Br. J. Addict., 1976, Vol. 71, pp. 369-376.
Longman.
Printed in Great Britain.
Methadone Maintenance: A Review and Critique David G. Peck* and Wayne Beckett Department of Sociology, Washington State University, Pullman
Summary The problem of heroin addiction and rehabilitation has caused considerable alarm in the past few years. The number of heroin addicts alone in the United States has been estimated at 300,000 {"The Heroin Plague: What Can Be Done", 1971, p. 27). Methadone maintenance is one approach to this problem of treating the addict so that he can become a productive member of society. It is being used in such cities as New Tork, Philadelphia, Pittsburg, Chicago, New Orleans, Portland, San Francisco, and Racine. The purpose of this paper is to present an overview of methadone maintenance by examining topics such as the program's background, the rationate behind the program, tegat aspects of methadone maintenance, resutts, advantages, disadvantages, and criticisms of the program.
Methadone hydrochloride is a synthetic narcotic that was developed in Germany during World War II as a substitute for morphine (Bell, 1970). The United States seized the formula at the end of the war and used the drug as an analgesic to relieve the pains of withdrawal (Samuels, 1967). Methadone is an addicting drug (Pearson, 1970). However, there are advantages in substituting methadone for heroin. First, it is possible to slowly build an addict up to a stable dose between 80 and 120 milligrams of methadone a day (Pearson, 1970, p. 2571). Secondly, at a stabilization dose, methadone does not produce the euphoric effect of heroin (Dole and Nyswander, 1966). Finally, methadone is longer acting than heroin (24—38 hour duration as opposed to the 2 hour effect of heroin) permitting the addict to take methadone on a fixed schedule every 24 hours (Dole and Nyswander, 1966). Methadone is orally effective and safe (Freymuth, 1971). The methadone addicted person does not continually need more drugs to prevent withdrawal once the daily doses are in the range of 40 to 80 milligrams a day, so the person's attention is no longer dominated by thoughts of opiate drugs or the fear of withdrawal (Milbauer, 1970). Methadone treatment is essentially a chemical approach which theoretically compensates for the chemical imbalance created by long term heroin abuse (Smith and Bentel, 1970, p. 32). Methadone does not block the effects nor help patients using or dependent upon other psychoactive drugs such as barbiturates, amphetamines, hallucinogens, or alcohol (Smith and Bentel, 1970 and Dole and Nyswander, 1966, p. 2015). The use of methadone as a maintenance drug is based on several pharmacologic properties of opiate narcotic drugs: tolerance, cross-tolerance, and physical dependence (Pet, 1969). When one develops a tolerance to an opiate narcotic, eventually a state is reached when large doses of the drug produce no "high" (Pet, 1969). When a cross-tolerance has been established the person who is tolerant to the *Now at the Centre for Research in Social Behaviour, University of Missouri-Columbia, Miss. 65201. 369
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effects of one drug is also tolerant to another, similar, drug (Pet, 1969). Thus, a person tolerant to the euphoric producing property of methadone will also be tolerant to this property of heroin and morphine. Repeated use ofthe opiate narcotics causes a physiologic requirement for the drug and abstinence from the drug will cause withdrawal pains (Goldenson, 1970, p. 354). The Dole—Nyswander hypothesis is that medical administration of methadone in quantities that can produce a high tolerance, in combination with other rehabilitative techniques, will lead to the end of abuse of illicit narcotic opiates in the person (Dole and Nyswander, October, 1966). Even if the person were to use an opiate, he would be tolerant to its effects. Eventually the person might give up his drug subculture (if we assume one exists) and find a new group of peers, since the excitement associated with drug-taking, along with the way of life of the addict (stealing, fear of arrest) would be gone (Milbauer, 1970). Patients on methadone feel no craving, are almost never subjected to withdrawal symptoms, are sensitive to pain, respond "normally" to analgesics, eat, sleep, and work normally, have normal reaction times, are alert and have normal sex lives (DuPont and Katon, 1971). Medical tests have shown no adverse effects except constipation (Pearson, 1970). Some patients have complained of temporary insomnia and occasional impotency when they first start using methadone, but these problems have been successfully handled through medication or therapeutic discussion (Nyswander, 1967). Mental and neuromuscular functions appear unaffected, and one cannot tell a methadone-maintained person from someone not on methadone, except by urine analysis (Reinert, 1965). Background of the Methadone Maintenance Program
In 1963 Dr. Vincent Dole requested Dr. Marie Nyswander (both were independently working on drug research) to work with him on a research project at the Rockefeller Institute (Hentoff, 1968, p. 111). The start ofthe research program began with two users of heroin who were hospitalized at the Rockefeller Institute (Berg, 1965). Both were single males, aged 21 years and 34 years (Hentoff, 1968, p. 111). Both of these men had used drugs for eight years, had been in prison for possession and for theft, and had made many attempts to get off drugs, by detoxification, in voluntary hospitals and at Lexington (Hentoff, 1968). Both men had tried psychotherapy, unsuccessfully (Hentoff, 1968). And both had dropped out of school during their first year, although their I.Q,.'s were tested at 124 and 120, respectively (Hentoff, 1968, p. 111). Drs. Dole and Nyswander tried to satisfy the addict's craving for a "fix" with morphine, but found that in order to keep them comfortable, they had to continually increase the dosages until the patients were passive, lethargic, apathetic, and needed a fix every few hours (Berg, 1965, p. 24). Realizing that morphine maintenance would not be practical, the researchers began to withdraw the patients from the morphine with the use of methadone to prevent the severe withdrawal pains associated with morphine (Hentoff, 1968). Because they had been on such high doses of morphine, they had to give them twice the usual amount of methadone (100-120 milligrams) than was usually given to aid the patient in withdrawing (Hentoff, 1968, p. 111).
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After 72 hours, Dole noticed that the patients' behaviour was changing markedly (Berg, 1965). The younger addict later urged the doctors to let him get his highschool-equivalency diploma and the older addict began to paint (HentofF, 1968). The patients were allowed to leave the hospital during the day but slept at the hospital (Berg, 1965). The researchers realized that methadone blocked out all other narcotics and that there was no craving for heroin in these patients (Berg, 1965). The switch to large, daily maintenance doses of methadone produced alert, normally functioning and thinking individuals. The patients were free to think or do something else other than worry about where their next fix would come from. The results of this initial program for the patients involved were dramatic. Both got their high-school-equivalency diplomas, the younger patient eventually went to an engineering college on full scholarship, and the older patient went to horticulture school and began working in a greenhouse (Hentoff ,1968, p. 116). Rationale Behind the Methadone Program
The diversity of approaches to the drug problem is related to the various theories of the causes of compulsive narcotics use (Jaffe, 1970). Dole and Nyswander, for instance, believe that the craving for narcotics is a result of a physiologic or metabolic change that is brought about by continued narcotics use—a change that does not reverse itself months after the drug has been withdrawn ("The Heroin Plague: What Can Be Done?" July 5, 1971). There are others who believe that narcotics are used by basically delinquent persons who are either completely unconcerned with the expectations of society or who are too immature to consider the consequences (Jaffe, 1970). And of course there are those who believe that people with emotional problems (inadequate, or passive-dependent persons) or Hmited opportunities use narcotics to escape this reality (Page, 1971, p. 352) and expose themselves to certain situations utilizing drug-taking behaviour (Russell, 1969, p. 30). One no doubt could find evidence to support all of the various positions, and perhaps the best type of rehabilitation program would be one that offered various services and approaches. However, statistics can be impressive and infiuential. What can be said about the success of withdrawal treatment when an estimated 90 per cent of the heroin addicts that undergo detoxification and counseling resort to heroin use again within six months (Reinert, 1965, p. 38) ? And what can be said about the theory of the "narcotic personality" when Drs. Dole and Nyswander have found no such typical personality and have thus arrived at the conclusion that if a person has used drugs for a long enough time he is physiologically different from anyone else (Samuels, 1967, p. 49) ? [They] support the methadone maintenance program on the grounds that methadone is an appropriate medical treatment—since heroin addiction is considered a metabolic disorder (Milbauer, 1970). The characteristics of the typical addict, [they] feel, are characteristics of the person while he is an addict and are a result of the addiction, not the causes (Nyswander, 1967, p. 33). If the belief that narcotic dependence as a metabolic disorder is correct, as the findings of methadone maintenance programs might suggest, then no amount of time or therapy will alone erase the addict's "hunger" for heroin. He or she must be chemically "blocked off" from heroin ("Heroin Cure Works", 1971, p. 116).
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Evaluating the "success" statistics of other drug programs, as opposed to those of the methadone maintenance programs, some people have changed their set of required goals, with abstinence, as the most important goal, being rejected (Jaffe, in Blachly, 1970). The goals are becoming directed at helping compulsive narcotics users to become emotionally mature, law abiding, productive, but not necessarily free from all drugs. The analogy has been made that we do not expect middle-aged people with heart trouble to become marathon runners, nor that diabetics not use insulin, and hence should not impose upon drug addicts goals that we do not impose on the medically or psychologically disabled (Jaffe, in Blachly, 1970). Compulsive drug use is beginning to be looked at as a chronic disorder that may require continued or intermittent treatment over a period of years. Leon Brill (1968, p. 31) states that a medication that permits chronic, compulsive heroin users to become law abiding, productive members of society, is medically and orally effective and safe to give over prolonged periods, relieves the preoccupation with the use of heroin, and allows a stabilization dosage to be acquired, is a valid therapeutic technique for the treatment of narcotics addicts. Methadone has all of these characteristics. As one researcher states (Hentoff, 1968): What it comes down to is that we take care of the pharmacological problems, leaving the addict free to turn his attention to other problems. It does not strike me as relevant whether these patients ever get off methadone. Some may want to and that is fine. What is relevant is that a treatment can be developed so that the addict can become a socially useful citizen, happy in himself and in society. That's much more important than whether he's on or off medication (p. 117) Legal Aspects of Methadone Maintenance Treatment
Methadone is viewed as a narcotic drug much like morphine. Methadone use is controlled by various Federal drug laws. Possession and use is generally prohibited. However, it may be prescribed by physicians in the course of legitimate medical practice and may be used in drug maintenance programs on an experimental basis under closely supervised conditions (Milbauer, 1970, p. 174). Methadone is now classed as an investigative drug for long-term treatment of addicts and can be used legally only in federally approved programs (Welsh, 1970). As of May 8, 1970, the Food and Drug Administration's position on methadone was "non-approved use" since, so far, safety and effectiveness have not been demonstrated for the new use of the drug (in methadone maintenance programs instead of in withdrawal) (Welsh, 1970, p. 686). The dispute over the effectiveness of methadone maintenance centers around the goals the agency assigns top priority. If methadone is safe and effective in the goals that the agency sets forth, then the author can see no reason why its use should be blocked even though the Government may not "approve" of maintenance programs. For those who still rely on the Harrison Act (1914) for their legal opinions, doctors would be violating the federal law for using methadone as a maintenance drug (Lindesmith, 1965, p. 4) since that act was the basis for Webb v. United States (1919)
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which defined "legitimate medical purposes", as mentioned in the Harrison Act, as treatment which attempted to cure the addict's habit (Lindesmith, 1965, p. 6). Hence drugs could not be prescribed to maintain an addict's usual use or comfort, but could be used only in withdrawal (Lindesmith, 1965, p. 6). However, in Linder V. United States (1925) the Supreme Court ruled that whether the doctor was engaged in "good faith purpose" depended on the circumstances and evidence and not by a specific method of treatment (Lindesmith, 1965, p. 9). An interpretation of this ruling would be that a doctor who dispenses drugs for a "good faith medical purpose" has not violated the Harrison Act. To be subject to the Harrison Act's criminal liability the doctor must be acting with no "good faith" treatment purpose. If he were dispensing large quantities of the drug or was deficient in standards or control in his program, the court could decide he was not acting in "good faith" treatment. Current methadone programs would appear to be immune from legal attack under the Harrison Act as long as the physicians in charge are dispensing it for the purpose of curing the disease or relieving pain. Good faith might also be indicated by counseling and other aid given the addict in his treatment. Results of Methadone Programs
The results of any program must be evaluated in terms of the goals of that program. The main objective of a methadone maintenance program is to rehabilitate the addict to become a functioning member of society. A report of a committee from Columbia University's School of Public Health and Administrative Medicine ("Help From Methadone", June 8, 1970, p. 52) covered the administration of methadone to 2,279 patients in 27 New York City treatment centers. The following statistics come from the source cited above. Although most patients had tried heroin once or twice during the first few months of treatment (as is typical), none had returned to the regular use of hard narcotics. The patients showed greater decrease in antisocial behavior than addicts in other rehabilitation programs. For those patients who have been on methadone for four years, their rate of arrest is about 1/13 that ofthe patients in other programs not employing methadone. The committee also noted a "steady and rather marked increase in the employment rate of methadone users and a corresponding drop in the number of patients on welfare." Fifty per cent of the former addicts who had taken methadone for six months were employed, while among those who had been in the program for four years, 80 per cent had jobs. In an Illinois study (Jaffe, September, 1969, p. 490) of 60 patients on methadone, seven months after initiating the study, 75 per cent of these patients who had started treatment were still in treatment and making progress. Of these, 75 per cent were working, 15 per cent still showed use of illicit drugs, and over a 768 man-week period of exposure, there was only one arrest. Convictions in New York City alone have decreased from 52 convictions per 100 man-years of addiction to 5 8 man-years of treatment for a population of 912 addicts between January 1964 and May 1968 ("Joseph, "Narcotic Addiction, Crime, and Methadone Maintenance"). Prior to admission 91 per cent ofthe addicts had one or more criminal convictions, after, only 5 6 per cent were convicted (Joseph, p. 3). An obvious advantage in lowering the crime rate and encouraging productive living is the benefit to the taxpayers. For crime alone, it is estimated that we lose 8 billion dollars a year as a country due
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to thefts and burglaries by addicts ("The Heroin Plague: What Can Be Done", 1971, p. 28). If one examines the statistics available in regard to the effectiveness of methadone programs, the conclusion that may be drawn is that the treatment approach is effective. The methadone maintenance program as a whole claims a success rate of 80 per cent ("The Heroin Plague: What Can Be Done, 1971, p. 31). In terms of the goals, the results are impressive, although one should always keep in mind that no systematic evaluation research has been done on methadone programs by independent resources. Advantages of the Program
In discussing the advantages of the program, no doubt one of the most outstanding advantages is the high rate of reported success. It is probably safe to say that no other form of treatment for heroin addiction in this country has such a high rate of "success" ("The Heroin Plague: What Can Be Done", 1971), up to the present. Another important advantage is that the effects of methadone maintenance are manifested very early, even in as little as two or three weeks after entry (Freymuth, 1971). It, no doubt, would take a longer period of time for long-term changes to take place, but the fact that the methadone maintained person can be out functioning in society as opposed to living in a "therapeutic community" for a year or so, is an advantage over other programs. Another advantage is that the methadone maintenance program is relatively easy to set up and operate (Dole, February, 1971, p. 1131; Knowles and Anderson, 1971, p. 22; and Nyswander, 1967, p. 27). The program does not depend upon very elaborate facilities or an unusually trained staff to carry out its operation. For the most part, the program could be located and carried out in office buildings, apartment houses, or store fronts—whatever is available. The staff consists of people with general training. The "patients" do not have to go to an inpatient unit anymore. Another advantage is the cost per patient, which can be attributed to the relative ease of operation. In New York it is estimated that the state saves approximately $600 a month per patient treated in the methadone maintenance program as opposed to hospitalization programs not using methadone (Pet, 1969, p. 5). Another advantage is that the methadone maintenance programs make available valuable data in regard to narcotics rehabilitation, something that is required by the federal guidelines, but nevertheless is an aid to those who wish to study the problem (personal observation), keeping in mind that these statistics are open to in-house biases. Disadvantages of the Program
Because methadone blockade treatment is an addiction of the opiate type, although under medical control, the client must have a regular intake of the drug every day of the week indefinitely (Mental Health Division, Alcohol and Drug Section, Portland, 1970, p. 10). Unless the program were computerized so that a patient could use various facilities throughout the country, the patient would have to stay relatively close to his supply of methadone. Another disadvantage is that although there has been no adverse effect of the drug in patients using it for a five-year period, the long term effects of high doses of methadone are still unknown (Pet, 1969, p. 6). Also, withdrawal from methadone
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is more prolonged (Narcotics Treatment Administration, 1970). Another disadvantage is in terms of cost to the taxpayer in supporting methadone-maintained patients over a long period of time (Pet, 1969, p. 7). The number of patients in the program would continue to increase and administrative and monetary problems could become serious (Dole, 1971, p. 1131). A final disadvantage (to this writer) is that the program might not discourage narcotics use, but might actually mislead the addict into thinking that there is no reason to discontinue the use of the drug because he can have his addiction maintained with no problems or change in life style and have access to better social services than he would if he were not an addict. Criticisms of the Program
The most typical criticism of methadone maintenance programs is that methadone treatment is just shifting the addiction from one drug to another (Yablonsky, 1966, p. 14). It is important to distinguish between the use of methadone maintenance as a rehabilitative technique and the use of heroin. With methadone, the dose of the drug and the frequency of administration is determined by a physician. Attempts are made at helping the addict lead a productive life. Social and counseling services are available. The drug is safe and legally used. The effects of methadone on behavior and the different way of administering methadone (orally) as opposed to the intravenous method for heroin, "cannot be dismissed by the simplistic assertion that a narcotic is a narcotic no matter how it is used" (Jaffe, in Blachly, 1970, p. 61). To equate methadone and heroin does not seem logical. Also, the criticism has been voiced that methadone is a means by which a predominantly white society can keep minority groups from gaining power or equality ("Pittsburg Narcotics Addicts Find Hope in the Methadone Method", 1970, p. 52). Methadone has been referred to as "white man's opiate" ("The Lesser Evil", 1971, p. 60). The more rational view of this situation is that the large majority of heroin addicts, both from white and minority groups, would never withdraw from heroin without something like methadone. With methadone they are free to return to school, to work, to return to their families, and to develop their individual and group pride (Freymuth, 1971), or at least have a greater opportunity to do so. Another criticism is that methadone turns patients to alcohol, since many of the people dismissed from the program or who quit turn to alcohol (Dole and Nyswander, 1966, p. 2016). It would be hard to distinguish those who had drinking problems before they were on methadone from those who did not, so a causal relationship cannot be assumed, at this time. A similar criticism along this line is that the patients may have to use methadone forever—why can't they eventually be withdrawn from methadone (Smith and Bentel, 1970, p. 42). Doctors at the Beth Israel Medical Center have tried to lower the dosages with the hope that after a patient has been protected from the effects of methadone long enough he will no longer need methadone. But they have found that as soon as the dosage gets low enough, the "craving" returns (Coodman, 1971, p. 84). This may indicate that methadone maintenance at this point is not able to deal with any addict activity other than maintenance. Other criticisms are that methadone maintenance is not interested in the prevention of drug addiction, that it is not the most effective program for everyone, and that it offers false hope to people (Yablonsky, 1966, p. 16). The authors have
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found no claim of methadone maintenance being preventative in nature, no indication that the proponents wish to use methadone alone (without counseling), or that because methadone seems to work we will give up our research on the nature and causes of drug addiction. One must study each program's goals and claims before blatantly criticizing it.
References BELL, G. (1970). Escape from Addiction, New York: McGraw-Hill. BERG, R . (1965). "New Hope for Drug Addicts", Look, November 30, pp. 23-27. BRILL, L. (1968). "Three Approaches to the Casework Treatment of Narcotics Addicts", Social Work, 13 April, 25-35. DOLE, V. (1971). "Methadone Maintenance Treatment for 25,000 Heroin Addicts", Journat ofthe American Medicat Association, 215, February, 1131-1134. DOLE, V. and NYSWANDER, M . (1966). "Rehabilitation of Heroin Addicts After Blockade with Methadone", New Tork State Journal of Medicine 66, August, 2011-2017. DOLE, V. and NYSWANDER, M . (1966). "Narcotic Blockade", Archives of Intemat Medicine 118, October, 303-309. DuPoNT, R. and KATON, R . (1971). "Development ofa Heroin-Addiction Treatment Program: Effect on Urban Crime", Journal of the American Medical Association 216, May, 1320-1324.
DuPoNT, R. and KATON, R . (1971). "Physicians and the Heroin-Addiction Epidemic", Modem Medicine, 28 June, pp. 123-129. FREYMUTH, HANS W . (1971). Director, Drug Substance Dependency Section, New Jersey State Department of Mental Health, 1 October. GOLDENSON, R . (1970). The Encyctopedia of Human Behavior: Psychologii, Psychiatry, and Mental Heatth. New York:
Doubleday & Co. GOODMAN, W . (1971). "The Choice for Thousands: Heroin or Methadone?", Mew York Times Magazine, 13 June, pp. 14, 81-S4. "Help from Methadone" (1970). Newsweek, 8 June, p. 52. HENTOFF, N . (1968). A Doctor Among the Addicts, New York: Rand McNally. "Heroin Cure Works" (1971). Science News, 4 February, p. 116. JAFFE, J. (1969). "Experience with the Use of Methadone in a Multi-Modality Program for the Treatment of Narcotics Users", The Internationat Journal ofthe Addictions 4, September, 481-490. JAFFE, J. (1970). "Development of a Successful Treatment Program for Narcotic Addicts in Illinois", in Paul Blachly (ed.). Drug Abuse, Data and Debate, Springfield, 111." Charles C. Thomas, pp. 50-60. JAFFE, J. (1970). "Whatever Turns You Off", Psychotogy Today, May, pp. 42-44, 60-62. JAFFE, J. (1970). "Further Experience with Methadone in the Treatment of Narcotics Users", T/te Internationat Journal of the Addictions 5, September, 375-389.
JOSEPH, H . "Narcotic Addiction, Crime and Methadone Maintenance", New York State Committee Against Mental Illness. KNOWLES, R . R . and ANDERSON, G. (1971). "Setting up a Methadone Maintenance Program", Hospital and Community Psychiatrist, February, pp. 22-27. LiNDESMiTH, A. (1965). The Addict and the Law, New York: Random House. Mental Health Division (1970). Alcohol and Drug Section, Methadone Btockade Treatment for Opiate Addicts, Portland, Oregon. MILBAUER, B. (1970). Drug Abuse and Addiction. New York: Crown Publishers. Narcotics Treatment Administration (1970). Department of Human Resources, Facts About Methadone, Washington, D.C. NYSWANDER, M . (1967). "The Methadone Treatment of Heroin Addiction", Hospitat Practice, April, pp. PAGE, J. (1971). Psychopathologf, Chicago: Aldine-Atherton, Inc. PEARSON, B. (1970). "Methadone Maintenance in Heroin Addiction", American Journat of Nursing, 30 December, 2571-2577. PET, D . (1969). "Treatment and Rehabilitation of the Opiate Dependent Person Utilizing Methadone— A Resource Paper", Connecticut Department of Mental Health, 18 March. "Pittsburg Narcotics Addicts Find Hope in the Methadone Method" (1970). Ebony, November, pp. 48-50, 52. REINERT, J. (1965). "Now—A Drug that 'Cures' Drug Addicts", Science Digest, November, pp. 38-41. RUSSELL, R . (1969). "Behavioral Effects of Psychoactive Drugs", in H. Kalant and R. Hawkins (eds.). Experimental Approaches to the Study of Drug Dependence, Toronto: University of Toronto Press, pp. 2-33.
SAMUELS, G. (1967). "Methadone—Fighting Fire with Fire", New Tork Times Magazine, 15 October, pp. 44-47. SMITH, D . and BENTEL, D . (1970). Fourth Annual Report to the Legislature Drug Abuse Information Project. San
Francisco, California, December. "The Heroin Plague: What Can Be Done?" (1971). Newsweek, 5 July, pp. 27-32. "The Lesser Evil" (1971). Time, 4 January, p. 60. WELSH, J. (1970). "Methadone and Heroin Addiction: Rehabilitation Without a Cure", Science, 8 May, pp. 684-686. YABLONSKY, L. (1966). "Stoned on Methadone", New Republic, 13 August, pp. 14-16.
Longman.
Printed in Great Britain.
Methadone Maintenance: A Review and Critique David G. Peck* and Wayne Beckett Department of Sociology, Washington State University, Pullman
Summary The problem of heroin addiction and rehabilitation has caused considerable alarm in the past few years. The number of heroin addicts alone in the United States has been estimated at 300,000 {"The Heroin Plague: What Can Be Done", 1971, p. 27). Methadone maintenance is one approach to this problem of treating the addict so that he can become a productive member of society. It is being used in such cities as New Tork, Philadelphia, Pittsburg, Chicago, New Orleans, Portland, San Francisco, and Racine. The purpose of this paper is to present an overview of methadone maintenance by examining topics such as the program's background, the rationate behind the program, tegat aspects of methadone maintenance, resutts, advantages, disadvantages, and criticisms of the program.
Methadone hydrochloride is a synthetic narcotic that was developed in Germany during World War II as a substitute for morphine (Bell, 1970). The United States seized the formula at the end of the war and used the drug as an analgesic to relieve the pains of withdrawal (Samuels, 1967). Methadone is an addicting drug (Pearson, 1970). However, there are advantages in substituting methadone for heroin. First, it is possible to slowly build an addict up to a stable dose between 80 and 120 milligrams of methadone a day (Pearson, 1970, p. 2571). Secondly, at a stabilization dose, methadone does not produce the euphoric effect of heroin (Dole and Nyswander, 1966). Finally, methadone is longer acting than heroin (24—38 hour duration as opposed to the 2 hour effect of heroin) permitting the addict to take methadone on a fixed schedule every 24 hours (Dole and Nyswander, 1966). Methadone is orally effective and safe (Freymuth, 1971). The methadone addicted person does not continually need more drugs to prevent withdrawal once the daily doses are in the range of 40 to 80 milligrams a day, so the person's attention is no longer dominated by thoughts of opiate drugs or the fear of withdrawal (Milbauer, 1970). Methadone treatment is essentially a chemical approach which theoretically compensates for the chemical imbalance created by long term heroin abuse (Smith and Bentel, 1970, p. 32). Methadone does not block the effects nor help patients using or dependent upon other psychoactive drugs such as barbiturates, amphetamines, hallucinogens, or alcohol (Smith and Bentel, 1970 and Dole and Nyswander, 1966, p. 2015). The use of methadone as a maintenance drug is based on several pharmacologic properties of opiate narcotic drugs: tolerance, cross-tolerance, and physical dependence (Pet, 1969). When one develops a tolerance to an opiate narcotic, eventually a state is reached when large doses of the drug produce no "high" (Pet, 1969). When a cross-tolerance has been established the person who is tolerant to the *Now at the Centre for Research in Social Behaviour, University of Missouri-Columbia, Miss. 65201. 369
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effects of one drug is also tolerant to another, similar, drug (Pet, 1969). Thus, a person tolerant to the euphoric producing property of methadone will also be tolerant to this property of heroin and morphine. Repeated use ofthe opiate narcotics causes a physiologic requirement for the drug and abstinence from the drug will cause withdrawal pains (Goldenson, 1970, p. 354). The Dole—Nyswander hypothesis is that medical administration of methadone in quantities that can produce a high tolerance, in combination with other rehabilitative techniques, will lead to the end of abuse of illicit narcotic opiates in the person (Dole and Nyswander, October, 1966). Even if the person were to use an opiate, he would be tolerant to its effects. Eventually the person might give up his drug subculture (if we assume one exists) and find a new group of peers, since the excitement associated with drug-taking, along with the way of life of the addict (stealing, fear of arrest) would be gone (Milbauer, 1970). Patients on methadone feel no craving, are almost never subjected to withdrawal symptoms, are sensitive to pain, respond "normally" to analgesics, eat, sleep, and work normally, have normal reaction times, are alert and have normal sex lives (DuPont and Katon, 1971). Medical tests have shown no adverse effects except constipation (Pearson, 1970). Some patients have complained of temporary insomnia and occasional impotency when they first start using methadone, but these problems have been successfully handled through medication or therapeutic discussion (Nyswander, 1967). Mental and neuromuscular functions appear unaffected, and one cannot tell a methadone-maintained person from someone not on methadone, except by urine analysis (Reinert, 1965). Background of the Methadone Maintenance Program
In 1963 Dr. Vincent Dole requested Dr. Marie Nyswander (both were independently working on drug research) to work with him on a research project at the Rockefeller Institute (Hentoff, 1968, p. 111). The start ofthe research program began with two users of heroin who were hospitalized at the Rockefeller Institute (Berg, 1965). Both were single males, aged 21 years and 34 years (Hentoff, 1968, p. 111). Both of these men had used drugs for eight years, had been in prison for possession and for theft, and had made many attempts to get off drugs, by detoxification, in voluntary hospitals and at Lexington (Hentoff, 1968). Both men had tried psychotherapy, unsuccessfully (Hentoff, 1968). And both had dropped out of school during their first year, although their I.Q,.'s were tested at 124 and 120, respectively (Hentoff, 1968, p. 111). Drs. Dole and Nyswander tried to satisfy the addict's craving for a "fix" with morphine, but found that in order to keep them comfortable, they had to continually increase the dosages until the patients were passive, lethargic, apathetic, and needed a fix every few hours (Berg, 1965, p. 24). Realizing that morphine maintenance would not be practical, the researchers began to withdraw the patients from the morphine with the use of methadone to prevent the severe withdrawal pains associated with morphine (Hentoff, 1968). Because they had been on such high doses of morphine, they had to give them twice the usual amount of methadone (100-120 milligrams) than was usually given to aid the patient in withdrawing (Hentoff, 1968, p. 111).
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After 72 hours, Dole noticed that the patients' behaviour was changing markedly (Berg, 1965). The younger addict later urged the doctors to let him get his highschool-equivalency diploma and the older addict began to paint (HentofF, 1968). The patients were allowed to leave the hospital during the day but slept at the hospital (Berg, 1965). The researchers realized that methadone blocked out all other narcotics and that there was no craving for heroin in these patients (Berg, 1965). The switch to large, daily maintenance doses of methadone produced alert, normally functioning and thinking individuals. The patients were free to think or do something else other than worry about where their next fix would come from. The results of this initial program for the patients involved were dramatic. Both got their high-school-equivalency diplomas, the younger patient eventually went to an engineering college on full scholarship, and the older patient went to horticulture school and began working in a greenhouse (Hentoff ,1968, p. 116). Rationale Behind the Methadone Program
The diversity of approaches to the drug problem is related to the various theories of the causes of compulsive narcotics use (Jaffe, 1970). Dole and Nyswander, for instance, believe that the craving for narcotics is a result of a physiologic or metabolic change that is brought about by continued narcotics use—a change that does not reverse itself months after the drug has been withdrawn ("The Heroin Plague: What Can Be Done?" July 5, 1971). There are others who believe that narcotics are used by basically delinquent persons who are either completely unconcerned with the expectations of society or who are too immature to consider the consequences (Jaffe, 1970). And of course there are those who believe that people with emotional problems (inadequate, or passive-dependent persons) or Hmited opportunities use narcotics to escape this reality (Page, 1971, p. 352) and expose themselves to certain situations utilizing drug-taking behaviour (Russell, 1969, p. 30). One no doubt could find evidence to support all of the various positions, and perhaps the best type of rehabilitation program would be one that offered various services and approaches. However, statistics can be impressive and infiuential. What can be said about the success of withdrawal treatment when an estimated 90 per cent of the heroin addicts that undergo detoxification and counseling resort to heroin use again within six months (Reinert, 1965, p. 38) ? And what can be said about the theory of the "narcotic personality" when Drs. Dole and Nyswander have found no such typical personality and have thus arrived at the conclusion that if a person has used drugs for a long enough time he is physiologically different from anyone else (Samuels, 1967, p. 49) ? [They] support the methadone maintenance program on the grounds that methadone is an appropriate medical treatment—since heroin addiction is considered a metabolic disorder (Milbauer, 1970). The characteristics of the typical addict, [they] feel, are characteristics of the person while he is an addict and are a result of the addiction, not the causes (Nyswander, 1967, p. 33). If the belief that narcotic dependence as a metabolic disorder is correct, as the findings of methadone maintenance programs might suggest, then no amount of time or therapy will alone erase the addict's "hunger" for heroin. He or she must be chemically "blocked off" from heroin ("Heroin Cure Works", 1971, p. 116).
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Evaluating the "success" statistics of other drug programs, as opposed to those of the methadone maintenance programs, some people have changed their set of required goals, with abstinence, as the most important goal, being rejected (Jaffe, in Blachly, 1970). The goals are becoming directed at helping compulsive narcotics users to become emotionally mature, law abiding, productive, but not necessarily free from all drugs. The analogy has been made that we do not expect middle-aged people with heart trouble to become marathon runners, nor that diabetics not use insulin, and hence should not impose upon drug addicts goals that we do not impose on the medically or psychologically disabled (Jaffe, in Blachly, 1970). Compulsive drug use is beginning to be looked at as a chronic disorder that may require continued or intermittent treatment over a period of years. Leon Brill (1968, p. 31) states that a medication that permits chronic, compulsive heroin users to become law abiding, productive members of society, is medically and orally effective and safe to give over prolonged periods, relieves the preoccupation with the use of heroin, and allows a stabilization dosage to be acquired, is a valid therapeutic technique for the treatment of narcotics addicts. Methadone has all of these characteristics. As one researcher states (Hentoff, 1968): What it comes down to is that we take care of the pharmacological problems, leaving the addict free to turn his attention to other problems. It does not strike me as relevant whether these patients ever get off methadone. Some may want to and that is fine. What is relevant is that a treatment can be developed so that the addict can become a socially useful citizen, happy in himself and in society. That's much more important than whether he's on or off medication (p. 117) Legal Aspects of Methadone Maintenance Treatment
Methadone is viewed as a narcotic drug much like morphine. Methadone use is controlled by various Federal drug laws. Possession and use is generally prohibited. However, it may be prescribed by physicians in the course of legitimate medical practice and may be used in drug maintenance programs on an experimental basis under closely supervised conditions (Milbauer, 1970, p. 174). Methadone is now classed as an investigative drug for long-term treatment of addicts and can be used legally only in federally approved programs (Welsh, 1970). As of May 8, 1970, the Food and Drug Administration's position on methadone was "non-approved use" since, so far, safety and effectiveness have not been demonstrated for the new use of the drug (in methadone maintenance programs instead of in withdrawal) (Welsh, 1970, p. 686). The dispute over the effectiveness of methadone maintenance centers around the goals the agency assigns top priority. If methadone is safe and effective in the goals that the agency sets forth, then the author can see no reason why its use should be blocked even though the Government may not "approve" of maintenance programs. For those who still rely on the Harrison Act (1914) for their legal opinions, doctors would be violating the federal law for using methadone as a maintenance drug (Lindesmith, 1965, p. 4) since that act was the basis for Webb v. United States (1919)
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which defined "legitimate medical purposes", as mentioned in the Harrison Act, as treatment which attempted to cure the addict's habit (Lindesmith, 1965, p. 6). Hence drugs could not be prescribed to maintain an addict's usual use or comfort, but could be used only in withdrawal (Lindesmith, 1965, p. 6). However, in Linder V. United States (1925) the Supreme Court ruled that whether the doctor was engaged in "good faith purpose" depended on the circumstances and evidence and not by a specific method of treatment (Lindesmith, 1965, p. 9). An interpretation of this ruling would be that a doctor who dispenses drugs for a "good faith medical purpose" has not violated the Harrison Act. To be subject to the Harrison Act's criminal liability the doctor must be acting with no "good faith" treatment purpose. If he were dispensing large quantities of the drug or was deficient in standards or control in his program, the court could decide he was not acting in "good faith" treatment. Current methadone programs would appear to be immune from legal attack under the Harrison Act as long as the physicians in charge are dispensing it for the purpose of curing the disease or relieving pain. Good faith might also be indicated by counseling and other aid given the addict in his treatment. Results of Methadone Programs
The results of any program must be evaluated in terms of the goals of that program. The main objective of a methadone maintenance program is to rehabilitate the addict to become a functioning member of society. A report of a committee from Columbia University's School of Public Health and Administrative Medicine ("Help From Methadone", June 8, 1970, p. 52) covered the administration of methadone to 2,279 patients in 27 New York City treatment centers. The following statistics come from the source cited above. Although most patients had tried heroin once or twice during the first few months of treatment (as is typical), none had returned to the regular use of hard narcotics. The patients showed greater decrease in antisocial behavior than addicts in other rehabilitation programs. For those patients who have been on methadone for four years, their rate of arrest is about 1/13 that ofthe patients in other programs not employing methadone. The committee also noted a "steady and rather marked increase in the employment rate of methadone users and a corresponding drop in the number of patients on welfare." Fifty per cent of the former addicts who had taken methadone for six months were employed, while among those who had been in the program for four years, 80 per cent had jobs. In an Illinois study (Jaffe, September, 1969, p. 490) of 60 patients on methadone, seven months after initiating the study, 75 per cent of these patients who had started treatment were still in treatment and making progress. Of these, 75 per cent were working, 15 per cent still showed use of illicit drugs, and over a 768 man-week period of exposure, there was only one arrest. Convictions in New York City alone have decreased from 52 convictions per 100 man-years of addiction to 5 8 man-years of treatment for a population of 912 addicts between January 1964 and May 1968 ("Joseph, "Narcotic Addiction, Crime, and Methadone Maintenance"). Prior to admission 91 per cent ofthe addicts had one or more criminal convictions, after, only 5 6 per cent were convicted (Joseph, p. 3). An obvious advantage in lowering the crime rate and encouraging productive living is the benefit to the taxpayers. For crime alone, it is estimated that we lose 8 billion dollars a year as a country due
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to thefts and burglaries by addicts ("The Heroin Plague: What Can Be Done", 1971, p. 28). If one examines the statistics available in regard to the effectiveness of methadone programs, the conclusion that may be drawn is that the treatment approach is effective. The methadone maintenance program as a whole claims a success rate of 80 per cent ("The Heroin Plague: What Can Be Done, 1971, p. 31). In terms of the goals, the results are impressive, although one should always keep in mind that no systematic evaluation research has been done on methadone programs by independent resources. Advantages of the Program
In discussing the advantages of the program, no doubt one of the most outstanding advantages is the high rate of reported success. It is probably safe to say that no other form of treatment for heroin addiction in this country has such a high rate of "success" ("The Heroin Plague: What Can Be Done", 1971), up to the present. Another important advantage is that the effects of methadone maintenance are manifested very early, even in as little as two or three weeks after entry (Freymuth, 1971). It, no doubt, would take a longer period of time for long-term changes to take place, but the fact that the methadone maintained person can be out functioning in society as opposed to living in a "therapeutic community" for a year or so, is an advantage over other programs. Another advantage is that the methadone maintenance program is relatively easy to set up and operate (Dole, February, 1971, p. 1131; Knowles and Anderson, 1971, p. 22; and Nyswander, 1967, p. 27). The program does not depend upon very elaborate facilities or an unusually trained staff to carry out its operation. For the most part, the program could be located and carried out in office buildings, apartment houses, or store fronts—whatever is available. The staff consists of people with general training. The "patients" do not have to go to an inpatient unit anymore. Another advantage is the cost per patient, which can be attributed to the relative ease of operation. In New York it is estimated that the state saves approximately $600 a month per patient treated in the methadone maintenance program as opposed to hospitalization programs not using methadone (Pet, 1969, p. 5). Another advantage is that the methadone maintenance programs make available valuable data in regard to narcotics rehabilitation, something that is required by the federal guidelines, but nevertheless is an aid to those who wish to study the problem (personal observation), keeping in mind that these statistics are open to in-house biases. Disadvantages of the Program
Because methadone blockade treatment is an addiction of the opiate type, although under medical control, the client must have a regular intake of the drug every day of the week indefinitely (Mental Health Division, Alcohol and Drug Section, Portland, 1970, p. 10). Unless the program were computerized so that a patient could use various facilities throughout the country, the patient would have to stay relatively close to his supply of methadone. Another disadvantage is that although there has been no adverse effect of the drug in patients using it for a five-year period, the long term effects of high doses of methadone are still unknown (Pet, 1969, p. 6). Also, withdrawal from methadone
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is more prolonged (Narcotics Treatment Administration, 1970). Another disadvantage is in terms of cost to the taxpayer in supporting methadone-maintained patients over a long period of time (Pet, 1969, p. 7). The number of patients in the program would continue to increase and administrative and monetary problems could become serious (Dole, 1971, p. 1131). A final disadvantage (to this writer) is that the program might not discourage narcotics use, but might actually mislead the addict into thinking that there is no reason to discontinue the use of the drug because he can have his addiction maintained with no problems or change in life style and have access to better social services than he would if he were not an addict. Criticisms of the Program
The most typical criticism of methadone maintenance programs is that methadone treatment is just shifting the addiction from one drug to another (Yablonsky, 1966, p. 14). It is important to distinguish between the use of methadone maintenance as a rehabilitative technique and the use of heroin. With methadone, the dose of the drug and the frequency of administration is determined by a physician. Attempts are made at helping the addict lead a productive life. Social and counseling services are available. The drug is safe and legally used. The effects of methadone on behavior and the different way of administering methadone (orally) as opposed to the intravenous method for heroin, "cannot be dismissed by the simplistic assertion that a narcotic is a narcotic no matter how it is used" (Jaffe, in Blachly, 1970, p. 61). To equate methadone and heroin does not seem logical. Also, the criticism has been voiced that methadone is a means by which a predominantly white society can keep minority groups from gaining power or equality ("Pittsburg Narcotics Addicts Find Hope in the Methadone Method", 1970, p. 52). Methadone has been referred to as "white man's opiate" ("The Lesser Evil", 1971, p. 60). The more rational view of this situation is that the large majority of heroin addicts, both from white and minority groups, would never withdraw from heroin without something like methadone. With methadone they are free to return to school, to work, to return to their families, and to develop their individual and group pride (Freymuth, 1971), or at least have a greater opportunity to do so. Another criticism is that methadone turns patients to alcohol, since many of the people dismissed from the program or who quit turn to alcohol (Dole and Nyswander, 1966, p. 2016). It would be hard to distinguish those who had drinking problems before they were on methadone from those who did not, so a causal relationship cannot be assumed, at this time. A similar criticism along this line is that the patients may have to use methadone forever—why can't they eventually be withdrawn from methadone (Smith and Bentel, 1970, p. 42). Doctors at the Beth Israel Medical Center have tried to lower the dosages with the hope that after a patient has been protected from the effects of methadone long enough he will no longer need methadone. But they have found that as soon as the dosage gets low enough, the "craving" returns (Coodman, 1971, p. 84). This may indicate that methadone maintenance at this point is not able to deal with any addict activity other than maintenance. Other criticisms are that methadone maintenance is not interested in the prevention of drug addiction, that it is not the most effective program for everyone, and that it offers false hope to people (Yablonsky, 1966, p. 16). The authors have
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found no claim of methadone maintenance being preventative in nature, no indication that the proponents wish to use methadone alone (without counseling), or that because methadone seems to work we will give up our research on the nature and causes of drug addiction. One must study each program's goals and claims before blatantly criticizing it.
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DuPoNT, R. and KATON, R . (1971). "Physicians and the Heroin-Addiction Epidemic", Modem Medicine, 28 June, pp. 123-129. FREYMUTH, HANS W . (1971). Director, Drug Substance Dependency Section, New Jersey State Department of Mental Health, 1 October. GOLDENSON, R . (1970). The Encyctopedia of Human Behavior: Psychologii, Psychiatry, and Mental Heatth. New York:
Doubleday & Co. GOODMAN, W . (1971). "The Choice for Thousands: Heroin or Methadone?", Mew York Times Magazine, 13 June, pp. 14, 81-S4. "Help from Methadone" (1970). Newsweek, 8 June, p. 52. HENTOFF, N . (1968). A Doctor Among the Addicts, New York: Rand McNally. "Heroin Cure Works" (1971). Science News, 4 February, p. 116. JAFFE, J. (1969). "Experience with the Use of Methadone in a Multi-Modality Program for the Treatment of Narcotics Users", The Internationat Journal ofthe Addictions 4, September, 481-490. JAFFE, J. (1970). "Development of a Successful Treatment Program for Narcotic Addicts in Illinois", in Paul Blachly (ed.). Drug Abuse, Data and Debate, Springfield, 111." Charles C. Thomas, pp. 50-60. JAFFE, J. (1970). "Whatever Turns You Off", Psychotogy Today, May, pp. 42-44, 60-62. JAFFE, J. (1970). "Further Experience with Methadone in the Treatment of Narcotics Users", T/te Internationat Journal of the Addictions 5, September, 375-389.
JOSEPH, H . "Narcotic Addiction, Crime and Methadone Maintenance", New York State Committee Against Mental Illness. KNOWLES, R . R . and ANDERSON, G. (1971). "Setting up a Methadone Maintenance Program", Hospital and Community Psychiatrist, February, pp. 22-27. LiNDESMiTH, A. (1965). The Addict and the Law, New York: Random House. Mental Health Division (1970). Alcohol and Drug Section, Methadone Btockade Treatment for Opiate Addicts, Portland, Oregon. MILBAUER, B. (1970). Drug Abuse and Addiction. New York: Crown Publishers. Narcotics Treatment Administration (1970). Department of Human Resources, Facts About Methadone, Washington, D.C. NYSWANDER, M . (1967). "The Methadone Treatment of Heroin Addiction", Hospitat Practice, April, pp. PAGE, J. (1971). Psychopathologf, Chicago: Aldine-Atherton, Inc. PEARSON, B. (1970). "Methadone Maintenance in Heroin Addiction", American Journat of Nursing, 30 December, 2571-2577. PET, D . (1969). "Treatment and Rehabilitation of the Opiate Dependent Person Utilizing Methadone— A Resource Paper", Connecticut Department of Mental Health, 18 March. "Pittsburg Narcotics Addicts Find Hope in the Methadone Method" (1970). Ebony, November, pp. 48-50, 52. REINERT, J. (1965). "Now—A Drug that 'Cures' Drug Addicts", Science Digest, November, pp. 38-41. RUSSELL, R . (1969). "Behavioral Effects of Psychoactive Drugs", in H. Kalant and R. Hawkins (eds.). Experimental Approaches to the Study of Drug Dependence, Toronto: University of Toronto Press, pp. 2-33.
SAMUELS, G. (1967). "Methadone—Fighting Fire with Fire", New Tork Times Magazine, 15 October, pp. 44-47. SMITH, D . and BENTEL, D . (1970). Fourth Annual Report to the Legislature Drug Abuse Information Project. San
Francisco, California, December. "The Heroin Plague: What Can Be Done?" (1971). Newsweek, 5 July, pp. 27-32. "The Lesser Evil" (1971). Time, 4 January, p. 60. WELSH, J. (1970). "Methadone and Heroin Addiction: Rehabilitation Without a Cure", Science, 8 May, pp. 684-686. YABLONSKY, L. (1966). "Stoned on Methadone", New Republic, 13 August, pp. 14-16.
