Volume IV, Issue V (May 1999)
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Statements on Addiction Free Treatment Act
So, Why Is Methadone Maintenance Treatment
So Vigorously Resisted by Some Politicians? - Aaron Rolnick
Evidence that Opoid Dependence is a Medical Disorder
(From NIH Consensus Statement)
Employing and Accommodating Individuals with
Histories of Alcohol and Drug Abuse
Should chronic heroin addicts be withdrawn from
methadone? - by Dr. Jean-Jacques Deglon
Doctor's Column - Uses
of methadone for other than opiate addiction
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Statements on Addiction Free Treatment Act (S.
by Senator John McCain (R-AZ), author of S. 423
*S. 423 is not the resolution discussed in the February issue
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:
Mr. President, today I am introducing the Addiction Free Treatment
Act which reforms our nation's drug policy regarding the treatment of heroin
This bill would restrict Medicaid reimbursements and funding through
the Substance Abuse and Mental Health Services Administration for methadone
and LAAM maintenance programs. Maintenance programs would be limited
to six months. This bill requires that such programs conduct regular
drug testing, report all results, and terminate methadone treatment to
any patient testing positive for any illegal drugs. The legislation
directs the National Institute of Drug Abuse to study the methods and effectiveness
of nonpharmacological and methadone-to- abstinence heroin rehabilitation
programs and requires the Center for Substance Abuse Treatment to provide
an annual report to Congress on the relative effectiveness of heroin treatment
programs in achieving freedom from chemical dependency.
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
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
8) They are on-call 24 hours a day, 7 days a week for as long
as the participant needs them.
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.
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So, Why Is Methadone Maintenance Treatment So Vigorously Resisted by Some Politicians?
by Aaron Rolnick
Is it simply ignorance? This is certainly part of it.
But to believe that ignorance is the main reason that some politicians
attack methadone (and LAAM) maintenance treatment would be naïve:
most federal and state government officials, such as Congressmen, have
enough staff and resources available to them to be able to obtain the necessary
information fairly quickly. Every Congressman may not be thoroughly
educated on every issue, but a Congressman is normally very familiar with
an issue on which he/she has chosen to sponsor a bill (if only to be prepared
for the opposition).
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
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
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.
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Evidence That Opioid Dependence Is a Medical Disorder
[From page 6 of NIH Consensus Statement, volume 15 Number 6: November
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
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)
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Employing and Accommodating Individuals with Histories
of Alcohol and Drug Abuse
This publication was developed by Ellen M. Weber, Co-Director of
National Policy of the Legal Action Center,
236 Massachusetts Avenue, NE, Suite 510, Washington, DC 20002,
produced by the ILR Program on Employment and Disability, Cornell
University, Ithaca, NY.
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.
Although individuals with current drug problems are not protected,
the ADA specifically protects individuals who are participating in a supervised
drug rehabilitation program or who have completed a treatment program or
have been rehabilitated through self-help groups, employee assistance programs
or any other type of rehabilitation, and are no longer using drugs.
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.
[Editor's Note: Inquiries and drug testing to reveal information
about current illegal drug use is permissible prior to a conditional offer
of employment, once employed, or anytime in the hiring process, as current
use/abuse of illegal drugs is not a protected disability under the ADA.]
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.
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Should chronic heroin addicts be withdrawn
by Dr. Jean-Jacques Deglon
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 methadone
Nowadays, 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 opiates
Only 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
A biological problem
This 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.
For these reasons priority in withdrawal from methadone should be reserved
for motivated patients who show low psychopathology, a well-balanced personality
and only minor history of drug addiction.
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