08/25/14

Chained to a Dragon

By the time Stephanie (not her real name) had been seen for her first “counseling” appointment, she had already been activated as a client at the methadone clinic. She met the required criteria: 18 or over (she was 18); previous failed drug treatment (as an adolescent who smoked pot she had failed to complete an outpatient drug treatment program); she reported using heroin for a year (with her older boyfriend); she was eligible for Medicaid. Heroin addiction is considered a “life threatening medical condition” for which a doctor had already signed and completed the necessary paperwork for the clinic to get paid; and Stephanie to receive additional medical care. She didn’t realize she has just chained herself to a dragon.

Methadone maintenance is considered by many to be the “gold standard” for opiate/opioid use disorders. And leaving methadone treatment is seen as ill advised in the literature. “Methadone Maintenance Treatment: (MMT)” by Herman, Stancliffe and Langrod, said that: “Methadone maintenance reduces and/or eliminates the use of heroin, reduces the death rates and criminality associated with heroin use, and allows patients to improve their health and social productivity.” Leaving Methadone Treatment” by Magura and Rosenblum, cautioned that: “The detrimental consequences of leaving methadone treatment are dramatically indicated by greatly increased death following discharge.”

But let’s flip this gold standard over and look at the other side. A 2005 review of the MMT literature, “Eyes Wide Shut?” suggested that rigorous evaluation of MMT programs is rare. The evidence for the effectiveness of MMT is mixed; and largely partial and only over the short term. “The quality of existing MMT research, and evidence for its general effectiveness are limited.”

An HBO documentary, “Methadonia,” painted a bleak picture of the life of several MMT patients in NYC. Steve, one of the persons followed in the film, who was trying to get off of methadone, said: “Once they get you hooked, you’re nothing but a junkie. Come get your fix in the morning.” You can view “Methadonia” online for free here and here. It is also available through Netflix. At one point in the film, Steve nods out repeatedly in the middle of speaking to the camera.

A recovering heroin addict I know told me about a classroom discussion he participated in about the pros and cons of methadone maintenance. My friend was for abstinence-based recovery; a classmate who was in a MMT program was pro medication-assisted recovery. In the middle of a statement on the benefits of MMT, the classmate nodded out for several seconds, picked right back up where he’d stopped speaking and finished his statement. My friend’s comment was: “I rest my case.”

According to Magura and Rosenblum, a large percentage of those who attempt to taper off of methadone will either resume active heroin use or resume MMT. They pointed to the considerable evidence that individuals who left methadone treatment had a high rate of relapse to opiate use. “Until we learn more through research, it is unwise to structure methadone programs … to discourage or impede long-term maintenance, and at the same time to pressure patients overtly to accept abstinence.” Herman et al. said: “It may be necessary for patients to remain in treatment for indefinite periods of time, possibly for the duration of their lives.”

A recent article in the New England Medical Journal strongly advocated for expanded access to medication-assisted therapies (MAT) like methadone maintenance, saying: “Expanding access to MATs is a crucial component of the effort to help patients recover.” But the authors fail to clearly distinguish between opioid MATs like methadone and buprenorphine and non-opioid naltrexone.

Further, while the “abuse liability” of buprenorphine is acknowledged by the authors as a disadvantage, the “abuse potential” of methadone is not! The opioid addicts I’ve known with experience using or abusing methadone and buprenorphine have always testified of the exponentially greater difficulty they have withdrawing or tapering off of methadone and “bupe” than they have with heroin.

Steely Dan, in their classic song “Time Out of Mind”, sung about “chasing the dragon.” This was a reference to the technique of using a straw or tube to inhale the vapor from heroin that had been placed on a piece of tinfoil and heated. The metaphor is an allusion to the hope that the next dose of heroin will return the user to the nirvana of their first high. But continued use never quite lives up to the promise. Each use leads to diminishing positive effects, leading to a fruitless chasing of the dragon to recapture the initial high. That is what the promise of methadone maintenance is like—chasing a chained dragon. To learn more, see my paper “Chasing a Chained Dragon: Methadone Abuse and Misuse.”

Do you see any value to expanding access to methadone maintenance treatment programs?

Also read, “The Consequences of Ignoring the Past.”