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Experience argues against embrace of medication-assisted treatment

August 15, 2013
by Dan Cain
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This past week, our local newspaper reported on another person who died from an overdose of methadone. This comes on the heels of an op-ed article by a prominent physician extolling methadone’s virtues and implying that it is the only effective treatment for opiate dependence.

Americans are conditioned to discount conspiracy theories. In fact, it’s not uncommon to label those who espouse them as paranoid or mentally ill, stigmatizing them so as to discourage anyone else who’s suspicious from speaking out. It is why we believed that the tobacco industry wouldn’t intentionally take steps to get people addicted to their products—until we found out they did. It is why the pharmaceutical industry advertises prescription drugs without telling us what they’re meant to treat, and we believe they’re doing it in our best interest. After all, their intent is to find cures, not customers, right? And of course the medical profession would never intentionally mislead us on anything. The exponential increase in the cost of healthcare is just an anomaly.

The addiction treatment world is not immune to questionable tactics. Whenever a new drug epidemic emerges, or an old one re-emerges, we trip over ourselves to convince people that our particular approach offers the answer. I am reminded of the crack cocaine epidemic wherein programs that previously would bar the door to a cocaine addict scrambled to advertise themselves as cocaine treatment programs. Of course, the fact that around the same time prepaid medical assistance became available to the poor had nothing to do with it. “Follow the money,” despite the fact that it can be an overused term, should never be ignored.

It is generally accepted that the current rise in use of prescription narcotics, and by extension heroin, is driven largely by the medical and pharmaceutical industries. And the medical and pharmaceutical industries have a solution: easier access to methadone and buprenorphine. Originally promoted as “medication-assisted treatment,” wherein narcotic agonists are used in conjunction with traditional treatment, methadone and buprenorphine (Suboxone) are now touted by some as the only effective treatment for narcotic addiction. We shouldn’t ignore the motives behind this.

The recent rise in heroin use is not unprecedented. In fact, it’s remarkably similar, as is the response, to an increase in use that came about as a result of young men returning from Vietnam in the late 1960s and early 1970s with heroin addiction. It was largely responsible for President Nixon declaring the “War on Drugs.” Methadone, a narcotic as addictive as heroin, was sold as the treatment of choice. However, it must be noted that traditional treatment at that time had no interest in treating heroin addicts, focusing instead on alcoholics (particularly those with insurance coverage).

Methadone advocates pulled out study after study to support their contention that the medication constituted the only effective treatment for heroin addiction. Then, as now, those who treated addicts in abstinence-based programs were largely excluded from the debate, as were studies from such noted addiction researchers as George DeLeon and Harry Wexler, both with the National Drug Research Institute.

And addicts in stable abstinencewho had used methadone in the past were especially muted in the effectiveness discussion, under the guise of preserving anonymity and confidentiality—despite the fact that they were begging to weigh in. Yet then, as now, the proponents had no problem with exploiting the anonymity of patients who were currently on the drug.

Heeding experience

Experience was, and is, downplayed in the belief that science is the answer. You’d be hard pressed to find an addict in long-term abstinence-based recovery who would talk about methadone with anything but disdain. Long-term methadone patients fear detox, not just because they’ve been told by proponents that it’s a bad thing, but because withdrawal from methadone is considerably more acute than withdrawal from heroin.

My experience over the past 41 years has been that many long-term patients, those who have been prescribed the drug for decades with no plan to get off, experience a loss of hope. And treatment, if about nothing else, should be about hope.

Addicts and ex-addicts, some still on methadone, will talk about the ancillary physical effects that are downplayed by the researchers, including loss of focus, arthritis, pallid skin, tooth decay, liver damage, high blood pressure, labored breathing, and reduced energy/motivation.  Proponents will point out that none of these are supported by research, yet they continue to be believed by those affected.

Is it a coincidence that when a prescription for something as innocuous as amoxicillin is filled, it is accompanied by a document that cites real and possible side effects, yet no such warning is required for methadone? I also am not aware of any handout that cites methadone as the drug most often listed in narcotic overdose deaths. And the fact that most of those deaths result from methadone that has been diverted to the black market from “legitimate” programs raises more questions.

Interestingly enough, there is another similarity to earlier efforts. In launching the drug war, President Nixon took steps to increase the budget for drug treatment exponentially. Now we are on the cusp of the Affordable Care Act (ACA), wherein multitudes of addicts who were previously uninsured will have access to healthcare.

Understanding the addict

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Perhaps that within the environs of all this pharmaceutical advertising we see, it's time to bring back some of the good old "cures" - how about the Keeley Cure - or the Bi-Chloride of Gold Cure - or even the Irish Milk Cure. The advertising positioning line - - "The Easier Softer Way!"
Excellent article - I am so with you.

Couldn't agree more. We all want the easy way, but things that are worth having are rarely easy. It is the struggle, the confidence, the comaraderie of others that helps me to keep going. I've always wondered whether it is worhtwhile to replace heroin with Methodone, or Suboxene. Trading one drug that is illegal for one that is legal? Never have been able to figure that one out.

"Methadone and Suboxone [Actually buprenorphine/naloxone: Suboxone is just one brand.] have their place. And those who are using either one should never be automatically excluded from the recovery community."

That's the bottom line. Abstinence is preferable, but for opiate addicts it's not worth risking death. It's wrong to hold up methadone as equivalent to buprenorphine. Methadone is much more dangerous and does nothing to block the effects of other opiates. Neither blocks any of the other types of addictive drugs. No, we don't have a magic pill Dan.

You mislead with your claims about methadone overdose. Most deaths due in methadone prescribed for pain result from docs prescribing too high a dose. This has nothing to do with addiction. When addicts overdose it is more likely intentional, an attempt to get high, or results from combing with alcohol or other drugs.

The current epidemic of opiate addiction almost certainly resulted from people who had no business doing so telling doctors they should prescribe more for pain. But the real culprit is the failed war on drugs which created huge economic incentives. If all these drugs (even heroin, but especially buprenorphine) were available more like alcohol and tobacco (the real killers) there would be less damage all around.

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