, or relapsed each time within days of discharge.

    Has been to jail multiple times, used in jail, and has consistently returned to jail soon after release.

    Has had multiple drug overdoses including when just out of rehab or jail.

    Is living with HIV and HCV.

    Has untreated mental health issues, and does not have access to or is not willing to seek mental health treatment.

    Has never been able to attend outpatient treatment consistently because they are consistently discharged for too many missed appointments.

    Is on probation, and will be returned to incarceration immediately for 3 years if they get a positive drug test with their PO.

    Has a pending child protection case and is at risk of losing custody of their child if they fail to pass child protective services drug tests.

    Has new charges pending, and needs to demonstrate recovery progress to a prosecutor and a judge.

    Was using 10 bags of heroin per day, but recently started taking diverted Suboxone and found that it keeps them from wanting to use heroin.

    Is not likely to be able to successfully hold their own medication as required when participating in Suboxone treatment with a private doctor because they are likely to be targeted for their medication, or are likely to sell their medication to meet basic needs.

    Doesn’t think that counseling or rehab will work for them, and aren’t willing to try that route again.

    Has come to the conclusion that opiate-replacement therapy will work for them, and are ready to try it.

    Comparing most doctors with most people with complex addiction is comparing apples and oranges. I would like to see everyone have access to the same treatment as doctors, because for many it would work. For others, it would not. Others need methadone treatment. And that’s ok.

  4. Thanks for the thoughtful reply. I have 2 responses.

    First, the cases you describe are among the most complicated possible. They are the kind of addicts we frequently treat at Dawn Farm. However, they constitute a pretty small fraction of opiate addicts. And, many of them are still in active addiction, not because their form of addiction is more treatment resistant, but because the treatment system has failed them by providing inadequate care. (This failure may well create a form of addiction that is more treatment resistant.)

    Now that we’ve addressed the outliers, there is a common, but mistaken, assumption that addicted physicians are considerably less complicated cases than other addicts. Not so. They have relatively high rates of psychiatric comorbidity (http://www.ncbi.nlm.nih.gov/pubmed/14621346) and they often seek treatment only when their addiction is pretty advanced (http://www.ncbi.nlm.nih.gov/pubmed/19161896). In addition, they have pretty sophisticated defense structures, easy access to drugs and cadres of people to prevent their impairment from becoming more visible.

    Thanks again. All the best.

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  7. Cheryl

    I personally know lots of Health Professionals on Methadone for the treatment of their substance use disorder. There was recently a court case in Pennslyvania involving a nurse on Methadone. Isn’t it strange that you could take the same medication for a different reason and not be considered “impaired”? (pain vs. addiction)

    STIGMA is alive and well, even in the medical community!