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The Politics of Methadone

Even when we provide addiction treatment, we often erect barriers around it. The state of methadone treatment for heroin addiction is an example of how government policy collides with a goal of positive public health outcomes when it comes to dealing with drug addiction.

Untreated heroin addiction and its link to crime and illness cost society some $20 billion a year, according to the National Institutes of Health. The estimated cost of treating AIDS, hepatitis B and C, and other illnesses linked to dirty needles and heroin addiction accounts for $1.2 billion of that total. Heroin is also one of the hardest drugs to quit "cold turkey" and for good.

General Barry McCaffrey

Federal "drug czar" Barry McCaffrey now believes that methadone treatment should be more easily available to heroin addicts in this country.

Methadone maintenance is a replacement therapy in which heroin addicts take regular doses of the long-acting synthetic opiate methadone to quell withdrawal and cravings that would otherwise drive them back to heroin use. It is one of the most successful treatments for heroin addiction. "For IV drug users, injecting opiates and at significant risk of AIDS . . . who can't or won't give up that opiate effect, [methadone] is a tremendous public health benefit," says A. Thomas McLellan, a researcher at the University of Pennsylvania. A 1994 study of drug treatment in California found that methadone maintenance clients achieved greater reductions in illegal drug use, criminal activity, and hospitalization than addicts in any other kind of drug treatment.

According to the New York Academy of Medicine, the lifetime Medicaid cost for each injecting drug user with AIDS is about $109,000. In contrast, one year of methadone treatment costs about $5,000 per patient.

Methadone treatment is also highly cost-effective. According to the New York Academy of Medicine, the lifetime Medicaid cost for each injecting drug user with AIDS is about $109,000. In contrast, one year of methadone treatment costs about $5,000 per patient.

But there are many obstacles in the way of heroin addicts who seek methadone treatment. The dispensing of methadone is rigidly regulated. Only a handful of physicians in the U.S. are registered to provide methadone treatment in their practices today, since, to dispense the drug and be approved for treatment, physicians have to make a special application to the FDA and the Drug Enforcement Agency. The Department of Health & Human Services and the FDA also decide dosage regimens and how, and under what circumstances, methadone maintenance may be used to treat opiate addiction. Most methadone is dispensed from clinics that must obtain an extra license and comply with a mountain of both federal and state regulations.

The result is that, for many heroin addicts, getting methadone treatment is a tremendous burden. There are approximately 737 active methadone clinic programs in the U.S., according to the FDA. Although programs vary with regard to methadone dosing and take-home policies, most dispense medication as well as provide counseling and other medical services. But many states don't allow methadone clinics, forcing some patients to drive hundreds of miles each day to get their required daily dosage. Idaho, Mississippi, Montana, North Dakota, South Dakota, West Virginia, Vermont, and New Hampshire don't allow methadone clinics. Clinics in states that do allow methadone often have strict morning hours that make it difficult for patients to stick to the regimen. One heroin addict featured in a 1997 New York Times article said he traveled four hours round-trip every day to swallow his methadone and produce a urine sample -- a process that takes five minutes. He described his quest to stay off heroin as a sometimes "white-knuckle experience" because he has to travel during snowy and icy New England winters to arrive at the clinic by 9 a.m. and return home to begin work.

Heroin addicts in Athens, Ohio, also have to travel long distances if they want methadone. The closest methadone clinic to Athens is Columbus, Ohio, 74 miles away. Betty Woellner, a drug and alcohol counselor with Health Recovery Services, Inc., in Athens, agrees that laws need to be changed to make access to methadone easier but she says changing the public's attitude toward heroin addiction is an important first step. Woellner says the public remains undecided over whether addiction is a disease or a moral failure and the fear of opiate addicts creates an unwillingness to spend treatment dollars on them. Many members of the public fear the consequences of opening new methadone clinics in their communities. "There is a lot of old historic judgment about heroin addiction," says Woellner. "But it is a myth that anyone will go on methadone for fun. These are people who truly are desperate and can't get through the day without heroin."

Many states don't allow methadone clinics, forcing some patients to drive hundreds of miles each day to get their required daily dosage.

Some of these burdensome regulations stem from concerns that addicts will sell their methadone on the black market. But while some drug enforcement experts believe the practice is common and contributes to health problems, the data belie that. "While methadone has some potential for abuse when diverted from normal channels, the extent of the abuse associated with diverted methadone is small relative to heroin and cocaine," reports a 1995 Institute of Medicine report on methadone. Dr. Lewis Judd, psychiatric department chair at the University of California at San Diego and chair of a National Institutes of Health panel that examined methadone's utility, describes the black market for methadone as a "negligible" problem. Most of those who take diverted methadone are seeking to stabilize themselves before entering treatment, or want to quit but aren't yet ready to seek help, he says. Most experts agree that methadone rarely is a preferred drug for illicit drug users because its action is too slow and the level of euphoria it provides is too mild.

Medical experts have begun pushing the government to relax restraints on methadone disbursement. Judd and his colleagues on the NIH panel last year urged the federal government to reduce or even eliminate some regulations on methadone providers to make treatment more widely available.

There are signs of change. In a 1997 speech, General Barry McCaffrey, director of the federal Office of National Drug Control Policy, indicated that the request would get a hearing. McCaffrey said he had become convinced that methadone and other drugs to treat heroin addiction should be given a chance. Methadone maintenance "is no magic bullet," says McCaffrey, "but if properly supervised, it will be a tremendous help in reducing crime." McCaffrey also agrees that physicians' clinical judgment about methadone dosage should not be second-guessed by the government. "Dose rates and the execution of the program ought to be a medical challenge and not a programmatic one run from Washington, D.C.," he says.

Nevertheless, many medical experts are doubtful that methadone treatment will become accepted and accessible enough to reach a lot more addicts, because there is so much stigma associated with it. Former Bush drug policy advisor Dr. Herbert Kleber, executive vice president and medical director of the National Center for Addiction and Substance Abuse at Columbia University, says there are so many mixed feelings about methadone he's not sure how much more it can be expanded into the medical dispensing system.

Even addiction experts are not unified in support of methadone treatment. Paul Earley is a physician specializing in addiction who runs an addiction treatment program near Atlanta. While methadone "has a clear place" in the treatment of heroin addiction, Earley says, he worries that using methadone "is a deeper jail than heroin" because it is harder to quit and is addicting. Methadone, like heroin, just becomes another chemical stepping stone to help addicts cope, Earley says. "For the right people widening availability is the right thing . . . but it is not the cure for everything," he adds.

Both Kleber and Earley are more optimistic about another pharmacological treatment for heroin addiction, buprenorphine, due to be approved by the FDA later this year. Like methadone, buprenorphine is a replacement therapy. It is easier to withdraw from than methadone, however. And the risk of it being diverted illegally is even lower than for methadone; if it is injected by a would-be abuser (rather than being taken by the mouth, as it is intended to be used therapeutically), it causes withdrawal symptoms and not a "high."

-- Janet Firshein

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