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Chemical Dependency Research Working Group |
The effects of stigma and the question of what constitutes a medical condition affects the treatment of methadone patients. These issues involve the value systems which physicians adopt and affect their perceptions and understanding of conditions presented by patients. There is a difference in concept and attitudes towards patients depending on whether methadone is prescribed to control a character disorder or to normalize an aberrant physiology. Is addiction a legitimate illness? How does this question influence the dose of medication prescribed, the duration of treatment recommended for a particular condition and the attitudes towards patients. In this section, interviews with Dr. Dole, the co-developer of methadone maintenance and others, including patients, will deal with the effects of stigma on the treatment of methadone patients within the medical profession. The article about addiction and methadone treatment by Jaffe (1990) in the basic medical and pharmacology text by Goodman and Gilman is a straightforward description of opiate addiction and the role of methadone treatment. Jaffe reports the metabolic basis of addiction as hypothesized by Dole and Nyswander and the role of methadone as a legitimate therapeutic intervention to relieve craving. Notwithstanding Jaffes article, stigma against methadone treatment and the patients persist.
The Institute of Medicine (1995) recently issued a sober report about methadone maintenance. This report while not directly addressing stigma should resolve many of the biases that are found within the professions. The following is a quote about the report by Yarmolinsky and Rettig (1995):
"Methadone is a weak opiate that does not induce drug euphoria. When properly used, it reduces or eliminates the craving for opiates and reduces the symptoms of opiate withdrawal.
Because methadone does not produce the high of other opiates the risk of its being diverted for illegal uses is very low. It is generally not an abused drug, and there is no evidence that it has been the object of organized crime drug trafficking. Most of what is diverted from licensed treatment programs appears to go to addicts who are trying on their own to manage temporary withdrawal from heroin."
Stigma, A Limiting Factor
Interview with Dr. Vincent P. Dole
Dole (1994) in an interview discusses the effects of stigma on attitudes towards addiction and methadone treatment within the medical profession.
Question: When you first began studying addiction were you aware of any stigma that was directed against this population within the medical profession?
Answer: "Stigma was a limiting factor because I soon found out that nobody among my friends in the medical profession was interested in addiction as a medical topic. They saw it primarily as a behavioral deviation and its management was the responsibility of the enforcement agencies. I grew up in a medical world quite ignorant of anything to do with the physiology of addiction. Of course the medical school curriculum had no courses and the people who taught were uninformed about addiction. The only people who had any contact with this problem were the pharmacologists who studied the pharmacology of addictive drugs. They studied addiction through animal experiments and under rather artificial conditions. They had no clinical contact. The efforts that I made in the early days (1960s) to arouse peoples interest to study narcotic addiction were quite futile. Nobody was willing to give the effort and thought to study addiction as a disease. Marie (Dr. Nyswander) in the 1950s tried in her way as a solo person to set up treatment for addicts. She was harassed by the Bureau of Narcotics who saw her efforts as an invasion on their authority. Generally speaking, it was assumed that addicts were persons with histories of criminal activity and their management was controlled by law enforcement agencies. If there was any medical intervention it would be only in the context of being at the Public Health Hospital in Lexington, Kentucky under lock and key."
Dole and Nyswander (1967) published the article, "Heroin Addiction: A Metabolic Disease," in which they proposed an alternate theory for narcotics addiction: the craving for heroin in an extended addiction may be symptomatic of a metabolic dysfunction within the central nervous system rather than a psychological aberration.
Question: What was the response to the paper, "Heroin Addiction: A Metabolic Disease?"
Answer: "Surprisingly negative on the part of the medical profession. It was not regarded seriously, it was regarded as sort of a story and not reality. The medical profession took as an axiom that using drugs was a sign of psychiatric disturbance. ... it was unquestioned by virtue of the medical profession that this was a disturbance of behavior or some sort of character defect or weakness of will and the only cure that could be accepted was total abstinence."
Dole (1992) indicates that: "..for the majority of physicians, teachers and practitioners of the past generation, addictions were moral problems, a sign of depraved character, not diseases. This attitude is still prevalent. However, it is not likely to persist in the mainstream of medicine beyond this generation. A judgmental attitude is inconsistent with the current advances in neurobiology."
The attitudes that Dole described as prevalent in the 1960s are still prevalent years after clinical and neuroscience research began. An example of trivialization of Dole and Nyswanders work may be found in journals, prestigious books and in statements by physicians themselves.
The most often quoted criticism of methadone maintenance is that "it just substitutes one addiction for another" or, in another form, "one drug for another." This criticism implies erroneously that patients are in effect receiving a legal high or methadone euphoria. The simplicity of the statement reveals an inability to differentiate clearly between a heroin addict and a stabilized methadone patient. The statement is an example of Millers (1974) conceptualization that the primary and secondary deviance of heroin addiction has been transferred as tertiary deviance to methadone patients and methadone treatment. Although this criticism was first published in 1966 by Dr. David Ausubel in the Illinois Journal of Medicine, it is still levelled at the program with stigmatizing effects for both the patients and the program. The article was reprinted for widespread distribution in 1968 by the New York State Narcotic Addiction Control Commission. The purpose was to garner support for the New York State Civil Commitment Program, one of the most expensive failures in the history of public health in New York State.
In this article, Ausubel (1968) advocated closed ward commitment of addicts as the most humane and effective treatment for heroin addiction. Ausubel did not understand the stabilization process and the development of tolerance to the narcotic effects of methadone in a maintenance regimen. Therefore, he attributed the reported success of methadone maintenance "to the free methadone euphoria" dispensed by Dole and Nyswander. He trivialized the regimen by putting the word treatment in quotes and went on to attack the publication by Dole and Nyswander (1965), a progress report on the first 22 patients who had been maintained on methadone from about 1 to 15 months. The patients doses were reported, their duration of treatment and their jobs. The data were clearly and honestly presented but were attacked by Ausubel in almost hysterical and vituperative language. Ausubel inferred that Dole and Nyswander did not know what they were doing and were no more than unscientific publicity seekers.
In his classic book, The American Disease: Origins of Narcotic Control, Dr. David Musto (1973), the medical historian, devoted little more than perhaps two and a half pages to methadone maintenance. Although he appears to favor methadone maintenance, Musto also trivializes the use of methadone by placing the phrase medical treatment in quotes. He subtly rejects the idea that this is a medicine for heroin addiction in the following statement:
"... methadone maintenance helped create favor for "medical treatment" of heroin addiction. From the care with which it is dispensed, the public appears to believe that methadone is a medicine like an antibiotic rather than what it is - a synthetic and addictive morphine substitute discovered by German scientists in World War II."
This statement inherently promulgates the stigmas associated with methadone treatment and opioid addiction with all of its connotations: German Nazi research, methadone is not real medical treatment (since the phrase is stated in quotes), and finally methadone is not a real medication but a narcotic. Mustos clear exposition incorporates the basis of the very biases that cause stigma for many successful patients. The view of Musto is refuted by methadone patients and will be dealt with in a later chapter.
The rejection of drug addiction as an illness and the "Nazi" connection to methadone, was alluded to by the psychiatrist, Thomas Szasz (1986: 101) in the following misguided statement:
"After all, not only the whites, but most of his own black people (referring to Malcolm X) and all of the black leaders, believed " and continue to believe " that drug abuse is an illness. That is why they demand and demonstrate for "free" detoxification programs " and line up for methadone programs like Jews did for the gas chambers."
In the above statement Szasz distorts the reality in African American communities. Methadone treatment as previously discussed is looked upon with ambivalence. Its rejected by many African American leaders and accepted by others. Furthermore, the allusion to Jews lining up for gas chambers and comparing this horrendous genocide to minorities receiving methadone treatment is a distortion that belies comment. Methadone maintenance is not genocide. Overall it has saved thousands of lives, reduced crime, increased productivity, improved health and successfully prevented the transmission of HIV for the majority of patients who entered and remained in treatment.
In another statement Szasz (1986: 102) reveals that he regards methadone simply as an addiction to control dissidents.
"The Russian tries to narcotize its dissidents with alcohol, tobacco, work and Communism; when these fail ..... it deals with them accordingly by incarcerating them in prisons or insane asylums. Similarly, the American government tries to narcotize its dissidents with alcohol, tobacco, work, money and methadone; when these fail ..... it deals with them accordingly, by incarcerating some in prison, others in mental hospitals, and putting the rest on "methadone maintenance."
Szasz is against all drug laws and rightfully argues against the excesses of certain laws that have created classes of criminals, over crowded prisons because of harsh sentences and serious social problems. He is also an advocate for legalization of heroin. However, his perception of methadone treatment is distorted in his attempt to create a logical argument for his position. Methadone maintenance is not a medical procedure in Szaszs conceptualization but a means of social control by narcotization. Social control is a danger in methadone maintenance that has been resisted by patients. However, patients have accepted methadone because of its valid therapeutic qualities. Szasz does not perceive of addiction as a metabolic disease independent of the social circumstances of drug availability (legal vs. illegal). That a psychiatrist of the caliber of Szasz would make such incredulous statements reveals an ignorance of methadone maintenance, the differences in the pharmacology of opiates (long vs. short acting), the years of research and evaluation on methadone maintenance, and a profound ignorance of heroin addiction itself. That a man with Szaszs acknowledged leadership is unable to assimilate and abstract conceptually the concepts of addiction and maintenance shows how an ideology can distort perception and understanding. There is probably no procedure in all of modern medicine that has been subjected to such scrutiny as methadone maintenance and has aroused such feelings of hostility, revulsion and rejection.
Effects of Stigma on Dose and Delivery of Services
The attitudes prevalent in the medical profession against the concept of addiction as a legitimate disease are seen as impeding the delivery of necessary services to stem the transmission of HIV. Cooper (1992) addresses these issues and reviews doses of methadone prescribed to approximately 100,000 patients nationwide in surveys conducted by the National Institute on Drug Abuse. Approximately half of the patients are receiving inadequate dses of 55 mg/day or less with about 25% receiving doses under 40 mg/day. About 50 percent of the programs encourage patients to withdraw prematurely within six months. Also, several states do not permit long term treatment of nonmalignant pain with opiates. For example, New Hampshire has legislation prohibiting the prescribing of methadone for pain and maintenance. Cooper attributes these counterproductive practices to attitudes within the medical profession itself. Certain conditions are not viewed as legitimate medical disorders. Drug hunger, depression and fear may be associated with "a weak will." "Cures" and legitimate therapy are associated with the "building of a value system" and strengthening the patients "will power." Patients with symptoms perceived as volitional are regarded with bias, stigmatization and subjected to feelings of shame. The symptoms of their illnesses such as drug craving are dismissed as trivial. Hence patients are under medicated and encouraged to leave treatment prematurely. These practices, based on prejudices, rather than scientific studies and evaluation research are hampering the delivery of adequate methadone treatment to prevent the transmission of HIV.
Coopers comments have direct applicability within the staffs of methadone treatment programs. In Washington, D.C., Brown, Jansen and Bass (1974) studied attitudes of staffs in methadone programs. One of their conclusions is as follows and reflects Coopers concern about staff attitudes, biases and moral judgements:
"Essentially, staff attitudes appear to reflect a basic ambivalence regarding methadone treatment. Methadone is of positive value in that it helps clients become independent of the drug heroin, but long term maintenance on methadone is not a desired end state. Rather it is seen as suggesting a certain lack of personal integrity on the part of these clients as compared with clients who have become abstinent. It is as if "treatment" or "cure" is incomplete until the client is completely drug free."
There are other reports in the literature that corroborate the findings of Brown, Jansen and Bass. A counselor, Greg Gordon (1994) at a Seattle based methadone program places methadone maintenance in an adversarial relationship to what he considers treatment. Treatment is considered therapy (12 step, group therapy, etc.) that restructures the patients life to enable withdrawal from methadone. The dose level to achieve blockade is questioned despite research that has shown blockade doses at least at the beginning of treatment are most effective. Withdrawal from methadone over a period of six months to two years is recommended. Long term methadone is seen as a last resort for specific groups of patients " repeated failures, pregnant women and persons with health problems.
A second example of the concerns that Cooper writes about is incorporated in an article by Bratter and Pennacchia (1976). In this article the metabolic theory of addiction is seen as a negative concept for patients who want to be withdrawn. The second author presents himself as an example of a patient who withdrew from the medication and then entered Daytop Village, a therapeutic community for what he considered treatment. Neither Gordon or Bratter and Pennacchia have data to back up their theories or approaches. However, studies by Caplehorn and colleagues (1993) showed results contrary to the expectations and opinions of Gordon, Bratter and Pennacchia. The study involving 227 patiens referred by a team of psychiatrists and psychologists to what they considered appropriate treatment " either an abstinence oriented methadone program or an indefinite maintenance program. Both programs were staffed with professional general and psychiatric nurses for counselling and a medical officer. The conclusion of the study is as follows (Caplehorn, 1994):
"... investigations have found that heroin addicts assigned to the abstinence-oriented program were progressively more likely to leave during the first 2 years maintenance and as a result, were more likely to be arrested than those assigned to the indefinite maintenance program. ...addicts assigned to abstinent-oriented treatment were more likely to use heroin and inject drugs while in treatment and more likely to relapse and return to maintenance after discharge. The abstinence-oriented program was also less able than the indefinite maintenance program to attract heroin addicts into treatment. It is recommended that methadone programs abandon abstinent-oriented treatment policies and, instead, offer heroin addicts long-term maintenance."
The ambivalence expressed about the effectiveness of long term treatment by the staffs of the programs investigated by Brown and the articles of Gordon, Bratter and Pennacchia are of concern since data from reliable studies show long term treatment to be more effective than abstinence oriented treatment.
Miller (1974) indicates that the tertiary deviant status of methadone treatment and its "semi-stigmatized" state produce a cognitive and social dissonance among staff and patients. There are patients who have educated themselves about methadone, addiction and theories of addiction to a greater extent than most counselors, nurses and physicians in the clinics. These patients have become frustrated in their dealings with a clinic staff whose philosophies (e.g., short term, abstinent treatment) may be destructive to their best interests. One such patient who is a former student from an Ivy League university indicated the following:
"...my opinions of methadone and the programs that administer it could not have been farther apart. Methadone itself had been a Godsend, literally saving the lives of myself and my friends, allowing us to reclaim ourselves and rejoin society. I had every reason to believe that given continued access to methadone, I would be able to lead a full and healthy life - a life indistinguishable from those of normal people. Of the clinics staff and policies however, I could not have had lower expectations. By and large, they succeeded in demeaning and dehumanizing their patients, mixing open disdain for the treatment they dispensed with such ignorance that many patients came to feel trapped by a poison worse than heroin. While some staff members showed genuine compassion for their patients and a few were even good therapists, even these exceptions demonstrated such a lack of understanding of methadone as to negate their good intentions. The system seemed hopeless and I resigned myself to the fact that any progress I made would be in spite of it, not because of it. That counselors working for methadone maintenance programs would feel this way confused me until I learned that the vast majoriy of counselors who had themselves been addicts were graduates, not of methadone programs, but of anti-methadone therapeutic communities and twelve step programs."
Umbricht-Schneiter and colleagues (1994) compared methadone patients who were treated in a methadone clinic for various medical conditions other than addiction to methadone patients who were referred to mainstream medical clinics for treatment. The site (methadone clinic or mainstream clinic) of treatment was randomly selected. It was found that 92% of the patients treated on site in their methadone programs received medical treatment as opposed to 35% of the referred group. The reasons given for the differences between the two groups are:
In this study, the referred group received adequate instructions about procedures to register, and all financial obstacles were removed. Nevertheless, only a minority received treatment in the referred system.
Dr. Umbricht-Schneiter (1994) was contacted and indicated that there appears to be a great deal of stigma directed against methadone patients within the medical profession. She states that addiction is not taught in medical school and that physicians are not aware that this is a medical condition related to opiate receptor and endorphin dysfunction within the brain. She is aware of the bias towards patients within the medical profession and the fears of patients. Dr. Umbricht-Schneiter indicated that stigma against patients was an undercurrent in her study. She admits that she herself was once abusive to methadone patients by misinterpreting their behavior before she became aware of the biological factors that are involved in an addiction. Dr. Umbricht-Schneiter related that a patient from her clinic was referred for breast surgery, and the hospital did not provide post operative pain medication. This, she indicated, "...is ignorance, and physicians have to be educated." She also advised that patients are aware of the anti-methadone attitudes of physicians. She herself lectures to physicians about addiction and treatment trying t change attitudes and practices since information about methadone may not be available to the average physician.
Patient Interactions and Experiences with Physicians
Methadone patients have had a variety of experiences with physicians. Some have been good but unfortunately the vast majority of the experiences have reflected prejudicial attitudes by the physician and ignorance about medical procedures involving methadone, as noted by Dr. Umbricht-Schneiter. One patient who revealed his methadone status to an examining physician in a hospital was faced with an abrupt change of attitude:
"Ill never forget this. I went to the local hospital because of pains in my chest. When I told the physician that I was on methadone, his attitude abruptly changed. He told me that "all I wanted was drugs" and "to get the hell out of here and if you dont leave immediately Ill call a cop."
The physician obviously thought of this patient as an untreated drug addict while in reality he was a very successful business man and a model methadone patient.
Another methadone patient and the vice president of NAMA was hospitalized in a Manhattan hospital for gall bladder surgery and was not given adequate post operative pain medication when the physician learned she was a methadone patient. "He thought that my methadone dose would relieve the pain. I was in agony and he did not believe me." That methadone patients do not need pain medication is a commonly held misconception about methadone among physicians.
Methadone patients who are employed in the health care professions in hospitals report that there is widespread prejudice against patients by doctors and nurses. Three health care workers maintained on methadone and employed in different hospitals commented on the widespread stigma against methadone patients. One patient is in a graduate program in health care maintaining an 3.85 average reported the following:
"In my class methadone is put down as a treatment. I just have to sit and listen. They describe patients in the most derogatory way " referring to methadone patients as "methadonians." I also hear methadone patients referred to as "methadonians" in comments in the hospital where I work. Some of the worst people with the most negative attitudes towards methadone patients are in the medical profession. They treat methadone patients very badly. It is very difficult for me just to listen. I get very angry and do not say anything.
Not all doctors are that way. My old dentist knew that I was a methadone patient and treated me very well. He was understanding. My new dentist is not very understanding. However, I had a physician for hepatitis C. He thought I contracted it on my job and was very sympathetic. I told him I was a methadone patient since I may not have contracted the virus on my job. I really dont know when I contracted the hepatitis. His attitude changed immediately " It was like Dr. Jekyll and Mr. Hyde. He thought I was dirty - under his foot. I told my medical maintenance doctor and he is referring me to another liver specialist who understands methadone."
Another methadone patient who is a health care professional employed for years in a suburban hospital is applying for medical maintenance. She stated that methadone patients are treated very poorly by staff and sometimes referred to as "animals." She relayed the following about a physician with whom she worked but who did not know that she was a methadone patient:
"A patient came to the department for an examination for a surgical procedure. He tried to explain to the physician that he was a methadone patient. The doctor stated that he did not want to hear about that since he was here only to treat the patients hip. When the patient tried to explain to the doctor that he had to know about the methadone, the doctor told him that probably he had the wrong doctor. After the patient left the doctor remarked to me, "Can you imagine these animals getting on methadone?""
A third health care worker was interviewed. She verified that anti-methadone attitudes were prevalent among doctors and nurses. She indicated that most doctors are not trained about methadone and therefore may be ignorant about pain and proper dosing procedures. She has heard the term methadonians frequently used to refer to methadone patients. She relayed the following:
"About two years ago in a Manhattan hospital, I noted a patient that was tied in a restraint. It turned out that he was a methadone patient and was not given methadone for three days. I got very angry and when I spoke to the nurses they brushed the matter off stating that he was difficult to treat and they referred to him as an animal and that it was his fault that he was an addict. I told them that he should be medicated and when he was, he turned out to be a very cooperative patient. I then turned to the nurses and said "who is the animal now."
A patient with a chronic thyroid condition stated that one of the ways she "determines a quality doctor is by his attitude towards methadone treatment." If she informs a physician that she is on methadone and the physician attributes all of her medical problems to the methadone, she knows that the physician is either ignorant about methadone or may be biased in his attitudes. Her current physician is aware of her enrollment in methadone treatment and is currently treating her thyroid condition without requiring her to detoxify or change her dose. This patient is also a counselor in a methadone program. One of her patients in the clinic has AIDS. He was told by the physician who is treating him for AIDS to withdraw from methadone since methadone lowers immune functioning. She told her patient that this was not true, and that he should get another opinion before he makes a decision.
Methadone patients are concerned about their confidentiality in medical matters and the way they will be accepted by physicians and dentists. However, their decision to withhold information about their enrollment in methadone treatment can have dire consequences. Physicians in medical maintenance are sensitive to the concerns of the medical maintenance patients and usually work with other physicians if their patients have serious or chronic problems. However, sometimes emergencies arise and the patients may become ill, go to an emergency room and not reveal that they are enrolled in methadone treatment. One of the physicians in medical maintenance relayed that one of her patients complained of pain went to a local hospital, did not inform the medical staff about his enrollment in methadone treatment and was administered narcan, a painkiller classified as an antagonist drug. Antagonist drugs precipitate the withdrawal syndrome in opiate dependent people. Therefore, it is contraindicated for methadone patients. After the administration of narcan, the patient went into acute narcotic withdrawal.
Stigma from Advocates of Alternative Medications
Advocates of alternate medications for the treatment of opiate dependency present their viewpoints by denigrating methadone maintenance treatment or the population that chooses to enter methadone treatment. As an example, the drug naltrexone has been introduced over the years as an effective medication for the treatment of narcotic addiction. Naltrexone is a medication that was developed by DuPont. It essentially blocks the effects of heroin if tried but it does not relieve the craving for narcotics. The patient feels the need for opiates but is unable to address this need. Naltrexone has not been accepted by most patients. There are some side effects such as dysphoria and nausea. The drug stimulates the hypothalamus-pituitary-adrenal axis and precipitates withdrawal symptoms in the acute phase of narcotic withdrawal. The drug, in the opinion of this writer, also exacerbates the secondary withdrawal syndrome. Patients have complained that it has exacerbated drug craving. Relapse usually follows cessation of naltrexone treatment (Azatian, Papiasvilli and Joseph, 1994). It is estimated that about 15% of the heroin addicts will respond to this drug. The medication is stated to be effective only for motivated addicts who do not want to get high. Published studies acknowledge a high drop out rate (Azatian, Papiasvilli and Joseph, 1994). However, addicted physicians who are threatened with loss of their medical licenses, middles class suburban addicts and addicted parolees are reported to do well on this medication (Greenstein, Fudula and OBrien, 1992). The medication, therefore has been marketed for motivated, educated and employed addicts (Resnick, Volavka, Freeman and Thomas, 1974). The inference is that methadone is for addicts who want to get high or who are not motivated. This immediately places a stigma on those patients who choose to enter methadone treatment. Conversely, patients who choose naltrexone are more "motivated." There are no large studies over a period of two or more years in the literature that validate the claims of physicians who advocate naltrexone maintenance for certain groups of "motivated addicts."
Conclusion
Stigma within the medical profession directed against methadone patients appears to be widespread. Dole indicated that addiction was not taught as a subject in medical school nor is it taught in medical schools today. When it is taught there is the possibility that it may be presented simply as substituting one addiction for another. In the 1960s, addiction was considered a moral or behavioral problem and Dole found that stigma was a limiting factor since he was unable to galvanize interest in the subject as a legitimate study. In 1995 the same situation exists. Physicians are not taught in medical school about addiction or the use of methadone as a therapeutic intervention. However, with the emergence of neuroscience, Dole feels that the stigma will be reduced since a judgemental attitude is incompatible with findings of current brain research and that addiction will be considered a metabolic disease.
Methadone patients currently face widespread ignorance and bias within the medical profession which may result in the denial of methadone or adequate pain medication when they are hospitalized. Also, methadone patients may experience sudden rejecting attitudes when the physician learns that the patient is enrolled in methadone treatment. They are treated like virtual heroin addicts which is a result of the tertiary deviant status of methadone treatment as described by Miller (1974) and the resulting stigmatization.
These attitudes based on moral judgements have impacted negatively on prescribing practices " ineffective low doses of methadone, premature discharge from treatment and inadequate prescribing of pain medication. Educated and knowledgeable patients find program staffs uneducated about methadone. Staff opinions about the effectiveness of short term abstinence-oriented methadone treatment are not born out in a major study evaluating short term abstinence oriented vs indefinite methadone treatment. The moral attitudes about addiction and methadone treatment appear to prevail to the detriment of patients. Public health issues are also involved since adequate methadone treatment can blunt the spread of HIV. However, current practices minimize the potential therapeutic effects of methadone treatment. A vast educational campaign is indicated that would introduce neuroscience and the findings of rigorous evaluation studies to change attitudes within the medical profession and staffs in clinics.
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Last Update: March 15, 2001 |
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