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Wednesday, March 18, 2009

one pill makes you larger and one pill makes you small

I recently got a chance to watch Michel Negroponte's documentary, Methadonia. I highly recommend that you also see it. It moves quickly, isn't preachy, and packs a lot of information into an engaging structure.

The film has met a lot of controversy for many reasons. One is that Negroponte takes the "addiction is a disease" point of view, which many people reject. (For more about rejection of the addiction as a disease model you can read Gary Greenberg's book Noble Lie: When Scientists Give the Right Answers for the Wrong Reasons.)

Also controversial is the documentary's suggestion that methadone treatment is not, as previously thought, the best modality of drug addiction therapy. In fact, it might be just as harmful as addiction to illicit drugs in a lot of ways.

Methadone is a synthetic opiod. It is used both for chronic pain management because of its long acting analgesic properties, as well as to treat withdrawal from opiates.
The way it works as an opiod antagonist is by binding to opiod receptor sites in the brain. In doing so it effectively stops withdrawal cravings as well as blocking the "high" of any secondary opiod. (You don't get a buzz from shooting up while on methadone). When an individual is dosed properly they aren't getting high or nodding off from the methadone. They are simply avoiding the pain and unpleasant side effects of withdrawal and should be able to live healthy and "normal," lives otherwise.

In the United States methadone has been used as treatment of choice for opiod addicts for about 30 years. We are not alone, as of last year there were 69 other countries using methadone clinics. The Netherlands takes it a step further, as they are still carrying on research which involves some patients having heroin actually prescribed and administered intravenously in clinics designated for that purpose.

Both the legal doling out of heroin and the clinical dosing of methadone fall under the broad category of "harm reduction" therapy.

I understand the damage that can be done by removing all ownership of behavior from the addict's control. After all, "I can't help it, I'm addicted," is a phrase that isn't useful to anyone.
However, I do have enough belief in neuroscience to understand the relationship between behavior and nerve pathways. And I believe enough in chemistry to understand how opiates, (and any other chemical we put into our bodies), change the way our brain responds to those substances subsequently. I also know enough about pathophysiology to say with confidence that some people are more genetically predisposed to certain illnesses than others, including mental illness. This is why I believe that addiction is more like a disease than it is not like a disease.

As for methadone dosing being the best/worst treatment for addicts, I'm not convinced either way.
Clearly, a legal and safe dose of methadone is better than people shooting up bad batches of heroin with dirty needles. However, it seems to me that the system right now is flawed. Ideally, someone with an addiction would receive the lowest dose needed to stop cravings and would be able to live a normal life. As it stands there is a lot of abuse in the system. Many people on methadone "play" with their dosage because they aren't actually trying to stay sober, they're trying to get high. As Methadonia points out, it's cheaper and safer to get dosed and then to buy some "sticks" (benzodiazapines) on the street than to buy a bag of dope. The high from combining methadone with a benzo is just as good as (if not better than) shooting up, according to Negroponte's subjects.
Perhaps if all methadone treatment programs also involved counseling, groups, or mandatory day programs the mind could be trained along with the body.

Methadonia also points out that even those who are trying honestly to stay sober are never really free of "the liquid handcuffs." It's almost unheard of to completely taper off of methadone. It's like insulin for a diabetic, a life long medication. But unlike insulin there is a stigma attached to methadone that can be socially debilitating. Whether this is the fault of clinics being unwilling to help patients detox (as one addict in the film claims), or whether it is the nature of long term management of the disease or just an inherent flaw of methadone itself, is never really answered.

I guess for myself I'd rather see people taking methadone every day than living the desperate, dangerous and risky life of an addict. However I think that there needs to be a push for the next best thing. We've been doing it this way for 30 years, and there's got to be something better; a new and better way to treat addiction and the people who are still people underneath the label of their disease.


zenith15 said...

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, almpost 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.

MischMash said...

Thank you for your very well written and clearly thoroughly thought out response. I apologize if I misrepresented individuals on MMT or flamed any fires by bringing up the film at all.

I actually did get a chance to watch 'Addiction 101', and should have prefaced my entry as such. I'm not sure how long you've been following my blog but since I am a nurse who works primarily with the homeless population in my city the film is actually very relevant to my practice and to the daily lives of my co workers who haven't seen the film.

I am sorry if my entry furthered any stereotypes of MMT because that was not my intention. I clearly undertand that it is a very effective and in many cases life saving therapy. In addition, I fully support the funding and maintaining of clinics in the United States. I have also, like yourself, strived to educate misinformed providers and patients alike about the long term effects of addiction on brain chemistry, likening methadone treatment to insulin or anticonvulsants, and defending a population of people from the stigma attatched to MMT.

However, every day I see people whose lives are *not* improved by this treatment (and although I understand that this is because of the population I work with, it is still a hard reality). 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.

In the meantime, I will post something later this week that hopefully will help clarify things further, and to diminish any harm I may have caused.