Phoenix described a repeating nightmare that will be familiar to many harm reductionists, social workers, physicians, advocates, and—most importantly—to people who want and need this effective and lifesaving medication. “I am doing everything they asked of me, bending over backwards to make sure I stay healthy, in recovery and giving back to my community,” he said. “But it isn’t good enough.”

Phoenix is just the kind of person that federal agencies—like the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Disease Control and Prevention (CDC) and the National Institute on Drug Abuse (NIDA)—highlight when they define recovery and promote high-barrier access to medication for opioid use disorder (MOUD).

To Phoenix, methadone was a form of safe supply that empowered him to improve his mental and physical health.

Phoenix is a compassionate and always-smiling Black grandfather in his 50s, who was previously incarcerated for possession of a substance. When he was younger he sought to escape the trauma of living in poverty, and of a childhood spent in and out of the foster care system.

To him, methadone was a form of safe supply that empowered him to improve his mental and physical health. He no longer used state-banned substances from the adulterated unregulated market. He had even been able to find a part-time job that made accommodations for methadone’s “liquid handcuffs” access regulations, which compel people to attend clinics in person up to six days a week, regardless of how much this hampers their lives.

So Phoenix met those agencies’ definitions of recovery in multiple ways—even if the “stability” of his life still did not “earn” Phoenix the right to take-home doses in his clinic’s estimation, despite SAMHSA’s relaxation of take-homes guidelines during the COVID-19 pandemic.

Phoenix was also honest about his new job, reporting the tiny income to Medicaid.

That honesty came with a devastating cost. Because reporting that little bit of income, about enough to pay for Phoenix’s gas money to pick up his daily dose, made him immediately ineligible for Medicaid coverage.

In most circumstances, losing health insurance means signing a financial waiver and receiving some kind of assistance, however inadequate. When you lose your prescription coverage, you at least have the remaining medication for the month in a bottle. Not so with methadone, which is administered under a deliberately cruel and humiliating system.

The clinic simply imposed an “administrative discharge”—abruptly terminating his methadone access.

When Phoenix lost coverage and could not afford self-pay costs of $500 a month, there were no safety nets. Rather than providing quality care to ensure Phoenix was not left in a state of crisis, the clinic simply imposed an “administrative discharge”—abruptly terminating his methadone access.

For a clinic to callously tell a person under such stress that their medication, which has been working, will no longer be available to them—leaving the person to scramble alone while going through withdrawals—perfectly illustrates the brutality of the system. When the unregulated opioid supply has never been more dangerous, when methadone is a gold-standard medication to reduce mortality for people with opioid use disorders, this could easily have amounted to a death sentence.

I called the county’s Mental Health Insurance Plan to explain the situation, and they seemed willing to help. But their extremely limited powers of oversight, together with a severe lack of funding set aside for safety nets in such circumstances, were starkly clear.

This type of medicalized harm is a product of the profiteering of these clinics, enabled by a lack of qualified oversight. Unforgivably, the United States methadone system is regulated not by a medical body that prioritizes patients’ needs, but by a drug war agency: The Drug Enforcement Administration (DEA) cares only about preventing “diversion.”

On the DEA’s watch, patients endure inadequate services, intrusive surveillance, humiliating stigma and abuse. It’s having someone watch you while you provide a urine sample for a drug screen. It’s having someone check under your tongue after you take your medication, to ensure you’re not hiding any to sell later. It’s being treated like a criminal for seeking health services. It’s being abandoned when the funds run out.

Phoenix called me for emotional support and a withdrawal care package. I did everything I could, rushing to purchase him kratom in hopes it would buy time until we got him back on methadone. The street supply has been increasingly toxic, and I was concerned how Phoenix’s body would react to something he hasn’t had in many years, since before illicitly manufactured fentanyl took over the heroin supply.

Phoenix’s grandkids are his life and he is theirs, especially since their father was taken too soon by a fatal car accident. He was determined to tough it out, as he stayed in the bathroom, in agonizing pain, becoming increasingly dehydrated and weak.

A group of us made calls non-stop to gather enough money to pay for his methadone for the month. Most of it came from our own pockets. It is hard to convince people of the seriousness of withdrawal and the need for MOUD. And since COVID-19, fundraising within our mutual aid groups has become more difficult, despite increased needs, as safety-net services have struggled to keep up.

Phoenix ended up going to the emergency department on night two, as his weakness became concerning to his wife. The physicians treated his withdrawals and the next day he went and gave that clinic its money so he could receive his life-saving medication.

He then had to quit his job, before spending hours on the phone to get Medicaid to cover him again for the next month.

This environment of discrimination, neglect and abuse is a backdrop to—and a cause of—the  most devastating polysubstance overdose crisis the United States has seen.

Phoenix isn’t the first person I’ve met who’s gone through this “administrative detox.” Nor is he the 10th. It’s something that happens over and over again in this system. When decision-makers, funders, and those in power, want to know why people don’t go to treatment, they should remember that—even if this issue only scratches the surface of the systemic problems with the treatment-industrial complex.

The Urban Survivors Union’s Methadone Manifesto heartbreakingly lays out these barriers and abuses, and urges collective action from people who use drugs and utilize methadone treatment. The National Alliance for Medication Assisted Recovery’s Medication Assisted Recovery Support (MARS) project, Legal Action Center and National Advocates for Pregnant Women and many more also provide advocacy and resources for those discriminated against and criminalized for using drugs.

But these groups have a mountain to climb, when methadone treatment is surrounded by continuous misinformation, myths, stigma and outright racist rhetoric established many decades ago. Substantial federal regulations create inaccessible conditions, particularly for Black, Indigenous and Latinx communities disproportionately impacted by systemic oppression—like racism, sexism, classism, homophobia, transphobia—and by poverty, houselessness and food insecurities. These social determinants of health are used to blame and pathologize methadone patients, while cycles of structural violence go unaccounted for and determine who is more (or less) likely to die of overdose.

This environment of discrimination, neglect and abuse is a backdrop to—and a cause of—the  most devastating polysubstance overdose crisis the United States has seen. It is traumatizing, exhausting and infuriating, but worst of all, preventable.

Phoenix is doing much better now, and is back to the methadone regimen that works for his body. When I last checked in on him, he smiled and said, “I went from handcuffs in prison because of trauma to handcuffs in a clinic that causes more trauma.”

Photograph by Helen Redmond

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