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Chemical Dependency Research Working Group |
The effect of stigma on policy and regulations will be discussed in this chapter. In essence, methadone regulations are extensions of the narcotic laws passed on federal and local levels prior to the establishment of methadone treatment. These laws were enacted to control a perceived dangerous population that threatened the survival of values within capitalism. During the early post-World War II period the international distribution of narcotics was regarded as a "communist conspiracy" linked to Red China. In the 1960s, civil commitment of addicts was implemented in California and New York to institutionalize addicts legally (Joseph, 1988). The diversion of methadone and questionable prescribing practices by a few unscrupulous physicians in the late 1960s and early 1970s served as an impetus to pass restrictive legislation regulating methadone treatment at every level of government. The over restrictive nature of these regulations has elicited the following response from the Institute of Medicine (1995):
"Current policy ... puts two much emphasis on protecting society from methadone and not enough on protecting society from the epidemics of addiction, violence and infectious diseases that methadone can help reduce."
Stigma and Social Policy
Dr. Enoch Gordis (1991), the Director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), in an essay about the relationship between science and public policy, cites methadone maintenance as an example of "Good science, but policy obstructed." He states:
" the widespread provision of methadone-maintenance therapy for narcotic addiction is a policy that does not lack for scientific justification of its effectiveness. Nonetheless, it is a policy that has been blocked by many obstacles since its introduction as a therapeutic technique for narcotic addiction. ....Part of this battle has to do with a failure to educate the public about methadone, a very complex educational challenge."
He identifies the following four groups of obstacles that impede the acceptance of the expansion of methadone treatment in the face of an expanding AIDS epidemic:
According to Gordis, these concepts influence the thought and action of government policy makers and administrators. He cites, as an example the report of the 1988 White House Conference for a Drug Free America. With all of the research that has been completed on methadone, an intelligent group of people came to the "incredible recommendation" that the only treatment for narcotics addiction that required a "thorough new evaluation was methadone maintenance!" Gordis emphasizes that, no other treatment in alcohol and drug abuse has been as extensively evaluated or showed such consistent results. The results of evaluations for drug free programs are "far thinner and much less convincing." He sums up his observations with the following statement:
"Once again we see a group of intelligent, well meaning people being swayed by a combination of the stigma of addiction and the failure to understand the complexities of methadone maintenance."
Funding Allocations
In the 1980s about half the admissions to methadone treatment were infected with the human immune deficiency virus and during the cocaine/crack epidemic it was estimated that about 60 percent of the admissions were dually addicted. New patients also presented serious social problems such as homelessness and chronic unemployment endemic to minority groups within the inner cities (Joseph, 1992). The counselor to patient ratio was funded 50 to 1 (Corradi, 1994). Other drug and alcohol programs were funded at ratios of patients to staff of 30 and 20 to 1. Although AIDS counseling was provided in methadone programs, the counseling ratios and legislative monies allotted to the programs reflects another aspect of stigma since programs were being discriminated against by the lack of funding and services that should have been provided. In summation other social service, drug free programs, therapeutic communities and alcohol treatment programs are more generously funded although they had never been subjected to the rigorous evaluations that methadone programs underwent since its inception. Most importantly, these programs were never able to demonstrate the same type of successful outcomes as methadone treatment with large groups of patients over long durations of time.
Clinic Regulations
Experiences with a few unscrupulous physicians in the 1970s gave the federal government the rationale to regulate methadone treatment. Also, other abuses came to light on the street level. Methadone was sold by poor unemployed patients on the streets who diverted some of their medication to the "black market." Diverted methadone was sold primarily to untreated addicts (Galea, 1994, Institute of Medicine, 1995). Primary methadone addiction has not emerged as a public health problem since the mood altering quality of methadone for non-tolerant persons is dull as compared to the rush and euphoria of heroin. The DEA regard methadone as a euphoria producing narcotic and a major diversion issue. The Institute of Medicine (1995) has seriously questioned the claims of the DEA and from available data concludes that methadone diversion is a "relatively small part of the drug abuse problem generally." Furthermore, the Institute of Medicine indicates that data to support the allegations of the DEAs concern about widespread methadone diversion "are not available" and "... it is impossible to arrive at a clear assessment of any potnetial public effects of diverted methadone."
Emergency room episodes involving controlled substances show that methadone ranks last of the 20 controlled drugs monitored by the Drug Abuse Warning Network (DAWN). Furthermore, some of the methadone mentions in the DAWN report may include methadone patients who may have used the emergency room for legitimate medical conditions not related to the use of drugs (Institute of Medicine, 1995).
Instead of expanding and improving services, the federal government instituted a multi-tier regulatory process though the following three agencies (Institute of Medicine, 1995):
Additional tiers of regulations have been created by individual states, counties and municipalities. These multi-levels of regulation have been instituted to control diversion by dysfunctional patients (Molinari, Cooper and Czechowicz, 1994). However, all patients are subject to these regulations irrespective of their adjustments and level of social functioning. These regulations could be seen as the successors to the numerous narcotic laws passed by the federal government, states and localities since the Harrison Narcotic Act of 1914. In effect methadone patients are placed by these regulations under more strict supervision than convicted probationers and parolees.
The Effect of Regulation on Compliant Patients
Regulations govern every aspect of treatment (admissions, staffing, record keeping, treatment plans, reporting requirements for patients, frequency of urine testing, dose ceilings, amount of methadone a patient is allowed to take home, amount of time a patient can travel with methadone, etc.). State and municipal regulations may be more restricting than the federal regulations and even contradict them: patients must report seven days a week, ceilings on maximum dose which are lower than the recommended effective dose and time limits on the duration of treatment are some examples. Methadone treatment cannot be obtained in 10 states (11 if you include upper Michigan) and one state, New Hampshire has made it illegal to prescribe methadone to treat addiction and chronic pain (Lowinson, Marion, Joseph and Dole, 1992).
These regulations affect every aspect of the patient's life: personal and business travel are restricted, the patient must report at least once per week to clinics within set hours that may conflict with work, home responsibilities and education. Furthermore the patient must urinate on demand if randomly picked to do so. The clinic physician is also bound by these rules and must request permission to prescribe methadone above certain amounts if the patient feels uncomfortable, has a medical condition, or taking a medication that accelerates the metabolism of methadone (Lowinson, Marion, Joseph and Dole, 1992).
Dole (1994) has the following to say about the regulations and its relation to stigma:
"By the time the early 1970s arrived the methadone program was treating thousands of people around the country and several national methadone conferences had been held. It was clear that the fiction of it being an investigational program had passed and one would have to face up to the reality that it was an established program that had been thoroughly evaluated. It was clear medically that it was the best available treatment for narcotic addiction. So we were forced into the position of letting this now be brought into the new drug category as opposed to its previous investigational status. This now opened the way for anti-methadone forces to converge from the Bureau, now transformed into the Drug Enforcement Administration but staffed by the same people, and competitive drug free programs and others, all converged on the fact that methadone should be eliminated. If it couldn't be eliminated then it should be contained in a very rigid package. So without any consultation with us, the primary treatment program, a group from the Food and Drug Administration, the Drug Enforcement Administration and various other agencies set up the most rigid set of protocols that have been experienced in the field of medicine. An unprecedented invasion of medical responsibility. In all respects programs were restrained to a certain format dosage, objectives which radically changed the nature of the program and many became punitive.
Now on the stigma side, patients in the early years of the program, from 1964 to 1972 or so, were proud to be in methadone programs. They saw how much they had accomplished and were proud that they had jobs and took care of their families. They were often times proud to discuss their progress with medical people who visited the program. However, the pressure from the federal government early in the 1970s translated into oppressive rules which began to transform the programs. Also, the type of doctors that were willing to work in them were themselves abstinence minded and saw methadone as a crutch that should be thrown away."
Dr. Dole's observations were corroborated by several employed patients in medical maintenance. Programs are now subjected to audits by inspectors from various agencies who never see a patient. Also the inspections have little or nothing to do with quality treatment or program outcomes but with conformity to regulations that can be cited as violations. Therefore, in order to survive, a major objective of programs is to conform to the regulations of various agencies by developing forms and record keeping that are acceptable to inspectors. The regulations made the programs less flexible and the rigidities imposed by the regulations affected counseling by staff. The following statement issued as a petition to the administration of the methadone program at Beth Israel Medical Center by the Committee of Concerned Methadone Patients (CCMP), a organization that preceded the current National Alliance of Methadone Advocates (NAMA), highlights the effects of the newly imposed federal regulations on the adjustment of patients and the counselling that emphasized control rather than rehabilitation.
"Re: Commentary on Our Program
It is our considered opinion that were we to enter into treatment today, we would most certainly not succeed. In fact, given today's restrictive and repressive conditions, we probably would not even apply for treatment.
In general, we can say with certainty that the program is being operated for the convenience and benefit of staff rather than the patients. Patients are treated disrespectfully. Psychological and health needs are being met minimally, if at all. Common courtesy is more forthcoming from strangers than staff members who are ostensibly charged with patient care. This must change or there will be no program in the future (Research Assistants and Patients, 1975)."
In many instances the clinics became centers of control imposing the regulations in rigid ways that further stigmatized and infantilized patients. One of the first women patients admitted to the program in 1967 related that until the early 1970s the programs really helped patients:
"The clinics were pleasant to come to and if a patient had a problem the staff was interested. There was also flexibility. However around the early 1970s this began to change. Before I became a counselor, I used to work two or three jobs. My elderly mother lived in Florida. Before the 1970s I was able to obtain methadone to go to see her. However, during the 1970s the regulations became strict. I remember asking for a two week supply of methadone, but the clinic doctor felt that I was taking too many vacations. I told him that my boss would let me go and that I had the money for the trip but the clinic doctor refused my request even though it did not require too much on his part to get the approval. It is the control and the different levels of supervision. You have the nursing staff with their supervisor, the counseling staff with their supervisor and the doctor who is responsible for dose changes and reporting. There may be conflicts between the nursing and counseling staff on decisions about reporting and dose and who the doctor relies on for decisions."
Another patient who is in the medical maintenance program and works for a large methadone program indicated that the clinics were part of an institution:
"I would never want to go back to a clinic. My medical doctor is terrific and I get personal attention. In a clinic, at best, you have to manipulate a few systems. There is the nursing staff and sometimes a nurse would be in a bad mood. So there is also the counseling staff and the counselor might not be in such a great mood. Then there were different supervisors in the clinic and the doctor who was hardly ever there. When everything came together it was okay, but sometimes someone would come in, get up on the wrong side of the bed in the morning and you would have to adjust.
Another thing is the vacation medication and the regulations. I have known patients who did not go on vacations because the clinic would not trust them with medication. They wanted to visit their families in other states. The families did not know about the patient being on methadone. The program wanted to assign the patients to pick up methadone everyday in local programs in cities where they were going - to pick up for a week or so. Now the patients would have to make excuses everyday to pick up methadone at strange clinics the families might find out. Patients would rather not go on vacation if they couldn't get extra bottles to travel. The most you can get is up to two weeks beyond that the program has to get permission from the government."
There are patients in medical maintenance who profited from the counseling offered in some of the clinics despite the regulations. One patient remarked:
"In the clinic I attended, the staff was friendly, I never had any trouble. However, it was a clinic with a set of regulations. I thought that clinic staff did the best they could considering the system. Medical maintenance with a private doctor is much better, its more personal."
Some patients had been in more than one clinic and were able to compare the implementation of regulations under different administrations. One patient who was treated in two clinics gave the following account:
"In the first clinic the atmosphere was friendly. It was like a waiting room. We sat and waited to be called and the nurse individually medicated us. We were treated as patients. Then when I moved from the city I was transferred to another hospital where everything was strict. The doctor was like a "Nazi." There was drug dealing around the clinic and patients were not trusted. However, I was a model patient in both clinics. I never abused drugs and when other doctors prescribed medications, I told the clinic. My urines were 'clean' from the time I entered treatment.
I will never forget the time I was asked for a urine sample and could not urinate freely. After much effort I did give the nurse a very small sample. She was not satisfied, and my take home privileges were suspended for the week."
This patient was an employed mother. From all criteria she could be considered responsible yet according to the regulations or the interpretation of the regulations, she was to be punished for not being able to urinate freely on demand. In this particular instance a model patient could not be trusted by the staff and therefore, regulations about random urine samples were not modified.
Another patient stated that in the first clinic she attended:
"The attitude towards the patients was terrible. I remember I had a urine that was positive for heroin and I denied using. Fortunately, I was in therapy and the therapist was also taking urines. I had a urine specimen which showed that I did not use heroin. When I brought in the results of the test taken by my therapist, the clinic staff accused me of being a trouble maker. I transferred to another clinic connected to a hospital and found that the counseling and the attitudes were better."
Notwithstanding the regulations the quality of the clinics developed unevenly during the past two decades. Regulations have limited the prescribing of methadone within a marginalized clinic system that perpetuated the stigma associated with methadone maintenance treatment. Molinari, Cooper and Czechowicz (1994) indicate that the excessive multi-layers of regulations by federal, state and local jurisdictions have hampered the administration and expansion of methadone treatment that is unique in medicine in the following statement.
"In addition to the separate federal registration and regulation of narcotic treatment ..., many states require separate registration and compliance with state treatment standards. Multiple federal and state registrations have established a relatively small treatment system, ... with a federal and state oversight bureaucracy. While this closed system has presumably reduced methadone diversion, the correlation between quality of patient care and program registration or compliance to treatment standards has never been established. To the contrary, some evidence suggests that the quality of programs and treatment outcomes may be getting worse. ... Patients are rarely treated in private physicians' offices. Most patients are treated in large numbers in a clinic setting and actually do not consult with a physician. Unlike any other medication, a psychiatrist or internist treating one or several opiate-addicted AIDS patients in their private medical practice must refer such to a government-licensed narcotic addiction program... Keeping methadone treatment isolated from small individual medical practice continues to stigmatize further this particular patient population and the treatment modality."
Molinari, Cooper and Czechowicz (1994) indicate that the regulations have to be changed and that organized medicine "will need to take a leadership role." They conclude by stating, "We believe it is time to initiate the process of making narcotic addiction treatment more consistent with the other medical therapies and to mainstream this treatment (methadone) into the general health care system." In 1995 the Institute of Medicine addressed the oppressive regulatory system. The following statement was issued acknowledging the problem:
"... the scope of federal regulation of methadone treatment should be reduced in favor of authorizing greater clinical discretion in determining appropriate medical treatment. One means of assuring that clinical discretion is exercised is through clinical guidelines .... Such guidelines are making their appearance in the substance abuse area, most notably in the Treatment Improvement Protocol (TIP) series of the Center for Substance Abuse Treatment ... the committee considered then as a complete alternative to regulations."
Interestingly, the issue of stigma towards patients was not addressed directly as a major problem by the Institute of Medicine.
Summary
Stigma has been an underlying current in the implementation of regulations of methadone treatment. The Drug Enforcement Administration which is the successor of the Federal Bureau of Narcotics has been most zealous in its controlling attitudes and practices concerning methadone treatment. Philosophically the Drug Enforcement Administration has supported and espoused an anti-maintenance position. This agency therefore has adopted an adversarial relationship to both patients and the programs under the pretext of controlling a major diversion problem This powerful regulatory agency linked to other federal agencies that promulgate regulations sanctions the current multi-tiered system of regulations. From the perspective of the working and socially rehabilitated patient this multi-tiered system acts as an invisible and perpetual jail with the programs designated as caretakers.
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Last Update: March 15, 2001 |
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