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AM. J.
DRUG ALCOHOL ABUSE, 4(2), pp. 267-272 (1977)
Methadone Maintenance Treatment-A Reply HERBERT D. KLEBER, M.D. Professor of Clinical Psychiatry Yale University School of Medicine New Haven, Connecticut 06519 Director Substance Abuse Treatment Unit The Connecticut Mental Health Center New Haven, Connecticut 06508
In 1965, Dole and Nyswander published the results of their initial experiences with using the drug methadone as a maintenance treatment for chronic heroin addicts [I]. The results were very encouraging and set off a tide of both medical and public expectations as to the ability to successfully treat what had been seen as an almost untreatable problem. Ten years or so later the authors reviewed what had transpired and concluded that the original hopes had not been realized [2]. Following a hugh expansion in the availability of methadone treatment in the 197Os, numbers seeking admission were now dropping, retention rates had substantially dropped, and both addicts and the public viewed methadone programs with cynicism and alarm rather than hope. The authors attribute these gloomy results to interference with treatment programs by excessive, unreasonable, and rigid governmental rules and regulations. “It is mainly the programs rather than the addicts that have changed.” While one can agree with Dole and Nyswander as to the onerous nature of the current government regulations relating to methadone maintenance, it does not necessarily follow that such regulations are the main cause of the distressing situation in which programs today find themselves. Instead, it is
267
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by York University Libraries on 12/31/14 For personal use only.
268
KLEBER
my belief the predicament relates primarily to the changing nature of the client population of the programs and secondarily t o prograril staffing. When methadone maintenance programs arrived on the scene in cities across the country, they found a pent-up demand awaiting them. Addicts who had been on heroin for years and tried unsuccessfully to remain abstinent hailed methadone maintenance as a life saving treatment, and in many cases it was. These individuals tended to be older, to have relapsed repeatedly back to heroin after hospital detoxification or jail time, and to be more “sociological” than “psychological” addicts. They got on the program, often overcoming obstacles such as waiting lists to do so, and tended to do well. They stopped heroin use, decreased or stopped criminal activity, got jobs (which were more plentiful then), and eventually many were able to successfully detoxify completely from methadone. It was these patients that gave all of us in those halcyon days such hope and enthusiasm as to the possibility of eventually cutting heroin addiction down to a small problem. Unfortunately, we soon discovered that the woods were not full of these kinds of clients. As time went on the average age of people applying for treatment markedly decreased, their length of addiction decreased, their number of previous failures decreased, and, most important, their attitude was different. Methadone maintenance was no longer the great hope to beat the drug habit being put forward by rebels against the standard position about addicts. Instead, it was merely another attempt by them, by the law enforcement or treatment establishments, by the powers that be, to get you to stop taking something, heroin, you still wanted to take. And if you didn’t make it this time, you could try again later. Unlike the waiting lists and other obstacles encountered by the earlier applicants, you could usually get on programs right away. In some cities you could even shop around and find the program with the least restrictions and demands on your time. And if you didn’t want any program hassle at all, there was all that illicit methadone on the street you could buy, at a fraction of the cost of heroin, and it could tide you over between fixes. As such clients increased in number in programs, it is not surprising that retention rates dropped and the number of urines containing heroin rose. What is surprising is that the figures were not worse than they were. Also, there was an interactive effect with staff attitudes. Program expansion had already staffed a number of programs with employees who would never have been hired in the early days of methadone maintenance. Earlier staff tended t o be dedicated, capable, enthusiastic individuals, both professionals and paraprofessionals or exaddicts. They worked long hours but were rewarded by seeing many success
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by York University Libraries on 12/31/14 For personal use only.
METHADONE MAINTENANCE TREATMENT-A REPLY
269
stories. As programs expanded, and money flowed into addiction treatment, staff changed just as clients did. Later staff were more apt to regard the work as just another job, and professionals at times just tried to get as much money as possible for as few working hours as possible. This attitude not only led to increased client cynicism and acting-out but tended to be self-justifying in that continued client irresponsibility could then be cited as a reason for not bothering to try harder. More dedicated staff found it hard to maintain enthusiasm in the face of such behavior by staff and clients, just as more motivated clients found it hard to maintain their interest and progress. Both high program morale and marked patient cynicism are contagious but not at the same time. Too many programs were dispensing stations rather than treatment centers. In this context the role of government regulation becomes clearer. While in some instances it may have caused problems where none existed, in most areas it was reactive to the abuses that were going on in programs. Unfortunately, as in other aspects of life, the good suffered with the bad. Well-run programs had to cope with sharply increased paper work, decreased freedom to use clinical judgment, and a welter of regulations that spelled out the rules of daily work in a manner not found in any other medical program of which I am aware. Likewise, clients who were doing well had to put up with increased restrictions on their daily life. Programs and patients who paid lip service to the concept of rehabilitation probably found it easier in some ways to cope with the rules than better programs and clients. This plus the shrinking funding available had the effect of driving out of the treatment area some of the more innovative professionals and paraprofessionals, further exacerbating the staffing problem mentioned earlier. It is my belief, however, that if all the federal regulations regarding methadone maintenance were lifted tomorrow, the problems cited by Dole and Nyswander would not only not disappear, they would be made worse. The regulations can and must be improved. They must be made more responsive to the needs of the treatment sector. They must be applied in a way that does not penalize the well-run programs or the motivated clients. But it is unrealistic to expect them to be substantially removed in the near future or to blame them for the failure of methadone programs. The community attitude about methadone clinics is another problem that was not due just to external forces, e.g., antimethadone agencies, but relates as well to the behavior of staff and clients. Suitable locations for treatment are always hard to come by. One must cope not only with zoning and fire codes but with the attitude of neighbors who take the position, “it’s important to treat them-but not in my neighborhood.” Often, however, once all of
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by York University Libraries on 12/31/14 For personal use only.
270
KLEBER
these have been overcome and the clinic established, it begins to wear out its welcome quickly. Haphazard parking, littering of grounds, harassment of passer-bys, and loud, boisterous behavior all serve to alienate neighbors. Ironically, the issue on which initial opposition is in most cases based, the fear of increased crime, is not usually the cause of the new opposition. This behavior can be prevented and many methadone clinics make good neighbors, but sufficient staff and cooperative patient attitudes are essential.
THE FUTURE OF METHADONE MAINTENANCE In these past 10 years we have learned a lot about the strengths and limitations of methadone maintenance and its place in the therapeutic armamentarium of drug addiction treatment. If the following points are kept in mind, there is no reason why the programs should not both survive and thrive, albeit at a reduced size. 1. Methadone maintenance is not a panacea for heroin addiction as Dole and Nyswander point out and does not function very well as a form of social control. If society simply wants to reduce some of the social costs of addiction, it should consider heroin maintenance in the form proposed a few years back by the Vera Foundation [3]. It is important to keep in mind that the English do not consider their method of heroin maintenance as treatment. Treatment begins when the individual tries to come off heroin. We should reserve methadone maintenance for those individuals who want treatment and use other approaches for social control. Both the decrease in retention rate and the decreased attractiveness to new clients occurred as methadone became more acceptable to the criminal justice system. 2. Regulations need to be written and enforced in such a way as to restrict or eliminate the shady operators while giving other programs the maximum possible clinical freedom. The attitudes of the federal and state agencies should be to help clinics, not harass them. 3. Increased research on detoxification from methadone needs to be done to improve this very real stumbling block to patient and community acceptance [4]. Likewise, judicious use of the long acting form of methadone, Q-alphaacetyl methadol, may solve some of the diversion vs take-out dilemma. 4. Methadone is a drug, not a treatment. Rehabilitation involves effective
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by York University Libraries on 12/31/14 For personal use only.
METHADONE MAINTENANCE TREATMENT-A REPLY
271
psychotherapy and vocational/educational help along with the methadone. This takes money and is more expensive than simply methadone dispensing. The current federal funding approach tends to penalize programs that attempt to do effective therapy with the patient and his family. The funding method rewards the numbers game and hinders quality treatment. If NIDA’s funds are too limited to provide adequate care for all, they would be better advised to decrease the number of slots and increase the reimbursement per slot. Small waiting lists, in fact, probably aid the treatment process and improve program morale. Also, although it is harder to administer, differential slot costs related to the extent of rehabilitation services offered by the program are better than one standard reimbursement schedule. 5. Effective rehabilitation of adult heroin addicts requires the ability of such individuals to get suitable employment. An individaul who has all day and night on his/her hands and nothing to work toward is simply not going to remain off drugs. The country cannot have effective heroin rehabilitation in the presence of double digit unemployment rates in the inner cities. 6. Methadone maintenance may effectively keep an individual from heroin and do nothing for his use of drugs such as cocaine and alcohol. We need both to understand better such drug use and to decide whether it is grounds to consider methadone maintenance a failure in an individual instance if such excessive use occurs. Persuasive arguments on both sides can be made. Even more important, we need to tIy and prevent such drug substitution by more research into its underlying causes. Dole and Nyswander arrived at a humane and conceptually sound program 10 years ago. What is needed now is to improve it on the basis of what we have learned during the time it has been in effect rather than point an accusatory finger at external agencies as the source of all our problems.
REFERENCES
[l] Dole, V. P., and Nyswander, M., A medical treatment for diacetylmorphine (heroin) addiction, J. Am. Med. Assoc. 193:646-650(1965). [2] Dole, V. P., and Nyswander, M. E., Methadone maintenance treatment: A ten-year perspective, J. Am. Med. Assoc. 235:2117-2119(1976). [ 31 Riordan, C. E., and Could, L. C., Roposal for the Use of Diacetylmorphine (Heroin)
272
KLEBER
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by York University Libraries on 12/31/14 For personal use only.
in the Deatment of Heroin-Dependent Individuals, Report to the Vera Foundation, New York, 1971. [4] Kleber, H. D., Detoxification from methadone maintenance: The state of the art, Int. J. Addict. 12(7), (1977).
AM. J.
DRUG ALCOHOL ABUSE, 4(2), pp. 267-272 (1977)
Methadone Maintenance Treatment-A Reply HERBERT D. KLEBER, M.D. Professor of Clinical Psychiatry Yale University School of Medicine New Haven, Connecticut 06519 Director Substance Abuse Treatment Unit The Connecticut Mental Health Center New Haven, Connecticut 06508
In 1965, Dole and Nyswander published the results of their initial experiences with using the drug methadone as a maintenance treatment for chronic heroin addicts [I]. The results were very encouraging and set off a tide of both medical and public expectations as to the ability to successfully treat what had been seen as an almost untreatable problem. Ten years or so later the authors reviewed what had transpired and concluded that the original hopes had not been realized [2]. Following a hugh expansion in the availability of methadone treatment in the 197Os, numbers seeking admission were now dropping, retention rates had substantially dropped, and both addicts and the public viewed methadone programs with cynicism and alarm rather than hope. The authors attribute these gloomy results to interference with treatment programs by excessive, unreasonable, and rigid governmental rules and regulations. “It is mainly the programs rather than the addicts that have changed.” While one can agree with Dole and Nyswander as to the onerous nature of the current government regulations relating to methadone maintenance, it does not necessarily follow that such regulations are the main cause of the distressing situation in which programs today find themselves. Instead, it is
267
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by York University Libraries on 12/31/14 For personal use only.
268
KLEBER
my belief the predicament relates primarily to the changing nature of the client population of the programs and secondarily t o prograril staffing. When methadone maintenance programs arrived on the scene in cities across the country, they found a pent-up demand awaiting them. Addicts who had been on heroin for years and tried unsuccessfully to remain abstinent hailed methadone maintenance as a life saving treatment, and in many cases it was. These individuals tended to be older, to have relapsed repeatedly back to heroin after hospital detoxification or jail time, and to be more “sociological” than “psychological” addicts. They got on the program, often overcoming obstacles such as waiting lists to do so, and tended to do well. They stopped heroin use, decreased or stopped criminal activity, got jobs (which were more plentiful then), and eventually many were able to successfully detoxify completely from methadone. It was these patients that gave all of us in those halcyon days such hope and enthusiasm as to the possibility of eventually cutting heroin addiction down to a small problem. Unfortunately, we soon discovered that the woods were not full of these kinds of clients. As time went on the average age of people applying for treatment markedly decreased, their length of addiction decreased, their number of previous failures decreased, and, most important, their attitude was different. Methadone maintenance was no longer the great hope to beat the drug habit being put forward by rebels against the standard position about addicts. Instead, it was merely another attempt by them, by the law enforcement or treatment establishments, by the powers that be, to get you to stop taking something, heroin, you still wanted to take. And if you didn’t make it this time, you could try again later. Unlike the waiting lists and other obstacles encountered by the earlier applicants, you could usually get on programs right away. In some cities you could even shop around and find the program with the least restrictions and demands on your time. And if you didn’t want any program hassle at all, there was all that illicit methadone on the street you could buy, at a fraction of the cost of heroin, and it could tide you over between fixes. As such clients increased in number in programs, it is not surprising that retention rates dropped and the number of urines containing heroin rose. What is surprising is that the figures were not worse than they were. Also, there was an interactive effect with staff attitudes. Program expansion had already staffed a number of programs with employees who would never have been hired in the early days of methadone maintenance. Earlier staff tended t o be dedicated, capable, enthusiastic individuals, both professionals and paraprofessionals or exaddicts. They worked long hours but were rewarded by seeing many success
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by York University Libraries on 12/31/14 For personal use only.
METHADONE MAINTENANCE TREATMENT-A REPLY
269
stories. As programs expanded, and money flowed into addiction treatment, staff changed just as clients did. Later staff were more apt to regard the work as just another job, and professionals at times just tried to get as much money as possible for as few working hours as possible. This attitude not only led to increased client cynicism and acting-out but tended to be self-justifying in that continued client irresponsibility could then be cited as a reason for not bothering to try harder. More dedicated staff found it hard to maintain enthusiasm in the face of such behavior by staff and clients, just as more motivated clients found it hard to maintain their interest and progress. Both high program morale and marked patient cynicism are contagious but not at the same time. Too many programs were dispensing stations rather than treatment centers. In this context the role of government regulation becomes clearer. While in some instances it may have caused problems where none existed, in most areas it was reactive to the abuses that were going on in programs. Unfortunately, as in other aspects of life, the good suffered with the bad. Well-run programs had to cope with sharply increased paper work, decreased freedom to use clinical judgment, and a welter of regulations that spelled out the rules of daily work in a manner not found in any other medical program of which I am aware. Likewise, clients who were doing well had to put up with increased restrictions on their daily life. Programs and patients who paid lip service to the concept of rehabilitation probably found it easier in some ways to cope with the rules than better programs and clients. This plus the shrinking funding available had the effect of driving out of the treatment area some of the more innovative professionals and paraprofessionals, further exacerbating the staffing problem mentioned earlier. It is my belief, however, that if all the federal regulations regarding methadone maintenance were lifted tomorrow, the problems cited by Dole and Nyswander would not only not disappear, they would be made worse. The regulations can and must be improved. They must be made more responsive to the needs of the treatment sector. They must be applied in a way that does not penalize the well-run programs or the motivated clients. But it is unrealistic to expect them to be substantially removed in the near future or to blame them for the failure of methadone programs. The community attitude about methadone clinics is another problem that was not due just to external forces, e.g., antimethadone agencies, but relates as well to the behavior of staff and clients. Suitable locations for treatment are always hard to come by. One must cope not only with zoning and fire codes but with the attitude of neighbors who take the position, “it’s important to treat them-but not in my neighborhood.” Often, however, once all of
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by York University Libraries on 12/31/14 For personal use only.
270
KLEBER
these have been overcome and the clinic established, it begins to wear out its welcome quickly. Haphazard parking, littering of grounds, harassment of passer-bys, and loud, boisterous behavior all serve to alienate neighbors. Ironically, the issue on which initial opposition is in most cases based, the fear of increased crime, is not usually the cause of the new opposition. This behavior can be prevented and many methadone clinics make good neighbors, but sufficient staff and cooperative patient attitudes are essential.
THE FUTURE OF METHADONE MAINTENANCE In these past 10 years we have learned a lot about the strengths and limitations of methadone maintenance and its place in the therapeutic armamentarium of drug addiction treatment. If the following points are kept in mind, there is no reason why the programs should not both survive and thrive, albeit at a reduced size. 1. Methadone maintenance is not a panacea for heroin addiction as Dole and Nyswander point out and does not function very well as a form of social control. If society simply wants to reduce some of the social costs of addiction, it should consider heroin maintenance in the form proposed a few years back by the Vera Foundation [3]. It is important to keep in mind that the English do not consider their method of heroin maintenance as treatment. Treatment begins when the individual tries to come off heroin. We should reserve methadone maintenance for those individuals who want treatment and use other approaches for social control. Both the decrease in retention rate and the decreased attractiveness to new clients occurred as methadone became more acceptable to the criminal justice system. 2. Regulations need to be written and enforced in such a way as to restrict or eliminate the shady operators while giving other programs the maximum possible clinical freedom. The attitudes of the federal and state agencies should be to help clinics, not harass them. 3. Increased research on detoxification from methadone needs to be done to improve this very real stumbling block to patient and community acceptance [4]. Likewise, judicious use of the long acting form of methadone, Q-alphaacetyl methadol, may solve some of the diversion vs take-out dilemma. 4. Methadone is a drug, not a treatment. Rehabilitation involves effective
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by York University Libraries on 12/31/14 For personal use only.
METHADONE MAINTENANCE TREATMENT-A REPLY
271
psychotherapy and vocational/educational help along with the methadone. This takes money and is more expensive than simply methadone dispensing. The current federal funding approach tends to penalize programs that attempt to do effective therapy with the patient and his family. The funding method rewards the numbers game and hinders quality treatment. If NIDA’s funds are too limited to provide adequate care for all, they would be better advised to decrease the number of slots and increase the reimbursement per slot. Small waiting lists, in fact, probably aid the treatment process and improve program morale. Also, although it is harder to administer, differential slot costs related to the extent of rehabilitation services offered by the program are better than one standard reimbursement schedule. 5. Effective rehabilitation of adult heroin addicts requires the ability of such individuals to get suitable employment. An individaul who has all day and night on his/her hands and nothing to work toward is simply not going to remain off drugs. The country cannot have effective heroin rehabilitation in the presence of double digit unemployment rates in the inner cities. 6. Methadone maintenance may effectively keep an individual from heroin and do nothing for his use of drugs such as cocaine and alcohol. We need both to understand better such drug use and to decide whether it is grounds to consider methadone maintenance a failure in an individual instance if such excessive use occurs. Persuasive arguments on both sides can be made. Even more important, we need to tIy and prevent such drug substitution by more research into its underlying causes. Dole and Nyswander arrived at a humane and conceptually sound program 10 years ago. What is needed now is to improve it on the basis of what we have learned during the time it has been in effect rather than point an accusatory finger at external agencies as the source of all our problems.
REFERENCES
[l] Dole, V. P., and Nyswander, M., A medical treatment for diacetylmorphine (heroin) addiction, J. Am. Med. Assoc. 193:646-650(1965). [2] Dole, V. P., and Nyswander, M. E., Methadone maintenance treatment: A ten-year perspective, J. Am. Med. Assoc. 235:2117-2119(1976). [ 31 Riordan, C. E., and Could, L. C., Roposal for the Use of Diacetylmorphine (Heroin)
272
KLEBER
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by York University Libraries on 12/31/14 For personal use only.
in the Deatment of Heroin-Dependent Individuals, Report to the Vera Foundation, New York, 1971. [4] Kleber, H. D., Detoxification from methadone maintenance: The state of the art, Int. J. Addict. 12(7), (1977).
