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Chemical Dependency Research Working Group |
Evaluations worldwide over the past two decades have shown that methadone maintenance is the most successful treatment for heroin addiction and one of the most effective programs for the prevention of the transmission of human immunodeficiency virus (HIV) (Joseph and Appel, 1993). Nevertheless, methadone maintenance treatment has been subjected to professional trivialization and misunderstandings, has consistently received sensationalized negative media coverage and been the target of widespread community opposition (Zweben and Sorensen, 1988). These attitudes have prevented the opening of needed clinics within the past 15 years, notwithstanding the current acquired immune deficiency syndrome (AIDS) and heroin epidemics. Methadone patients are perceived as addicts: weak willed, unemployed, untrustworthy and dysfunctional. Employed stable patients whose lives have been saved by enrollment in methadone treatment have been forced to conceal their status as methadone patients from members of their families, friends and employers for fear of losing their jobs, social ostracism and stigmatization. They are hiding a "dirty secret." (Murphy and Irwin, 1992).
Methadone maintenance was developed in 1964 at The Rockefeller University from research conducted by Vincent P. Dole, principal investigator and senior physician at the university. His co-principal investigator was Marie E. Nyswander, a psychiatrist specializing in the treatment of heroin addicts. A third member of the team was Mary Jeanne Kreek who as a research physician has specialized in studies on the long term medical safety of methadone maintenance (Joseph and Appel, 1993).
A major focus of this study will explore the adjustments and perceptions of a group of compliant and functional methadone patients who are aware of the stigma directed towards patients. Most of the methadone patients in this study are currently being treated in the hospital-based private medical practices of internists affiliated with Beth Israel Medical Center in New York City. This pilot project, called medical maintenance, is an advanced phase of the methadone maintenance program for the treatment of heroin addiction. In contrast, methadone maintenance programs operate in identifiable neighborhood clinics that are highly regulated by the federal government and often hinder the further social adjustments of employed and compliant patients. The medical maintenance program is currently operating from the offices of four internists with hospital-based medical practices and was implemented to demonstrate that chronic opiate dependence can be treated as a chronic disease in private medical practice. In contrast, neighborhood clinics treat a variety of patients including those with serious social and medical problems.
The medical maintenance program removes socially and medically stable methadone patients from the visible, stigmatized and highly regulated clinic system and places them within the concealment of private medical practice. Therefore, it is anticipated that patients can further improve or enhance their personal lives and resolve the stigma associated with their treatment.
To understand the type of stigma socially rehabilitated methadone patients are subjected to, the initial portion of this study will be devoted to an investigation of the development and accretion of stigma directed against opiate dependent groups within the past century in the United States. The patients who are the focus of this study will therefore be placed within a social context with a historical base. The attitudes and experiences of the physicians who treat the patients in private medical practice will also be investigated. These are the first doctors permitted to treat opiate dependent patients on an ongoing basis in medical practice since the passage of the Hrrison Act in 1914. This is an important accomplishment. Prior to the development of methadone maintenance in 1964, many physicians who treated opiate dependent patients in their offices merely wrote one or two prescriptions. Few were able to maintain patients, as they were harassed by the Federal Bureau of Narcotics, arrested and prosecuted and subsequently incarcerated. While some of the physicians may have been unscrupulous, most were upstanding physicians who tried to treat the addict (Courtwright, Joseph and Des Jarlais, 1989). The physicians participating in this study of medical maintenance are highly capable, respected and ethical professionals with specialties in internal medicine and general medical practice.
Differences Between Heroin Addiction and Methadone Maintenance
The following briefly explains the differences between heroin addiction and methadone maintenance. This is important conceptually since heroin addiction and methadone maintenance are often incorrectly equated without taking into consideration the profound differences that exist (see Appendix for Comparison Chart).
Heroin is a short acting narcotic (4 to 6 hours) capable of producing a highly euphoric effect when administered usually by injection or nasal inhalation. Heroin, if continuously used, is also capable of impairing the functioning of the endocrine and immune systems and generating an overpowering, long lasting, narcotic hunger or drug craving. The addiction is characterized by increasing tolerance levels leading to the use of ever increasing amounts of heroin to achieve the same effect. The addiction process also creates physical dependence with a well defined abstinence syndrome. When involved with daily compulsive use driven by drug hunger and craving, addicts may accidently administer excessive amounts of the drug depressing the respiratory center of the brain with lethal results (Dole, Nyswander and Kreek, 1966). If contaminated needles are used, addicts can become infected with or transmit HIV, hepatitis and other pathogens (Novick, Joseph, Croxson et al, 1990; Novick, Khan and Kreek, 1986). The majority of heroin addicts probably can not hold down jobs and are dependent on street crime to obtain money for heroin (Courtwright, Joseph and Des Jarlais, 1989; Joseph and Dole, 1970).
In contrast to heroin, methadone is a long acting narcotic. When administered properly in a maintenance program, methadone has no mood altering effects and is effective orally, thereby eliminating the use of hypodermic needles. At adequate doses (usually over 60 to 120 mg/day), it functions not as a substitute euphoria producing narcotic but as a normalizer for a dysfunctional physiology (e.g., impaired endocrine and immune functioning), relieving narcotic craving and narcotic withdrawal symptoms. Although producing physical dependency, patients can be maintained indefinitely at the same dose level since tolerance remains constant. Patients have been maintained on methadone at the same dose level for about 30 years without toxic or long range health effects. The two minor side effects that have been reported are constipation, which subsides over time in treatment, and excessive sweating. Although some patients at the beginning of treatment complain about decreased libido, usually sexual functioning returns to normal within the first few months of treatment. Most importantly, socially rehabilitated methadone patients are protected from HIV infection (Dole, 1988 and 1980; Des Jarlais, Friedman, Novick et al, 1989; Kreek, 1973; Novick and Joseph, 1991; Novick, Joseph, Croxson et al, 1990; Novick, Khan and Kreek, 1986). The withdrawal syndrome associated with methadone is less severe than with heroin but more protracted, since methadone is a longer acting drug. The withdrawal syndrome, however, can be controlled by a slow reduction in dose if a patient wants to be withdrawn from the medication. However, as is with all narcotics there is a prolonged secondary abstinence syndrome that may last for long periods of time, or perhaps for the duration of the addict ife.
A major therapeutic advantage of methadone at high doses is its ability to block the narcotic effects of heroin and other opioids, including methadone itself, if the patient should administer non-prescribed opiates. Patients maintained at adequate doses can function without physiological or social impairment, provided they do not abuse other drugs such as cocaine, alcohol or benzodiazepines (Dole, Nyswander and Kreek, 1966). Since methadone maintenance does not produce overt narcotic effects, patients can function without detection of their opiate dependency and can be successfully employed within the full range of jobs and professions without impairment from the medication. Methadone patients can establish families, conceive healthy babies and lead essentially normal lives (Joseph and Appel, 1993; Joseph and Des Jarlais, 1980; Joseph and Dole, 1970).
Methadone Maintenance: A Stigmatized and Trivialized Program
Methadone maintenance is greatly misunderstood and has received extremely unfair coverage on television and in the press. The presence of clinics has been opposed in many communities, creating tension and conflict for patients that live and work in these communities. While the differences between heroin addiction and methadone maintenance are profound, methadone maintenance has been criticized and trivialized as "just substituting one addiction for another." The criticism and its many variations have denigrated the importance of the program (Zweben and Sorensen, 1988).
Media stories have usually concentrated on the sensational: patients who are dysfunctional, non-compliant, abusing drugs, loitering in the neighborhood near the clinic, selling their medication, homeless, chronically unemployed, or infected with HIV and drug resistant tuberculosis. Patients who are doing well and complying with the program are not highlighted for a number of reasons, including the fact that they do not make interesting or exciting copy. Because of the prejudice, many compliant patients avoid any publicity which could lead to personal stigmatization and loss of employment. Compliant patients usually conceal their status as methadone patients from employers, friends and even members of their immediate families with whom they live (Joseph and Des Jarlais, 1980; Novick and Joseph, 1991). They resent the regulations that they are required to adhere to and that were put in place to 'control' the dysfunctional patients. Compliant methadone patients are an example of patients in a double bind (Bateson, 1987). They are encouraged to be open and truthful in the clinic setting, but in their personal and business lives outside the clinic they are evasive and develop strategies to protect their confidentiality. Their past histories may include criminal behavior, in addition to their heroin addiction and current treatment status in a methadone program.
Literature Review
The major literature in this study deals with the problems of stigma related to methadone maintenance. This will include within the course of the study a review of selected of newspaper stories, books, and documentaries for television and movie theaters. As described by Erving Goffman (1963) in Stigma: Notes On The Management Of A Spoiled Identity, addicts are perceived as belonging to a particular category of stigmatized persons which includes alcoholics, homosexuals, criminals and people with mental disorders. Since methadone maintenance is considered "a substitute addiction," methadone patients in medical maintenance fall within this category. Furthermore, their stigma is invisible and they are, as Goffman describes, discreditable but not discredited persons. Some strategies that methadone patients adopt to conceal their status for fear of loss of employment, social ostracism and stigmatization have been described (e.g., concealing information from employers, not telling family members r friends) (Joseph and Des Jarlais, 1980; Murphy and Irwin, 1992).
Addiction is perceived as being self induced, rather than the result of injury or an inborn problem beyond the individual's control. This has an effect on the individual in terms of feelings of self worth and esteem (Crocker and Major, 1989) and the social perception of addicted persons. Conditions that are perceived as inborn or the result of incidents beyond the individual's control (e.g., accident resulting in loss of limb) elicit a degree of compassion while stigmas that are perceived as the direct result of a person's behavior are the target of social hostility and rejection. The stigmatization of methadone treatment is also reflected in the attitudes of patients and street addicts since an inaccurate folklore has developed that creates ambivalence towards methadone itself (e.g., it rots the bones) (Goldsmith, Hunt, Lipton and Strug, 1984; Rosenblum, Magura and Joseph, 1991).
Goffman (1973) in The Presentation of Self in Everyday Life, describes the strategies involved in the art of impression management. Methadone patients are constantly playing a role in which the management of impressions is paramount to their acceptance, namely "the normal person" who is not enrolled in methadone treatment. The major players who cooperate in this "disguise" are the patient, the program staff who will not speak to patients outside of the program, the physician who prescribes the methadone and those persons who the patients inform about their enrollment in methadone treatment.
Theories to explain compulsive addictive behavior can be placed in two categories. Addictive behavior according to Goffman (1963) is considered to be "blemishes of individual character, perceived as weak will, domineering or unnatural passions, treacherous and rigid beliefs, and dishonesty." These characteristics impute that psychosocial factors are the cause for the addiction. The second theory is derived from neuroscience and states that narcotic addiction or the daily compulsive use of narcotics has a metabolic origin (Dole, 1988 and 1980; Joseph and Dole, 1970). The belief about causality of addiction influences the formation of attitudes about addicts and the development of scientific theories (Mehan and Wood, 1975). Literature pertaining to methadone maintenance will be reviewed to develop a reliable scientific basis for claims of medical safety and the development of theoretical concepts about addiction (Dole and Nyswander 1965; Hartel, Selwyn, Schoenbaum et al, 1988; Kreek, 1988 and 1973).
This study will include a review of risk groups involved in opiate addiction in the United States for the past century, including the class and racial composition of the risk groups, the different theories of addiction, transformation of policy, and how these considerations interact to add to, or detract from the concept of stigmatization. Most importantly, the beliefs of a society find codification in statutes, law and policy that not only reflect, but encourage stigmatization, racism and discrimination (Brecher, 1972; Cooper, 1992; Courtwright 1982; Joseph and Des Jarlais, 1980; Mehan and Wood, 1975; Murphy and Irwin, 1992; Musto, 1992 and 1973).
Hypothesis for Study
With the relaxation of reporting regulations and the individualized treatment accorded patients in private medical practice, patients are better able to conceal their status as methadone patients. Medical maintenance, therefore, should reduce the anxiety of concealing an invisible stigmatized condition. The controls of regulatory agencies still exist in medical maintenance. However, they are concealed or reduced as in reporting schedules which are extended to monthly private medical office visits rather than weekly clinic visits. Medical maintenance helps patients conceal their status as methadone patients and therefore, further conceals the possibility of their exposure, ostracism and stigmatization.
Therefore, the hypothesis for this study is as follows:
For methadone patients in medical maintenance, the further concealment of their stigmatized condition in private medical practice enables them:
Methodology
To determine the extent to which this hypothesis holds, the following multifaceted strategy of analysis will be adopted.
Protection of Human Subjects
Approval to interview medical maintenance patients was obtained from the Institutional Review Board of the Beth Israel Medical Center. However, limitations were placed on information obtained in the interviews. The Institutional Review Board of the medical center and the physicians who were involved in this study are acutely aware of the stigmatization of this particular group of patients. The hospital did not permit this worker to interview patients who were both discharged for cause from medical maintenance and who were being treated in methadone clinics operated by the hospital. The interviews may prove to be embarrassing or traumatic for these particular patients. A compromise was reached. For patients discharged for cause, the medical director of the program would relay the patient's current adjustment without revealing the name, age, ethnicity or clinic of treatment. Since tapes were being used for interviews of patients in good standing, names, dates, birth dates, addresses, locations, names of hospitals and programs or any specific identifying information that could link a patient to a program or reveal identities could not be recorded.
Selection of Patients for Interviews
Originally a specific procedure was submitted for interviews. Every other alphabetical name was to be interviewed from the physician's records. However, this procedure had to be dropped since many patients chosen for the study refused to be interviewed. A convenience sample was then adopted. The physician explained the study to a patient with the provisions that names, ages or other identifying information would not be recorded. Those who wished to be interviewed were referred to this investigator who was in the physician's waiting room when a methadone patient was scheduled for an appointment. Forty-four patients were recruited in this manner. However, since they were employed and the researcher was unable to contact them by phone, the interviews had to be completed within about a half hour in an empty room in the hospital or in a secluded part of the cafeteria. The patient was permitted to answer freely and elaborate on his or her experiences but the interviews with medical maintenance patients were limited to the following areas.
1. Completion of a Perception of Stigma form.
2. Opinions about treatment in regular methadone clinics contrasted to treatment by a private physician in the medical maintenance program.
3. Whether being a methadone patient is a stigmatized condition and if so, how is this dealt with by the patient?
4. How has medical maintenance changed the patient's life and has it reduced the stigma?
5. If time permitted, the patient was asked to comment on certain slogans or statements that may or may not convey stigma: the term methadonians; methadone is just substituting one addiction for another; methadone takes your heart; methadone is a technological fix.
Significance of Study
This is the first in depth investigation of the problem of stigma directed against methadone maintenance patients. In this study, the initial chapters describe the social and historical implications of stigma. The final sections examine the effects of social stigma on the behavior and attitudes of a particular focal group socially rehabilitated methadone patients who are treated for addiction with methadone in private medical practice as opposed to highly regulated neighborhood clinics. A type of quasi-normalization has occurred that has implications for theories of addiction, of "passing" within a society and treating opiate dependency in private medical practice.
Central to this study are the attitudes that the public and physicians harbor towards methadone patients. For example, is there a difference in the perceptions of the doctor prescribing methadone to a patient in general medical practice to control a character flaw as opposed to normalize a dysfunction of the opiate receptor ligand system in the central nervous system? How do beliefs affect attitudes and medical decisions about patients? How do the patients perceive their condition, and the differences between being treated in a clinic and private practice?
This study also has important implications for public health. The successful treatment of socially rehabilitated methadone patients in private medical practice can potentially increase the number of patients treated with methadone. The stigmatization of methadone treatment has been a major factor in preventing a large scale expansion of the clinic program to treat an estimated 750,000 opiate addicts in the United States. Only 115,000 (15%) are in treatment. Stigmatization of methadone treatment has resulted in strong community opposition to the opening of new clinics. Within the last fifteen years in New York City only two new clinics have been opened, one that exclusively treats about 85 HIV infected patients in mid-Manhattan and another that treats about 350 patients in the South Bronx community. Thus, stigmatization has had a negative effect on the planning and expansion of addiction treatment, notwithstanding efforts to reduce the transmission of HIV and drug resistant tuberculosis.
As previously noted, methadone patients bear an invisible stigma. With further concealment of their methadone treatment, it is hypothesized that methadone patients can further enhance their social rehabilitation and in the process reduce the stigma associated with methadone maintenance treatment. The final conclusions and discussion will examine the findings and the validity of the hypothesis. Recommendations will be made concerning the expansion of medical maintenance, policy, areas of needed evaluation research and strategies for reducing the social stigma associated with methadone treatment and patients.
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Last Update: March 15, 2001 |
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