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Should chronic heroin addicts be withdrawn from methadone? - by Dr. Jean-Jacques Deglon
Doctor's Column - Uses
of methadone for other than opiate addiction
Editor's Note: In these statements, Senator McCain is referring to a bill he has proposed (S. 423) that would place severe restrictions and limits on Medicaid coverage and other federal funding of methadone and LAAM maintenance treatment programs. In effect, this bill would virtually eliminate any federal funding, subsidies, or Medicaid reimbursements for methadone and LAAM maintenance—the most effective treatments currently available for opiate addiction.
Mr. McCain is apparently either ignorant of or chooses to ignore overwhelming evidence from the past three decades that methadone maintenance treatment is extremely safe and effective, and is not "transferring] addiction from one narcotic to another." His assertion that methadone maintenance treatment patients are addicted to methadone flies in the face of modern medicine and is insulting not only to methadone maintenance treatment patients but to other patients who depend upon medication to treat a medical condition (e.g.: chronic pain patients on opioid medications to control pain, and epilepsy patients on phenobarbital to control seizures).
In spite of Senator McCain's supposed concern for "the scourge of heroin addiction," his bill would result in a far greater number of former heroin addicts returning to active addiction and far fewer heroin addicts entering and remaining in drug treatment. If Senator McCain really were interested in reducing the rate of heroin and other drug addiction, he would propose legislation to make drug treatment available on demand, regardless of ability to pay. Currently, drug treatment in general and methadone and LAAM maintenance treatment, in particular, is only available to a fraction of those who need it, and this bill would only further reduce the availability of drug treatment. McCain states:
Methadone maintenance programs simply transfer addiction from one narcotic to another. The methadone patient is every bit as dependent on methadone as he or she was with heroin. Patients who attempt to free themselves from their addiction to methadone experience withdrawal symptoms that are as violent, if not more than, those they would experience coming off of heroin. What is more, even the promise of freedom from illegal drug use is an illusion. For many methadone patients regularly test positive for other illegal drugs. And yet, for some 30 years, the only hope that U.S. policy has offered to our citizens addicted to heroin is an Orwellian addiction swap.
In the 105th Congress, I, along with Senator Coats and Senator Coverdell, introduced a Senate Resolution addressing the topic of methadone treatment. The resolution was a response to an emerging Clinton Administration policy designed to dramatically increase the federal government's activities in the area of methadone treatment. Barry McCaffrey, the so-called Drug Czar, proposed that ONDCP would double the number of heroin addicts in methadone treatment. Mr. President, this sounds less like the policy of a Drug Czar, and more like the policy of a drug bazaar—a bazaar where the federal government trades places with the street dealer, swapping heroin for methadone and feeding the addiction with taxpayer dollars.
This is disgusting and it is immoral. It does serious harm to the humanity of those people who have mustered the courage to walk into a clinic seeking help to free themselves from addiction. It is the ultimate in cruel irony that our government's first response should be to trade the shackles of heroin for the shackles of methadone.
Dr. Woodson puts it this way: `In contrast with psychiatric therapy and treatment that relies on medication, the goal of grassroots programs is not rehabilitation but transformation. Their end is not to modify behavior but to engender a change in the values and vision of the people they work with which will, in turn affect behavior . . . they do not simply curb deviant behavior but offer something more—a fulfilling life that eclipses the power of temptation.'
These community-based institutions possess certain common characteristics that can serve as a model for all who seek to address the challenges of addiction:
1) Their programs are open to all comers. Often, these programs take the worst cases, the long-term, homeless addicts that the `system' has abandoned as hopeless.
2) They have the same zip code as the people they serve. They do their work in the same neighborhoods, on the same streets as the addicts they serve. Reverend McPherson points out one of the pleasant benefits of Ready, Willing and Able: When they come into a neighborhood, the drug dealers go away. They leave because there is an unwritten code. If these guys are trying to get off of heroin, the dealers go somewhere else, taking their trade out of sight of the very addicts they have enslaved.
3) Their approach is flexible to the needs of the individual. The many behavioral, social/environmental, and physical challenges that contribute to drug addiction are unique to each individual. These organizations develop individualized programs for each individual.
4) They contain a central element of reciprocity. As Dr. Woodson says: `They do not practice blind charity but require something in return from the individuals they serve.'
5) Clear behavioral guidelines and discipline are critical.
6) These healers fulfill the role of parent, providing authority and structure, but also love and support.
7) They are committed for the long haul, not just for the duration
9) The healing offers immersion in an environment of care and mutual support with a community of individuals who are trying to accomplish the same changes in their lives.
10) They are united in their cause, providing mutual support in their struggles, and celebration in their accomplishments.
These concepts are not new. But combined and sustained, they offer hope and success in freeing the addict from a life of chemical dependency. That freedom should be the policy of the United States Government, and the relentlessly pursued goal of everyone concerned with the scourge of heroin addiction. End McCain's Stmt.
Specifically, it is unlikely that New York Mayor Rudolph Guiliani and now U.S. Senator John McCain would take a position that he knew would be strongly opposed by certain groups/individuals, without educating himself (about methadone maintenance treatment). Whatever opponents of Senator McCain think of him, they will admit that he is not stupid—and sponsoring an anti-methadone maintenance treatment bill was a calculated move.
First of all, Mayor Guiliani and Senator McCain know that methadone patients are generally not politically active and do not vote in large enough numbers to matter (simply because of the demographics); besides that, the majority of methadone patients who do vote probably weren't going to vote for a Republican anyway. Therefore, politicians like Guiliani and McCain see attacking methadone maintenance as a no-lose situation: Many Americans hate drug addicts and believe the negative myths about methadone maintenance. Furthermore, many of the Americans who don't share this sentiment either don't know what to think and/or don't care—they won't vote against a politician because of their anti-methadone views and policies (in spite of the fact that such policies negatively affect everyone, by increasing the crime rate, etc.).
Second of all, drug warriors like Mayor Guiliani and Senator McCain have a stake in denying the legitimacy of methadone maintenance. If you read Senator McCain's "Statements on Addiction Free Treatment Act," (see the left hand column of this page) he implies that substance abuse/addiction is not really a disease/medical condition but rather due to a lack of morality/spirituality. McCain will never mention the word "religion," but what he is saying is that some old time [fundamentalist] religion is all these "evil" drug addicts need. This is what the "community treatment" McCain refers to is all about—he explains how addicts won't be swayed by the "power of temptation" once the treatment changes their "values and vision."
The reason McCain and other drug warriors will not accept methadone maintenance as a valid treatment is because if they do, they must also acknowledge that drug addiction is a disease/medical condition and a physiologically based one at that! If they accept this, then they will have a very difficult time justifying incarceration of drug users—a medical condition should be treated by medical practitioners, not the criminal justice system. Americans might no longer be willing to support such harsh treatment of drug addicts if they thought that drug addiction was a medical condition instead of a moral deficiency.
Politicians who oppose, and even condemn LAAM and methadone maintenance treatment, do so for a variety of reasons. There is no doubt that ignorance about opiate addiction and methadone maintenance treatment is one of the reasons politicians like Senator McCain are so strongly opposed to it.
However, it is highly suspect that conservative politicians like McCain and Guiliani, who are typically not particularly concerned about the plight of the disabled, impoverished, or minorities, are suddenly worried about the supposed adverse impact a particular drug treatment modality has on drug addicts. There is no doubt that other factors are involved—especially political factors.
Regardless of why some politicians oppose methadone maintenance treatment, their condemnation of this safe and effective treatment is without merit. Since methadone maintenance treatment is not physically harmful and does not result in intoxication, inability to function, or other adverse consequences characteristic of addiction, the only difference between methadone maintenance treatment, that McCain condemns, and other medication-based treatments is that this medication [methadone] causes physical dependence.
But , in fact, there are other medications used to treat patients that cause physical dependence. For example, epilepsy patients are not drug addicts merely because they depend on a daily dose of medication that causes physical dependence (i.e., abstinence from it results in withdrawal symptoms). Certainly most people, including Senator McCain, would not consider epileptics to be addicted to phenobarbital [withdrawing from this is more dangerous than opiate withdrawal]. Similarly, methadone maintenance patients are no more addicted to their medication than diabetics are to insulin. It is time that the government, the medical community, and the public understand that drug addiction is no different than any other medical condition and methadone maintenance is no different than any other medical treatment.
For decades, opioid dependence was viewed as a problem of motivation, willpower, or strength of character. Through careful study of its natural history and through research at the genetic, molecular, neuronal, and epidemiological levels, it has been proven that opiate addiction is a medical disorder characterized by predictable signs and symptoms. Other arguments for classifying opioid dependence as a medical disorder include:
Despite varying cultural, ethnic, and socioeconomic backgrounds, there is clear consistency in the medical history, signs, and symptoms exhibited by individuals who are opiate-dependent.
There is a strong tendency to relapse after long periods of abstinence.
The opioid-dependent person's cravings for opiates induces continual self-administration even when there is an expressed and demonstrated strong motivation and powerful social consequences to stop.
Continuous exposure to opioids induces pathophysiologic changes in the brain.
(More from Consensus Stmt. Next Month)
Many employers do not realize that the Americans with Disabilities Act (ADA) protects individuals with drug and alcohol problems against discrimination in employment. This confusion exists because the ADA imposes some special requirements for the employment of individuals with current drug problems.
People with past drug or alcohol problems are protected from job discrimination
by the ADA, as are persons with current alcohol problems who are able to
perform their job. However, the ADA specifically excludes from the
definitions of "individual with a disability" any employee or applicant
who is currently engaging in the illegal use of drugs when the covered
entity acts on the basis of such use. This includes individuals who use
illicit drugs as well as those who use prescription medications unlawfully.
Individuals who use drugs under the supervision of a licensed health care
professional --such as methadone-- are not using drugs illegally and therefore
could be protected against discrimination.
In addition, the ADA protects individuals who are erroneously perceived as abusing drugs illegally but are not doing so. Because of societal attitudes about drug abuse, many individuals who have had drug problems in the past are perceived as still being drug dependent. Similarly, individuals who participate in methadone maintenance programs are also often perceived as drug dependent even though methadone is a lawfully prescribed medication, and individuals who participate in a methadone maintenance program are able to do every task—even safety-related tasks—that a person who is not receiving such treatment can do. These individuals are protected against discrimination under the ADA.
[Therefore], employers must be careful in conducting a drug test prior to a conditional offer of employment because the drug test could reveal information about other disabilities that applicants have a right to withhold until after an employment offer. For example, a drug test could reveal the presence of Dilantin, which is used to treat epilepsy, or methadone, which is used to treat heroin addiction. If such protected information is obtained, employers cannot use such information in a way that violates the ADA. The ADA also requires that information collected from medical examinations and inquiries be collected and maintained on separate forms and in separate medical files and treated as a confidential medical record.
Inquiries about alcohol use or past drug use, on the other hand, must
be treated like inquiries about any other disability. Such inquiries
cannot be made of applicants until after a conditional offer of employment
or of employees except when job related or required by business necessity.
What Accommodations Do Individuals With Drug and Alcohol Problems Need?Accommodations for individuals in recovery from a drug or alcohol problem will vary depending upon the requirements of their jobs and their length of time in recovery. For example, to permit participation in an out-patient continuing care program, accommodations may be necessary, such as a modified work schedule to permit an employee to pick up her daily methadone dosage or to attend an out-patient relapse prevention counseling session.
Some employees will need no accommodation, but simply a change in attitude
regarding what an individual with a past drug or alcohol impairment can
do. It is important to understand that such individuals are able to perform
all jobs safely, including safety-related jobs, and that they pose no risk
to others solely because of a past drug or alcohol addition. An employer's
most important obligation under the ADA is to evaluate the individual's
ability to do the essential job tasks and make employment decisions based
on the individual's qualifications and work performance.
For further information contact:Mid-Atlantic Disability and Business Technical Assistance Center
2111 Wilson Boulevard, Suite 400
Arlington, Virginia 22201
Voice/TDD: (703) 525-3268.
Based on more than 20 years' experience and the data from numerous international studies, Dr. Jean-Jacques Deglon highlights the regular failure of withdrawal from both opiates and methadone among chronic heroin addicts. The main reason for this is currently thought to be neurobiological in nature. The cerebral endorphin systems, which are more or less permanently unsettled by heroin abuse, must be stabilized through an appropriate dose of methadone for as long as is necessary and, in some cases, for life.
The therapeutic aim for these patients is no longer necessarily withdrawal
but rather the maintenance of a decent quality of life at all costs, with
or without a substitution product.
Effectiveness of methadoneNowadays, given the widespread evidence, no-one can seriously question the effectiveness of long-term substitution treatment using appropriate doses of methadone. These programmes, in conjunction with qualified psycho-social care, help to sustain the motivation of the majority of heroin addicts outside the drug-using environment, stabilize them emotionally, ease their reintegration in to the community and employment, reduce the risk of AIDS and reduce criminality.
But should we encourage withdrawal from methadone among these former
drug addicts who have sometimes been stabilized for a long period?
Don't we run the risk of them relapsing into their addiction or upsetting
their new-found quality of life? Shouldn't we rather continue their
methadone maintenance treatment for life?
The regular failure of withdrawal from opiatesOnly a minority of long-term chemically dependent heroin addicts appears capable of completing a withdrawal treatment and maintaining a stable abstinence while, at the same time, enjoying good quality of life. This is because long-term chronic heroin addiction is not simply a serious illness like pneumonia which can be treated in a couple of weeks. It's usually more like a chronic affliction such as arthritis, high blood pressure or asthma which requires very long-term treatment and, in some cases, life long treatment.
A biological problemThis more or less rapid adverse development of most chronically dependent heroin addicts after their withdrawal is not limited to any particular geographical area. The same pessimistic evaluations have been published in the United States, Sweden, Australia, Germany, Hong Kong, Switzerland, etc. It is impossible to observe any significant differences in the results through a comparison of types of education, culture, the social environment, living conditions and even types of health care.
This tends to lend some weight to the neurobiological hypothesis. Indeed, the only common factor observed in all these cases is the regular consumption of an opiate (opium, heroin or morphine).
Over the past few years, many important neuropharmacological studies have demonstrated that opiate abuse leads to modification, sometimes long-lasting, in the functioning of the endorphin system and its receptors. These neurobiological disturbances explain the clinical picture of withdrawal symptoms which, in all cases, are observed to a greater or lesser extent during the weeks that follow withdrawal from opiate use. Symptoms include extreme anxiety, sleeping problems, asthenia, concentration and memory impairment, learning difficulties, depressive tendencies, etc.
This neurobiological hypothesis is reinforced by the frequent failures
of methadone withdrawal treatment that have also been observed. For
almost thirty years now, as with heroin withdrawal, numerous studies throughout
the world have revealed an average rate of failure of 70%, often reaching
90% during the year following the discontinuation of methadone, especially
if this is abrupt. These failures among patients include relapses
into heroin addiction or anxious and depressive behaviour or the display
of withdrawal symptoms that can lead to the abuse of alcohol, cocaine or
benzodiazepine in the hope of calming their psychic tension.
So, who should be withdrawn from methadone?If we accept the neurobiological thesis of more or less long-lasting damage to the endorphins and their receptors as a result of long-term heroin abuse, then we should accept the idea of life long maintenance treatment for long-term dependency among drug addicts just as we accept insulin treatment for diabetics or medication for epileptics, anti-depressants to treat extreme mood changes, neuroleptic agents for psychotics or thyroid extract for patients suffering from a thyroid deficiency. It should be noted that all these treatments are perfectly acceptable to public opinion. But, on the other hand, we all know former heroin addicts who, even after years of treatment, manage to withdraw and to maintain a good level of psycho-social stability.
The hypothesis of a genetic element that encourages heroin addiction and its continuation is currently being proposed. As with alcoholics, certain patients are perhaps genetically more vulnerable than others to the effects of opiates and to dependence on them once they have been exposed to such drugs.
Because of this different genetic sensitivity, certain subjects may
experience more extreme withdrawal symptoms than others after stopping
opiate consumption. In the evaluation and prognosis of the withdrawal,
account should therefore be taken not only of personality structure, any
psycho-social problems as well as the amount and duration of opiate consumption,
but also of individual genetic factors.
Schaffer Library of Drug Policy
Major Studies of Drug and Drug Policy
Marihuana, A Signal of Misunderstanding - The Report of the US National Commission on Marihuana and Drug Abuse
Licit and Illicit Drugs
Short History of the Marijuana Laws
The Drug Hang-Up
Congressional Transcripts of the Hearings for the Marihuana Tax Act of 1937
Frequently Asked Questions About Drugs
Basic Facts About the Drug War
Charts and Graphs about Drugs
Information on Alcohol
Guide to Heroin - Frequently Asked Questions About Heroin
LSD, Mescaline, and Psychedelics
Drugs and Driving
Children and Drugs
Drug Abuse Treatment Resource List
American Society for Action on Pain
Let Us Pay Taxes
Marijuana Business News
Reefer Madness Collection
Medical Marijuana Throughout History
Drug Legalization Debate
Legal History of American Marijuana Prohibition
Marijuana, the First 12,000 Years
DEA Ruling on Medical Marijuana
Legal References on Drugs
GAO Documents on Drugs
Response to the Drug Enforcement Agency
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