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The post World War II era saw an increase in opioid addiction, which gave rise to crime in urban areas and, in turn, led to overcrowding in jails. With no effective treatments or detox methods available to addicts, the Joint Committee of the American Bar Association and the American Medical Association issued a report in 1958 recommending that an outpatient facility, prescribing opioids to treat addiction, be established on a controlled and experimental basis.
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German scientists first produced Methadone in the 1930s and it became available in the United States in 1947, but its use as a treatment for opioid abuse really took off in 1964 when Dr. Marie Nyswander and her husband, Dr. Vincent Dole, presented data for two patients that were responding well to high-dose Methadone maintenance therapy. They claimed that their patients felt relief from cravings and no longer experienced the euphoria associated with opioids. They were also free of side effects and avoided developing a tolerance to the drug. Nyswander and Dole believed that high-dose Methadone maintenance was the most realistic goal for many of their addicted patients and a preferable alternative to death, as well as the problematic behaviors associated with opiate addiction. They advanced the idea that Methadone maintenance was an acceptable alternative to abstinence and worked to promote its use as a harm reduction-style of treatment.
The concept at the center of the debate over Methadone maintenance therapy is whether harm reduction is an acceptable approach to treating opioid addicts. Though no definitive definition exists, Dr. Bernadette Pauly, an associate professor at the University of Victoria School of Nursing in Canada, characterizes harm reduction “as a philosophy (that) shifts the moral context in health care away from the primary goals of fixing individuals towards one of reducing harm.” To that end, addiction professionals who offer this type of treatment may be more concerned with decreasing the harms associated with drug abuse (overdose, crime and medical and psychiatric problems, just to name a few). The advocates of this treatment insisted it helped reduce the stigma associated with illicit and intravenous drug use. Those professionals who worked toward abstinence were mortified that physicians were once again making the mistake they had repeated in the historical past, treating one addiction with another addictive substance.
To the harm reductionists’ point, an article published in The Journal of the American Medical Association in 2008 reports that Methadone treatment and comprehensive rehabilitation programs have been associated with marked improvement in patients’ ability to function better overall. Experts tout Methadone’s legality and long half-life as a good alternative to illicit parenterally administered heroin. Its use is strictly regulated, which is intended to minimize the potential for abuse.
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Experts on the other side of the debate, including Dr. Robert DuPont, a former Drug Chief under Presidents Nixon and Ford, argue against Methadone maintenance treatment. DuPont, an early proponent of Methadone, said in an interview for PBS’ Frontline, “I think the simplest way to say it is that it’s an addicting drug. How can you treat addiction with an addicting drug? At the end of the day, you’re not going to make that sale. It’s not going to happen.” DuPont now believes that the harm reduction approach sends the wrong message.
Methadone is addictive and causes one of the most intense and protracted withdrawal syndromes of any substance. Once on Methadone it is very unlikely that the patient will come off the drug, committing the patient to this mode of care. Many patients must take high doses of the medication indefinitely in order to suppress the unwanted cravings and problematic behaviors. Severe difficulty functioning may also be experienced. What’s more, Methadone can still be abused and diverted (used in unintended ways) and causes several thousand deaths a year – especially when it is combined with alcohol and other drugs like benzodiazepines, which addicts do often.
The use of harm reduction strategies to control drug use rather than end it goes to the very core of what it means to treat addiction. Iatrogenic addiction (addiction caused by doctors) has both moral and ethical implications and consequences. It raises many questions about what a physician’s duty is with regard to bringing about a cure for patients. The bottom line is that Methadone maintenance therapy is considered an acceptable form of drug addiction that is facilitated and condoned by a large faction of the medical community. Despite good intentions, many people do not function to their fullest potential while on it because, at the end of the day, they are still in the grips of an exceedingly powerful drug.
The fact that this has been an acceptable standard of care for more than fifty years is concerning. Unfortunately, the latest opioid epidemic is merely another installment of the same story. In spite of everything we have learned about Methadone’s addictive qualities, and the inherent difficulty of weaning off of it, history is repeating itself right now – except the current harm avoidance strategy involves a new medication called Suboxone. Like Methadone, it has clinical utility but the excessive enthusiasm mirrors the mistakes the medical system has made over and over again when addressing opiate addiction. The current incarnation of harm avoidance involves large supplies of Suboxone being provided at each visit with a provider; this in marked contradiction to Methadone, which is provided on a daily bases. Those working with addicts are seeing younger abusers who are diverting this drug (using it in unintended ways) at an alarming rate, thus creating a substantial black market.
Opiate addiction is a complicated medical problem that requires an array of evidence-based treatments to properly address it. Finding the correct treatment for each patient is still a hotly debated topic.
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