Letters: Methadone treatment

Wonderfully well written and informative!!! Thanks so much for printing this letter!

Thank you Dr. Schaffer and Mr. Scobie for taking the time to write this article. When doctors and other professionals advocate for methadone, people tend to listen more and listen “better.” This is why we need more people in the various medical fields to speak out to the public about how methadone works. As you said, there are many successful methadone patients who are productive, tax-paying citizens, but they can’t speak out because of the stigma associated with methadone. All we have to do is to look at the hordes of people who come together to fight against methadone clinics opening throughout the U.S. to see how scared people are of methadone. They don’t see it as medicine; they see it as “legal heroin.” We have to make them understand that addiction is indeed a disease and that methadone can successfully treat addiction for many people. Once again, thank you for speaking up when it was essential for someone in the medical field to do so.

I certainly have not taken a position on this particular issue, and would not do so until having done more research on the current research regarding both forms of treatment. But, while I think it’s good you decided to counter Francke’s argument, I simply found his to be more persuasive.

Example: You argue he “misrepresented … the science of addiction treatment,” but give no specific examples. You also don’t respond to his point that many opiate addicts, after undergoing replacement therapy, have great difficulty in quitting methadone. Your point that methadone users are often very productive, well-adjusted members of society is good, but not addressing the issue of lingering methadone addiction is a glaring weakness of your argument.

Again, as I said, I haven’t taken a stance on the issue, but I would like to hear the supporters of replacement therapy make a better case.

Mr. Dobachesky requests further explanation of the “scinece of addiction treatment” and wants to know why methadone patients “have great difficulty in quitting methadone”. Well, sir, for the same reason that most diabetics have “great difficulty” in “quitting” insulin, and that many bipolar patients have great difficulty in “quitting” lithium.

The science of addiction treatment has shown us that many long term opiate addicts experience changes in the brain chemistry–specifically in the brain’s ability to produce endorphins–the brain’s natural opiates. When the brain senses that there is already plenty of a similar substance on board, it ceases to produce these chemicals. Then, when the patient stops taking opiates, they usually experience a period, even after acute physical withdrawals subside, of severe depression, anhedonia (inabiliy to feel pleasure), anxiety, restlessness, etc. It is an extremely miserable condition and often leads to relapse. Some patients–particularly those who are young, with a shorter period of addiction, may eventually return to normal endorphin production after a period of continued abstinence. However, many others–especially those with long histories of opiate abuse, or those who, perhaps, never had produced normal endorphins even prior to their addiction–may NEVER achieve normal endorphin production again. The damage to their brain chemistry has been permanent. In these patients, methadone acts as a replacement–not as is commonly thought, for the drug of abuse, but for the endorphins no longer being produced in the brain. In the same way that insulin replaces the insulin no longer being produced by the pancreas of the diabetic patient, and that lithium stabilizes the brain chemistry of the bipolar patient, so too does methadone stabilize and normalize the brain chemistry of those with ongoing endorphin deficiency.

It is also incorrect to refer to “lingering methadone addiction”, for the following reason:

The definition, medically speaking, of physical dependence and addiction, is NOT the same. Physical dependence refers to the onset of an abstinence syndrome in anyone who regularly takes certain medications, including opiates, when that drug is abruptly discontinued. Addiction, however, refers to not only physical dependence, but also includes a variety of behavioral symptoms that are NOT present in a stabilized methadone patient who is not using other drugs or misusing their prescribed methadone. Therefore, such patients, although they may have a history of addiction, cannot be said to be “addicted” to methadone, though they are dependent on it. You may feel this is semantics but I assure you it is not. Ask any stable methadone patient what their life was like when they were addicted to illicit drugs and now that they are stabilized on a medication that corrects their brain chemistry disorder and they will tell you that their lives have become functional and productive rather than dysfunctional and counterproductive–they are able to work, play, care for family and responsibilities and feel like a normal human being often for the first time in their lives. This is not a sign of addictive misuse of a drug, but of beneficial therapeutic USE of a medication.

I hope that helps to answer your questions. If you wish to research further, I refer you to the works of such eminent physicians as Dr Mary Jane Kreek, Dr Robert Newman, and of course, Dr Vincent Dole and Dr Marie Nyswander, all of whom conducted decades of testing and published volumes of findings on the science of addiction treatment. Despite this, the world continues to use outdated, non-medical approaches to what has been determined to be a medical illness–often a disturbance of the brain chemistry. We do not simply send schizophrenics, depressives, and bipolar patients off to support groups and ask them to make sin lists and beg forgiveness for their unpredictable behavior while in the grips of their disease and call that and that alone “treatment”–yet we do this with the disease of addiction, despite the fact that this method has been shown to be abysmally unsuccessful–particularly with long term opiate addicts. It’s time at last to treat this disease for what it is–a medical illness, often requiring medical treatment.

I appreciate the clarification, if not the apparent tone it conveys.

Francke argued, quite persuasively, that “methadone addiction” was a harmful social ill that did nothing to improve the lot of those who are addicted to opioids. Yet, assuming your rebuttal is correct, the information he presented was terribly inaccurate — so I am very grateful for your having cleared up this misconception. I’m certain I’m not the only one who was persuaded by Francke’s argument — do you think the general population, even at an institution of higher education such as this one, has the sort of knowledge needed to identify the flaws in his argument?

I simply did not feel like Dr. Schaffer and Scobie explained this clearly enough, and I greatly wanted more information about the matter so that, assuming many other readers were like myself and not very knowledgeable on the topic, some misconceptions could be cleared up.

Zenith, your response was excellent because it was so informative. Nevertheless, society is starting to worry me a bit. I always thought that once society understood what addiction was, meaning what it does to the brain, that people would understand that real treatment was needed, as with any other disease. While I still tend to believe that, I can’t help but wonder how many people will still hang on to the same old judgmental beliefs even after having all of the facts. It’s as if they feel that we are getting what we deserve–we started getting high and that behavior led to addiction; however, human behavior triggers many diseases. Some types of diabetes are triggered by poor diets, but we don’t tell diabetics that sheer willpower will regulate their sugar levels. Drinking too much alcohol can lead to liver disease, but we don’t leave those patients to fend for themselves. Unprotected sex can lead to AIDS, but we treat AIDS patients as people who need medical treatment, not as people who have “done wrong.” Nevertheless, when it comes to drug addiction, all bets are off. We are not a cruel society, so it must be that people just do not understand. I suppose it is up to methadone patients and doctors, alike, to explain the disease of addiction, but most methadone patients will proably have to do so incognito.

Zenith, you obviously have extensive knowledge of methadone/opiate addiction/dependency, but you really shouldn’t try to analogize it to physiological conditions such as diabetes and bipolarity. Methadone treatment is necessitated by substance abuse. Period. And while that substance abuse may result in actual physiological changes in the brain, it is not of the same origin.

Diabetes might be a consequence of overeating or over-inbibing of alcohol, but sometimes it’s a congenital deficiency. Insulin is a requisite for LIFE. Methadone, per both your and Dr. Scaffer/Mr. Scobie’s responses, is a building block for reversal of self-inflicted damage–a benefit to society. Lithium, as a quality-of-life-enhancer may be comparable (in your view) to methadone, but again, bipolarity is rarely the result of self-abuse (opiate use).

And Dr. Shaffer/Mr. Scobie, expressing an opinion…let me repeat that: OPINION, is exactly what an opinion page is for. Your “facts” (based on your limited work at Acadia), are applauded in the “opinions” of a couple of methadone advocates. You all have the same first amendment freedom of speech (and via publication–of press) that allows you to self-promote your “opinion” as being informed as Mr. Francke did, based on his experience and observation. Your “opinion” that he “misrepresented science” is hyperboly. Just because an opinion espoused is different from yours does not make it uninformed…it simply provides for a healthy debate.

I find it more than a little telling that you all request that PROFESSIONALS that wrote in show “proof” of their opinion….yet no one asked the same of the Mr. Francke? Although we have 40years of repetitive proof SCIENTIFICALLY that methadone treatment WORKS…we still have not ONE study that proves Mr. Franckes use of 12 step/abstienance based treatment works for more than 10% of it’s recipients….to bring them back to functioning members of society! Here is a little known fact: there is no proof that abstienance based programs work for more people than NO TREATMENT at all! That means an opiate addicts chance of becoming a functioning member of society again using Mr. Francke’s “beliefs” is no better than their chances of functioning again magically all by themselves with no treatment!

It just proves once again that when it comes to prejudice people are happy to continue believing what they believe simply because it’s what they’ve always believed…no matter how much proof or fact is thrown at them:
I call it the “earth is flat” syndrome!

It is important in this debate to clarify the term “works” when we say “treatment works”. Within the context of methadone treatment, “works” can mean all that has been discussed here in terms of improved functioning. When used outside of replacement therapy, “works” often means no relapses, or no illicit use of drugs. It is important to remember, though, that using methadone in a clinic is “illicit use” outside the clinic. Meaning, the same behavior is either treatment or relapse depending on its context.
Another important point is that clients often have a far more ambiguous relationship with methadone than the providers and staff who prescribe it. Read research by Gordon Roe or Margaretha Jarvinen (use google scholar and they will come right up) for more information on how complex this issue is. The orientation of the researcher (doctors or social scientists or criminologist, etc) has a huge impact on the type of research produced. It is important to get an understanding of the issue through as many lenses as possible if we are to really get a grip on the many forms and faces of addiction.