Thursday, February 28, 2013

Hidden Costs of Methadone Maintenance

    If addiction is a disease, and it is not at all clear that it is (I for one, remain unconvinced, which is one reason I oftentimes put "addict" in quotes), it is certainly not treated like any other disease. There is no known cure for opiate addiction, a relapsing-remitting disease. To be sure some addicts go into "spontaneous remission" or experience "natural recovery," most without any treatment whatsoever. When medicine is not able to cure disease, the next best thing is to reduce the harm of the disease by treating symptoms and doing everything possible to increase the patient's quality of life. In this context methadone could be considered a form of harm reduction, designed to make the symptoms of opiate addiction less burdensome to the individual and society.

    In addition to curing disease and palliating disease symptoms for which medicine currently has no therapeutic agents, medicine has also traditionally been used as a form of social control. Government control and medical controls have traditionally supported one another. Methadone maintenance, as a medical treatment, has aspects of both medicine and social control. Needless to say, the ethics of providing a medical service and the ethics of controlling people go by completely different rules. Methadone lies in between these two extremes, and as such is rife with paradoxes and contradictions.

Hidden Costs of Methadone

   The actual cost of methadone is very cheap. When bought in bulk (tens of thousands of mgs) the cost per dose is only pennies, pills for individual consumption only a few dollars. Methadone clinics charge between $10-15 dollars per day and may or may not be covered by insurance. The cost goes to paying for security guards, nurses, counselors and doctors. While not excessive, certainly no one is robbing banks to pay for their methadone, three to four hundred dollars per month can be a significant burden on poor people without health insurance. Some will say that since the addicts could find money to buy their black-market opiates, often at $100+ per day, they should be able to hustle up the cost of methadone. Such thinking is seriously flawed, do we really want people to commit crimes (petty theft like shoplifting, prostitution, low-level drug dealing) to be able to afford their medicine?

    Methadone clients have to go to a clinic everyday, where they might have to pass through metal detectors and wait, sometimes for hours under the watch of security guards, until they can see a nurse for their medicine. Counseling is also mandatory, regardless of whether the client wants it or not. One can only guess how efficacious forced therapy is, given that therapy usually requires mutual cooperation, understanding and trust.

    If diabetics had to go through such a routine they would be, rightfully, outraged. If methadone truly is a pharmaceutical treatment for a mental illness, why should patients suffering from this particular ailment not be able to get the medication from their primary care physician? If they desire to undergo counseling, they should be free to choose their own provider. Physicians may prescribe Prozac, Valium and a host of other psychotropic drugs, but methadone has its own series of restrictions. Of course these restrictions only apply to addicts, doctors are free to prescribe methadone for pain.

    Beyond the costs of the clinic, there is also the costs of transportation to and from the clinic. This is, of course, all born by the client. Also frequently overlooked is the opportunity costs of spending time traveling back and forth to the clinic, and wait time before dosing (which can range from minutes to hours). This has earned methadone maintenance the nickname "Liquid Handcuffs."

"What the [Baltimore] Sun utterly fails to recognize here is the human cost of seemingly benign regulations like limiting distribution of these drugs to special clinics and requiring that the addicts visit daily.
"For one, think about trying to hold down a job while having to make daily, sometimes lengthy visits to a clinic - a clinic typically located in a bad neighborhood that is usually open for only a few, fixed hours and that often makes you wait for your dose. You cannot go on a business trip, let alone a vacation. You cannot come in early or work late if you will miss clinic hours and you are literally tied to this daily visit no matter what else happens in your life or you will rapidly become ill.
"Such restrictions reduce the likelihood of addicts seeking treatment and succeeding at it if they do enter: Success in recovery is linked with employment (something you'd think everyone would want to encourage anyway). This is why allowing general practitioners to prescribe buprenorphine and let addicts take it home like any other prescription improves the odds of recovery. It also allows more addicts to get treatment, period."
-"The Wire V the Baltimore Sun: Which Covers Addiction Better?" by Maia Szalavitz
    Methadone does not work for everyone. How one defines success varies, but in my opinion the only measure that matters is quality of life. If an individual spends less time committing crimes to raise money, uses less "street" drugs, reconnects with family and community or gets a job following chronic unemployment, I would regard that as a success. Ideally once the client reaches a therapeutic dose they no longer require illicit opiates. Without having to spend most of each day trying to raise money to pay prohibition-inflated prices for opiates, and having to find a purveyor of said illicit opiates, the individual is then free to live a normal life. Unfortunately methadone is not well tolerated by everybody. Methadone is pharmacologically distinct from morphine-type opiates, including the most commonly "abused" opiates like oxycodone and heroin. While chemically distinct, methadone and morphine-type opiates are cross-tolerant, the dosages used at most clinics are high enough to "block" any attempts to use opiates. At this point many methadone clients turn to other drugs, the two most common being cocaine and benzodiazapines. When methadone is combined with benzodiazapines like valium or xanax, it provides an opiate-like high, though more sedated. Alcohol is also commonly used. When people turn to other intoxicants it can be debatable as to whether or not methadone is reducing drug harm.

    What happens when methadone doesn't work? If opiate addiction were like other diseases, the natural recourse would be to try a different medication. If methadone didn't work, other opioids could be tried. Again addiction is not treated like other diseases, the treatment "failures" are kicked out of the program. It is as though a easily cured patient is sick, a treatment resistant patient is a scoundrel and a malingerer.

Methadone is Substituting One Drug for Another

    One of the most common claims made against methadone is that it is just substituting one drug for another, and thus one addiction for another. Even in the drug treatment community, there is some debate as to whether addicts on opioid maintenance programs are truly "in recovery". The usual line by supporters of methadone is that there is a distinction between "addiction" and "dependence."

"This means that a person can be in complete recovery from addiction - in a stable job, supporting and loving a family, not taking any non-prescribed medications, appearing no different from anyone else - and still take methadone or buprenorphine. Addiction is not physical dependence on a drug. If it was, we'd have to consider all diabetics as "insulin addicts" and people who need antidepressants long-term as "antidepressant junkies."
"Instead, psychiatry defines addiction as compulsive use of a drug despite negative consequences. If the use isn't compulsive and the consequences are positive, the addiction has been resolved even if the physical dependence remains."
          -"The Wire V the Baltimore Sun: Which Covers Addiction Better?" by Maia Szalavitz

    It is hard to see how "compulsive use despite negative consequences" constitutes a disease state. Most heroin addicts use no more compulsively than tobacco addicts and few argue that constitutes a disease. According to such a definition, if a heroin addict is independently wealthy and is never arrested, or if another addict receives all their drugs through a prescription; that is, if they experience few negative consequences because they can afford the habit, are they not addicted? Moreover "compulsive" is inherently subjective, what may be a craving to one person could be conceptualized as a calling to another; few things in life have only positive consequences, each person weighs the possible positive and negative consequences of their actions and makes a choice according to their values and personal priorities. Drugs are no different, for some people drugs are their sole source of pleasure in this world. For some people the negative consequences are simply the price of admission to artificial paradise (the fact that prohibition makes these negative consequences far worse than they would be otherwise deserves to be repeated).

     In 2009 the New England Journal of Medicine published a research paper that showed that heroin was more effective than methadone for the treatment of opiate addiction. It is also more cost effective. I can't wait to see how the treatment industry is going to try to spin these results. If the same or better results as methadone maintenance can be achieved with regular doses of pharmaceutical heroin (known as HAT, heroin assisted therapy or heroin maintenance), one has to wonder if the negative consequences of dependence on black-market heroin has anything to do with the pharmacology of heroin and everything to do with the social circumstances surrounding heroin addiction (ie prohibition).

    I think the criticism of that methadone is a substitute for other opiates (eg heroin, oxycodone) is valid, though the assumption underlying this criticism is wrong. When methadone is criticized for being "just" a substitute for heroin, the implication is that addicts should not have access to drugs. Addicts are often accused of "escaping reality" through their drug use. This criticism is unevenly applied to only the "bad" (illegal) drugs. Persons taking antidepressants are not derided for an inability to "deal with reality," nor are they accused of chemical dependence. Nevertheless the belief that no one ought to use drugs to alter their consciousness is based on a religious ideal rooted in Christian tradition.
"No argument supporting the moral condemnation of drug use has had a stronger and more pervasive hold on the American popular imagination than the argument for protecting the perfectionist ideal of the person...The perfectionist ideal arose within the Radical Reformation and was carried to the United States by sects, such as the Quakers and Methodists, whose own moral conceptions appear to have decisively shaped the American conception of public morality...For the radical sects and their offshoots, all personal experience was considered religious; therefore, the state and quality of such experience was properly the subject of religious concern. The use of drugs, in particular alcohol, for nonmedical purposes, was thus eventually condemned." 

    It is my view that methadone maintenance is nothing more than a reinvention of the narcotic clinic model that evolved after the passing of the Harrison Narcotic Act in 1914. It has been known that when addicts are given stable, steady doses of opiates, they can live relatively normal lives. When deprived of a licit channel, what is at most a minor personal problem becomes a disaster for both the individual and society. The US government has always been hostile to the idea of narcotic maintenance, the last of the narcotic clinics were closed in the early 1920's. For methadone to be politically viable, it had to be sold as a treatment. The fact that a stable dose provides no euphoria is a selling point, since taking for drugs for pleasure is considered drug "abuse" (ie pharmacological masturbation), though from the user's perspective this is clearly a detriment.  

    It may seem that I am anti-methadone, nothing could be further from the truth. For many people methadone is a lifeline to normality. To cut off methadone access, or to limit the amount of time a patient may be on methadone, would be cruel. My problem with methadone is that it is over-regulated and administered in a way inconsistent with the treatment of other diseases. If opiate addiction is truly a disease, then it should be treated as such. Addicts should be given the full range of treatment options, including heroin. Ideology should yield to treatment outcomes.
"And yet here we are again, several decades later, engaging in the same misinformed debate, which often seems more about a puritanical vision of what’s “right” rather than what works. While it’s certainly possible for people with opioid addictions to thrive without maintenance—and while most of us prefer to be dependent on the fewest possible medications—there’s no need to stigmatize the treatment for those for whom it works.
"Type 2 diabetics who have conquered their disease through diet and exercise don’t go around calling those whose disease is more resistant “defective,” nor do they demand that insulin be pulled from the market or used only for limited periods of time in order to force those weaklings to recover more naturally. If they did, no one would listen. We know that personal experience doesn’t trump medical expertise and that medicine should be based on research, not anecdote."
          -How I learned to Stop Worrying and Love Methadone by Maia Szalavitz

Further Reading:


  1. This comment has been removed by a blog administrator.

  2. Joecole222 As a diabetic, albeit T1, who is well versed in diabetes, T1, T2, LADA, monogenic, and otherwise, I am compelled to tell you to take your trash medical advice and shove it someplace dark, preferably from behind.

    You don't and can't "jumpstart" your pancreas. Frankly that doesn't even make any sense in regard to the etiology if type 2 diabetes. It's pure woo to sell nonsense.

    Lose weight. Reverse T2. The pancreas nor insulin reduce insulin resistance. Resistance comes from fat. Fat comes from insulin...insulin allows the body to store fat just as it allows cells to use sugar. It doesn't do just one thing. Jump starting your pancreas, I assume , means to make insulin production more viable...which isn't going to help with the core of the problem. Eat right, exercise, fix the problem.

  3. This article is absolute and complete garbage. As a psychologist, I can refute and disprove almost every single claim made on this article. Completely biased and untrue. I don't even know where to begin there is so much crap in here.

    1. I'm a recovering addict, and you're right, this guy has no clue what he's talking about. Absolute nonsense!

    2. You say you can refute and disprove almost every claim I made but don't offer a single example.

      Am I biased? You bet I am. I have a generally positive view of opioids (the blog is named opiophilia), but I don't lie. If you have a problem with my data or conclusions, fine, but to claim the article is untrue without citing a single example is not helpful. And invoking an argument from authority ("I'm a psychologist") in such a worthless comment just makes you come off looking like an asshole.

  4. Who the hell told you that most opiate addicts"experience natural recovery" without any treatment at all!? I'd love to see your sources for this information please?

    1. Here's an article by Maia Szalavitz that has many embedded links you can follow for more research. It's a good overview of this topic.

    2. From the Szalavitz article:

      According to the American Society of Addiction Medicine, addiction is “a primary, chronic disease of brain reward, motivation, memory and related circuitry.” However, that’s not what the epidemiology of the disorder suggests. By age 35, half of all people who qualified for active alcoholism or addiction diagnoses during their teens and 20s no longer do, according to a study of over 42,000 Americans in a sample designed to represent the adult population.

      The average cocaine addiction lasts four years, the average marijuana addiction lasts six years, and the average alcohol addiction is resolved within 15 years. Heroin addictions tend to last as long as alcoholism, but prescription opioid problems, on average, last five years. In these large samples, which are drawn from the general population, only a quarter of people who recover have ever sought assistance in doing so (including via 12-step programs). This actually makes addictions the psychiatric disorder with the highest odds of recovery.

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