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Monday, March 23, 2009

Methadonia Part II

Last week I wrote about some first impressions I had of the documentary Methadonia. My thoughts came from a highly specific place because of the work I do. However, I did not specify that in my entry.

I received a very well thought out response from a stranger informing me that the film did a lot of damage within the MMT (methadone maintenance therapy) community. This was the result of Michel Negroponte's decision to only depict MMT clients on the edge of society, mostly homeless or close to being homeless. Because of this small percentage represented, "Zenith" explained, MMT was further stigmatized. Many people who are using methadone to prevent withdrawal and relapse live healthy and productive lives.

Although I am already aware of everything Zenith brought up, I didn't write much on it. My interest in the film began and ended with those who have not had success stories. I watched the film with a group of other nurses who also work specifically and almost exclusively with the homeless. On a daily basis I am confronted with members of our society for whom a "normal," life with a job, home and family is, for various reasons, out of reach.

However, I did not take into account that many other people reading this may not know anyone on MMT and may take my word as the only one on the subject. And it is never my intention to mis-educate people, so I would like to re-post the comment I received in the hopes that it will at least begin to explain why methadone maintenance therapy as shown in Methadonia is not the experience of every man or woman who undergoes it.

Mr Negroponte's film was the source of a great deal of conflict within the methadone community. The film focused solely on patients who were abusing their medication and combining it with other drugs, specifically benzos, to get high. They were shown nodding off, drooling, slurring speech, etc. In addiction, almost every pt shown was homeless or very nearly so, living a marginalized life at the fringes of society and spouting common methadone myths like they were going out of style. No effort was made to correct them nor to show the other side of methadone treatment.

Due to the uproar of anger this caused, an 11 minute add-on called "Addiction 101" was added to the DVD release of the film. This included two stable, professional methadone patients--an attorney and a businessman--who have been on methadone for decades, and two doctors who are experts in the field of MMT. Sadly, however, even their noble efforts were too little too late--most people did not see the add-on, and people were strongly influenced to accept Mr Negroponte's vision of the methadone patient as a homeless, drooling, pitiful character that they wouldn't want anywhere near their children or their homes.

This kind of filmmaking simply leads to increased discrimination and stigma on an already stigmatized population. The reason clinics do not generally encourage withdrawal from treatment is not, as is commonly though, because they are crazed with greed. There is an enormous shortage of clinics and clinics are NOT hurting for patients--most have lengthy wait lists--so there is no $$$ motivation for them to hang on to those who wish to leave. The fact is, 90% of those leaving MMT relapse within one year. Sure, most pts would like to be "drug free"--who wouldn't? Diabetics and epileptics would rather be "drug free" too, I'm sure, but their doctors do not encourage them to stop taking their meds because of this.

Long term opioid addiction can produce permanent changes in the brain chemistry--specifically in endorphin production. If the patient has a permanent suppression of endorphins, they are very unlikely to do well in an abstinence based recovery. The methadone serves to stabilize the brain chemistry without causing a high or euphoria. It enables people to resume a normal life. I know many many professional people, suburban mothers, college students, etc on MMT and none of them look like the people in the film--but that isn't very "entertaining" so it wasn't shown, sadly enough.

Right now, methadone is the MOST effective method of treatment available for opiate addiction, and has a high rate of keeping pts free of illicit drugs. Yes, there are some that continue to use illicits, but far fewer than in other modalities of care.

I agree with all of that.

If there were a movie that came out about the rate of diabetic related co morbidities in low income patients it probably wouldn't focus on any success stories either. The difference is that no one out there is arguing to stop the use of insulin in patients with diabetes, but many people including entire governments (what's up, Russia?) are dead set against helping opiate addicts.

And so I will end with this: the end of my lengthy comment in response to Zenith's:

My interest would never be to stop MMT for people who benefit from it, but rather it's my intention to urge the medical community to continue to look at the cases that aren't so successful and to push forward on remedying that.

1 comment:

zenith15 said...

Thanks so much for your thoughtful and honest reply to my comments. You took my remarks in exactly the way the were intended and drew from them exactly what I hoped you would, and I am grateful.

Through an online discussion many of us in the MMT community had with Mr Negroponte shortly after the release of the film, he stated something to the effect that he was not trying to portray all elements of the MMT community, and we understood that. However, as you noted, many who see the film have no other basis of comparison--they know no other methadone patients and have little or no knowledge of the treatment or how it works, or of its high success rate. It served to lead many to have a negative outlook on MMT, and we felt that even though the film may have been about pts who were not doing well, at least a mention that this should not be taken as the "typical" patient on MMT should have been made.

Sadly, there are many reasons why MMT does not work for everyone. Of course, some just do not tolerate the medication well, as with any drug. Others may be chronically underdosed by clinic physicians and staff who ignore adequate dosing guidelines, leaving them sick every evening and placing them in the path of severe temptation to use, to alleviate the nightly withdrawals.

Others may have come in with a severe poly-drug addiction. Unfortunately, MMT ONLY treats opioid dependence. It does not treat cocaine dependence, alcoholism, amphetamine abuse, etc. It is extremely difficult to find treatment for these individuals should they continue with or relapse into the abuse of non-opioid drugs while on MMT, because almost no treatment center in the country, in or out patient, will accept methadone patients unless they agree to stop methadone as well. I once spent a considerable amount of time trying to help a crack addicted MMT patient find treatment. He was well off financially and could go anywhere in the country--yet no one would take him unless he agreed to "get off that dope" (i.e., methadone).

These are only some of the reasons people may not do well in treatment--I could go on for ages. But the fact is, more people do well in MMT than in any other mode of treatment available for opioid addiction, and more people in MMT are free of illicit drugs than with other modalities of treatment.

Many groups in thie day and age rally against MMT, saying that MMT clinics must be built far far away from schools, businesses, residences, churches, funeral homes, parks, libraries, and so on. Towns are working to ban them before a clinic has even made any move to open there, fed by a frenzy of misinformation and hate. Yet, we are already among them--we are their neighbors, the parents of their children's friends at school, their co-workers. We are doctors, lawyers, businessmen and women, suburban moms, college students. We check their groceries, work on their cars, take their money at the bank, teach their children, lead their adult sunday school class. We are there, and we are often silent about our MMT status, because of the confusion, prejudice, stigma we must face every time we choose whether or not to "disclose" to someone, whether it be our doctors, our families, our employers, our friends. So, it is important to take care not to unintentionally stigmatize a population already running to stand still.

Thanks for your concern and kindness.