I suspect that the majority of people reading this article will have some strong feelings, perhaps negative, about patients who access methadone or buprenorphine treatment for chronic opioid addiction. In spite of the fact that medications have been used successfully to treat chronic opioid addiction for more than 40 years (principally methadone, and more recently buprenorphine), and in spite of overwhelming research demonstrating the efficacy of such medications, there is extraordinary stigma toward such individuals.
This stigma is fairly widespread in the general society but is also present in addiction treatment experts as well. Generally speaking, feelings of stigma include negative views and attitudes toward what is perceived to be an undesirable group of people.
There have been a number of researchers who have written extensively on this topic, including Drs. Herman Joseph1 and Charlie Winick.2 Most recently, William White discussed this issue in addressing the national conference of the American Association for the Treatment of Opioid Dependence (AATOD). He provided a moving and eloquent exploration of attitudes, including his own, toward patients who use methadone or buprenorphine to treat their chronic opioid addiction.
Stigma often meshes with mythology. Illustratively, many people believe that it is counterintuitive to provide a dependency-producing medication in order to treat an addiction. Some representatives from AA have characterized methadone as “giving a bottle of scotch to a recovering alcoholic.”
At times, stigma meshes with mythology to denigrate the medication being used to treat an illness as an extension of perceptions toward the illness as well. It is fair to state that many in our society still do not believe that opioid addiction is an illness; rather, they see it as a moral failing and a reflection of undisciplined will. These attitudes are shifting very slowly, but attitudes in the alcohol and drug treatment community are still entrenched in old beliefs about using medication to treat chronic opioid addiction.
The National Institute on Drug Abuse (NIDA) funds approximately 95% of the world's research in treating addiction. It has funded a significant number of studies, which have shown time and again the success the patient has experienced during the course of treatment.3 The Center for Substance Abuse Treatment (CSAT) within the Substance Abuse and Mental Health Services Administration (SAMHSA) has also published extensive Treatment Improvement Protocols (TIPs)4 and other advisories, which combine research with evidence-based practice. Such information has helped to strike down a fair amount of mythology and stigma in the use of medications. For example, methadone does not rot teeth, nor does it decay bone marrow.
Many people in the addiction treatment community also feel that there should be some time limit if patients need access to medication to treat an illness. A frequently asked question is: “How long should a patient remain in treatment?” The answer is as long as the patient continues to benefit from the ongoing use of such medication. It would be impossible to imagine a psychiatrist treating a chronically depressed patient, who has finally stabilized on an antidepressant, to suddenly terminate the medication to see how the patient might do. Equally impossible would be to imagine a cardiologist saying to a stable patient, who had years of coronary disease, that he/she should discontinue the medication that is stabilizing blood pressure. Why is it, then, that we have such a need to limit patients' continued use of medication even though they benefit from such treatment? Stigma and misunderstanding are the key ingredients that fuel such perspectives.
This stigma affects national policy in addition to the views of state policy-makers and communities. At the national level, there are governments, such as Russia's, which still will not provide access to medications such as methadone to treat chronic opioid addiction. Their view is that the science is still insufficient to understand the value of such medication. At a much darker level, a senior Russian narcologist once discussed such an issue during a meeting at the Kremlin. The general view was that individuals who use heroin are already lost to society, therefore it is not useful to treat them since they will never be productive citizens to “the mother country.” Accordingly, it is better not to treat them and let them die from the diseases that an untreated heroin user is prone to, such as HIV/AIDS.
The effective stigma is also significant in state policy-making. A number of states still do not provide access to methadone, while others have resisted providing access to methadone treatment. At a 1995 Maine public hearing considering the use of methadone maintenance treatment for its chronic addicted population, a senior health official took the position that the 200 or so patients currently being treated through outpatient detoxification programs were not really residents of the state.
Of course, there was no truth to this, but it is an interesting indication of how a state would claim that the patients were not their responsibility since they must have been born in other parts of the Northeast and managed to settle in their state. This is another example of how stigma can cause individuals to disown the negative and affected group. In the case of the state officials, if they could claim that the people in need of such care were not really from their state, then they would not be responsible for providing access to treatment. This is a version of magical thinking, but based on a stigmatized population. The public health official went on to claim that the state's public relations would also suffer if people knew that there was heroin addiction in the state. The easiest course was to deny it and not provide access to care.
What penetrated this barrier was a young woman who was modestly dressed and had asked to speak at this public hearing. While she did not have any scientific arguments to make, she was eloquent in talking about her family. It appeared that her husband was a heroin user and was also a fisherman. They had two daughters, ages 5 and 7, and the husband was doing well as he stabilized on his dose of methadone during the course of treatment. There was food in the refrigerator and their girls had new clothing. The woman was not worried about where her husband was at night and on weekends, since he would come home after work. Her family also changed its attitudes toward him and their marriage during the course of his care. Her point to the public health panel was that his success in treatment created stability in their lives as well. Ultimately, the state decided to approve the use of methadone to treat chronic opioid addiction.
Stigma in a therapeutic environment
Dr. John Caplehorn of Australia conducted a study to evaluate staff attitudes toward methadone-maintained patients,5 drawing both upon a survey of staff in drug-free residential programs in addition to staff in methadone programs. Curiously, the attitudes were not remarkably different and they were fairly negative. In this case, the staff of the program had “absorbed” society's general antipathy toward the patient in treatment and toward use of the medication. Most staff favored patients having short-term treatment in spite of research that demonstrated that there were better outcomes when patients remained in treatment for extended time periods. There was also a fundamental misunderstanding of the disease concept of addiction and its neurobiology.
A number of methadone program administrators/directors decided to replicate a version of this study throughout their programs in the United States. Their findings were remarkably similar to those of Dr. Caplehorn and his associates. In spite of access to training and research information, many of the staff simply did not understand why patients would need access to care for extended periods of time.
Recommendations to change such attitudes
If counselors are dealing with patients who are receiving methadone, buprenorphine or naltrexone to treat chronic opioid addiction, it really is critically important to read the scientific literature that established the evidence to support this treatment. It is not possible to treat the patient properly unless the clinician has a fundamental understanding of the disease concept of addiction and how medications such as methadone and buprenorphine work neurologically. The basic understanding of this use of medication came from the early work of Drs. Vincent Dole, Marie Nyswander and Mary Jeanne Kreek6 of Rockefeller University. There was a fundamental change in brain chemistry as the patient used exogenous opioids such as heroin for extended periods. This change in brain chemistry necessitated the use of the medication, which would normalize brain function so that the patient would be able to function in society. While there are many more elaborate explanations for this phenomenon, suffice it to say that individuals in the addiction treatment field must understand the science of what we do.
The second challenge is to understand what brings us to the work of treating chronic addiction. Where are our own belief systems, aside from the established scientific literature? It is surprising how many staff have negative views about the treatability of addiction. Some of the attitudinal research, as referenced above, even found a kind of hopelessness in the views of the staff toward the patients' eventually recovering from their addiction through the use of medications such as methadone.
It is also important to examine the individual clinician's concept of recovery. In the 1980s, a popular magazine in our treatment community discussed the fact that any patient in methadone treatment could not possibly be in a state of recovery. The view was that recovery required complete abstinence in order to move on to the next level of coping with the reality of one's addiction. William White spoke about such issues during the recently convened AATOD conference in New York (April 2009) and was able to come full circle to where he was many years ago, reflecting this kind of attitude. Many clinicians are still of the opinion that using methadone and buprenorphine interferes with the individual patient's ability to respond to the challenges that come through counseling. This is also not the case but is a convenient mythology, which springs from stigmatized views toward the patient and this particular treatment.
Additionally, clinicians need to be careful about the judgments they make about the patients they treat. It is curious to note that many individuals who work in this system and who provide therapy to the patients have never been in therapy themselves. It is fair to state, during my administrative career as the director of a methadone treatment program in New York, that I came to find that many clinical personnel had not come to terms with their own unexamined emotional issues. It was always instructive to note where the clinicians' unexamined feelings/psychological issues would conflict with a need to provide truly professional and therapeutic care to the patient.
I am not suggesting that every staff member who works in a treatment facility for chronic opioid addiction needs to go through long-term therapy. On the other hand, it is critical to understand the individual's motivation to work in this field and to be willing to explore the emotional issues that clinicians have in treating a patient, especially when the use of medications such as methadone and buprenorphine are involved.
This issue is pervasive enough for a number of methadone treatment programs, now called opioid treatment programs (OTPs), to have developed their own 12-Step programs in the facilities since their patients generally encountered negative and highly stereotypical attitudes among 12-Step groups that would meet outside of the facility. Typically, patients who had revealed their use of methadone were generally shunned and/or criticized during a 12-Step meeting. This goes on through the present day to the point where patients who decide to attend the 12-Step groups would typically prefer to remain silent about their treatment rather than risk the inevitable alienation that would follow.
The bottom line is that people who decide to work with this patient population really need to understand what they are doing and what the literature indicates as well. It is always critical to listen to the patient rather than to impose some unexamined judgment about what the patient needs. Once trust is established, a great deal of effective work can be done with the patient. In this case, the use of medication is simply a tool to treatment. The medication, in and of itself, is not the treatment. Many people talk about the value of comprehensive care and a fair amount of literature has been published that demonstrates that medications, in addition to counseling and other ancillary services, will ultimately improve patient outcome.
Finally, it is most important to be honest with oneself as one enters this field. If you honestly believe you cannot understand why medications are used to treat chronic opioid addiction and you decide not to read the literature, or examine where your own psychological issues may be, then it may be best to choose a different profession.
Mark W. Parrino, MPA, is President of the American Association for the Treatment of Opioid Dependence. Parrino has been a national advocate for sound public policy and best practices in clinical care for addiction treatment involving medications such as methadone, buprenorphine and others considered vital to recovery.
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