In particular, there were constant difficulties and dangers involved with obtaining heroin, a highly criminalized drug, and related problems when I was unable to do so and thus, too dope-sick to function. After many years of everyday use sapping all of my energy and resources, it was starting to seem like I was sick more often than not. So like a lot of people on MMT, rather than pursuing abstinence or recovery, I got on the program for the regular, stable and most importantly, legal access to opioids that it provides.

And it worked beyond my wildest expectations!

Within a few weeks, I had a job, a bank account and a television. Within a few years, I was a graduate student in DePaul’s Sociology master’s program. Once I began receiving take-home doses—I’m one of the lucky few who get 28 days—MMT provided me with the stability of knowing that my opioids would be there first thing in the morning so that I could go about living my life.

I still smoked pot regularly and got some heroin or other drugs here and there, but I no longer had to worry about dope-sickness or doing the kinds of things I had to do to avoid it. Plus, while methadone is not as euphoric as heroin, it is still a full-agonist opioid. So it made me feel pretty good, on an everyday, all-the-time basis. It wasn’t quite the dream of being allowed to use heroin legally and in peace, but it was about the best you could do while living under a regime at war with people who use drugs.

Yet, despite the obvious and dramatic improvements that MMT made in my life, I quickly learned that I had to keep the manner in which it helped me to myself⁠—or at least from clinic employees.

The majority of people I interviewed were involved with MMT for the same kinds of pragmatic reasons.

This is because MMT in the United States is conceptualized strictly as an abstinence-based treatment, designed to help “addicts” find “recovery.” Despite MMT’s widely recognized association with reduced rates of overdose, recidivism and transmission of blood-borne viruses like HIV and hepatitis C, as well as clearly helping people to live more stable lives, the notion that it should be used for anything but the pursuit of abstinence-based recovery is verboten. In fact, people who do use MMT that way can face serious disciplinary action—including being dismissed from treatment.

Later on, when I examined how well MMT programs aligned with patients’ needs and goals for my doctoral dissertation, I realized that I was far from unique.

The majority of people I interviewed were involved with MMT for the same kinds of pragmatic reasons that I was. They used it to avoid things like overdose and other harms from unregulated and adulterated supplies, withdrawal, arrest and most of all, to escape the constant hustle and hassle of dependence on an illegal drug. Although many had abandoned illegal drug use, they became involved with MMT primarily because of external pressures related to heroin’s illegality, rather than from an internal desire to stop using drugs.

I argue that this fundamental misunderstanding of how people use and benefit from MMT is to a large degree responsible for the punitive and paternalistic character of treatment.

Since programs are based on the notion that their purpose is the treatment of “addiction”—a construct that frames certain kinds of substance users as bad, or sick, or both—clinics are punitive and prescriptive, aimed at transforming rather than protecting people. Most clinics are abstinence-only when it comes to drugs other than methadone. And their typical focus on self–improvement principles is often out of step with patients’ goals and beliefs, which further prevents them from achieving stability.

Not surprisingly, MMT is very unpopular among people who use illegal opioids and has low rates of use and retention that limit its ability to help people.

Hence, the role of criminalization, forcing people who use drugs to seek treatment as a refuge, is erased in favor of a narrative that focuses on the individual as a site of intervention.

Perhaps even more important, the predominant MMT model also ignores the political nature of substance use treatment. According to the clinics’ view, people experience harm because of their disease or disorder—addiction—and pursue treatment as a response to it.

Hence, the role of criminalization and the War on Drugs as producers of harm, forcing people who use illegal drugs to seek treatment as a refuge, is erased in favor of a narrative that focuses strictly on the individual as a site of intervention. As I wrote in a paper based on my dissertation findings, “MMT cannot be understood outside of the structural context of criminalization and the War on Drugs, which shape illegal drug use as a difficult and dangerous activity, and consequently position MMT as a way to moderate or escape from those harms.”

I propose instead that we acknowledge MMT’s practical use as a refuge from criminalization, and similarly, understand that people who use illegal opioids are making treatment decisions within a context of oppression. Such an approach would have far better explanatory power for describing the ways that people use and benefit from MMT—one that may translate into greater use of harm reduction principles.

By acknowledging that MMT protects people from criminalization and the War on Drugs, we can begin to understand these harms as resulting, at least in part, from policy rather than addiction. The very fact that people benefit so much by switching from an illegal to a legal opioid suggests that the harms of opioid use are intrinsically linked to its criminalization.

It is important to be clear that I am not trying to deny or reject the lived experience of people who do see their treatment through the lens of addiction and recovery. Many have found this to be a useful and meaningful way of understanding their experiences. Rather, I’m pointing out that many use and benefit from MMT outside of that model, and that such patients are not only unrecognized by the current approach to treatment, but oftentimes harmed by it.

These implications are particularly timely because of the additional pressures on people who use illegal drugs during this pandemic. As people experience greater difficulties obtaining opioids, they will increasingly see MMT as a potential solution. Similarly, the still dramatically high rates of opioid-involved overdose, and related presence of fentanyl in the drug supply, continue to drive people in the US towards the safer style of opioid use available through MMT.

Unfortunately, since the current approach to treatment does not recognize the motivations I have described as legitimate, many more people will be forced into indefinite daily attendance and related punishments-described-as-treatment until most have either been kicked out or left on their own.

MMT should be made as accessible and barrier-free as possible. Policies that require complete abstinence for everyone—or those that link the ability to access take-homes to such standards—should be ended in favor of a more individualized, patient-centric approach that acknowledges the realities of criminalized substance use and recognizes the diversity of peoples’ treatment goals.

Until opioids become legally available and properly regulated, opioid-replacement programs, like MMT, will continue to function as a way for a criminalized population to obtain them without the risks created by the illicit market. In most cases, these people will benefit from their involvement with MMT. Rather than trying to force an ideological concern with abstinence and “self-transformation” onto others, clinics should appreciate the tremendous therapeutic value of simply obtaining opioids legally.

Photograph by Marilena Marchetti.

The post Methadone Is Helpfully Understood as a Refuge From Criminalization appeared first on Filter.

Like most people on methadone maintenance treatment (MMT), there’s almost nothing that scares me as much as not having easy access to my methadone. I’ve booked multiple overlapping flights, canceled important events, woken up at ungodly hours and much, much more—all to ensure that I get to my clinic in time to put another 24 hours between me and the creeping horror of withdrawal. And thus, this event has been stressful, not only from a healthcare perspective, but also in that it reminds us of our stigmatized status within the world of healthcare consumers. We know that if the methadone clinics do close, aside from a few doctors and advocates, most people aren’t going to care that much.

The main reason for my cynicism when it comes to the official messaging is that the clinic system doesn’t work very well during the best of times. Like any highly regulated government program, it is characterized by bureaucracy, inefficiency and wide variation in treatment quality and practices between programs in one location versus another. Relatively minor issues can thus cause major problems with service; catastrophic events, like the one we’re currently experiencing, almost always do. 

Many seeking medical help were met with stony indifference—sometimes even accused of diverting resources away from the “real” patients. 

During Hurricane Sandy, for example, large numbers of New York and New Jersey area patients had to go without service as their clinics closed—in many cases with no advance notification to patients and no backup plan to help them find alternative ways of obtaining their medication. Moreover, because of stigma against people on MMT and people who use drugs in general, many of those seeking help from hospitals and other medical providers were met with stony indifference—sometimes even accused of diverting necessary resources away from the “real” patients. 

As social scientists Ellen Benoit and Harlan Matusow, who studied the effects of Hurricane Sandy on methadone patients, described, many were forced to choose between suffering through withdrawal, or, if they were able, buying heroin (ironically participants reported that illegal opioids were easier to get than their prescription methadone). All of this while also trying to protect themselves and their loved ones from a hurricane.

Clinics’ insistence on daily attendance for the majority of patients is not only highly unfair, but is simply not a sustainable model of long-term treatment—that they have to abandon it so quickly in a crisis of itself suggests the system’s unworkability, and there are already reports of chaos at some New York City clinics as they try to implement the new rules during the pandemic. 

The failure of the clinic system is easy to observe in its consistently low rates of patient retention.

As I’ve previously written, any program that requires large numbers of people to show up somewhere on an everyday basis, indefinitely, is not going to work very well, particularly when many of the patients are already living with multiple difficulties. I’ve known countless patients who had to quit because showing up every morning was impossible to maintain along with their job, or because their clinic wouldn’t provide them with medicine for travel to a family member’s funeral. 

The failure of the clinic system is easy to observe in its consistently low rates of patient retention. According to the United States Treatment Episode Data Set, in 2014, more than half of those receiving methadone (or buprenorphine) either left treatment on their own (41 percent) or were discharged by their clinic (11 percent).

It is therefore my hope that in addition to demonstrating and possibly exacerbating the huge problems with the clinic system, this emergency will also serve as a catalyst for scrapping it—in favor of office-based, physician-managed care, like we do with every other prescription medication.

As numerous people who study substance use treatment have argued, there are many reasons for transitioning from clinic-based to office-based methadone maintenance treatment (MMT). In addition to the problems endemic to a giant bureaucracy, methadone clinics have also been criticized for their rigid, punitive and abstinence-only approach to treatment—an approach at odds with the goals of many patients, who use MMT as a pragmatic way of reducing the dangers and instability of illegal drug use such as overdose, withdrawal and law enforcement. 

By enabling patients to work directly with their doctors—as opposed to counselors, who often have very little training on substance use issues and yet are the primary point of contact for patients in the clinic system—treatment could become more individualized and better able to assist people with a range of treatment goals. 

Simply visiting doctors and pharmacies—rather than large, centralized treatment facilities at a siloed physical location—would also be far less stigmatizing for patients. It should even make local businesses and communities, who are usually opposed to having a methadone clinic located within their midst, happy. 

Envisaging a system like this doesn’t require much imagination. This is already how buprenorphine maintenance treatment, a substitution-based treatment similar to MMT, is typically administered, and while there are still problems, they pale in comparison to those generated by MMT.

Everyone should have access to office-based care. Given the choice, I believe most patients would vote with their feet.

Proponents of the clinic model sometimes argue that many patients actually benefit from, and prefer, the structure and stability that daily attendance at clinics provides. Although I sometimes find this argument disingenuous—in that I think this sentiment comes more from a desire to exert control over the lives of people who use drugs than from a genuine concern with their treatment preferences—I have no doubt that for many reasons, some people would opt for clinics, particularly early on in their treatment. 

I don’t therefore advocate for the summary closure of all clinics, but for the abolition of a system that makes them compulsory. Clinics could remain open for those who want them, but everyone should also have access to regular office-based care. Given the choice, I believe most patients would eventually vote with their feet.

Transitioning from a clinic-based system to a primarily office-based model is the only way that people on methadone will feel confident that their treatment is being administered through a reasonably reliable doctor-patient relationship—one stable enough to provide quality, individualized service both during emergencies and on a day-to-day basis. This is by far the best way of reducing many of the problems that make MMT a huge pain-in-the-ass during the best of times, and threaten to collapse it entirely during the worst. 

Photo of a New York methadone clinic by Helen Redmond

The post It’s as Good a Time as Any to Scrap the Methadone Clinic System appeared first on Filter.