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Chemical Dependency Research Working Group |
Methadone patients feel they are a highly stigmatized group in society. This was conveyed in interviews concerning their social interactions with relatives, friends and employers. However, there are other stigmatized groups prominent in society. The purpose of this section of the study, therefore, is to determine the patients' perceptions of society's stigma against methadone patients compared to other stigmatized groups. Some patients harbor more than one invisible stigma. To ascertain which invisible stigma is considered greater, four methadone patients with lesbian and gay sexual orientations were interviewed as well as patients treated for emotional problems and alcoholism. To determine whether another identifiable group holds similar or differing perceptions of social stigma, twenty-three elementary school teachers were also interviewed.
Methodology
A stigma rating form was created and administered to 58 methadone patients and to a comparison group of 23 elementary school teachers. The teachers were waiting on line for their paychecks when they were approached to volunteer by another teacher who was also the elected union delegate from the school and was regarded as a leader. The teachers evinced considerable enthusiasm for the study and consented to participate.
The purpose of the form was to determine the order of the perception of social stigma directed at the following ten groups which are highlighted in the media:
Each group was rated on a scale of from 0 to 5 with 0 being no perceived social stigma to 5 the highest rating for a particular perceived social stigma. A mean stigma score was computed for each group. The stigmatized groups were then ordered by the scores into two categories: methadone patients and school teachers. The mean stigma score therefore incorporates in one number the level of social stigma as perceived by the respondents directed to a particular group of people. (See Appendix for Stigma Score Form.)
Results
Table 1 summarizes the scores of socially perceived stigma of the ten groups as reported by the methadone patients and a contrast group of school teachers. They are ranked within the first five stigmatized groups that include active heroin and/or cocaine addicts, persons with serious criminal histories and people with AIDS/HIV. Methadone patients are placed within the first five socially stigmatized groups by both the methadone patients (Rank Order=3) and the teachers (Rank Order=5). For both groups methadone patients are perceived to be more socially stigmatized than alcoholics, the homeless, minorities, the physically disabled and gays and lesbians. These are probably among the most stigmatized groups in society. Furthermore, with the exception of the mentally retarded and mentally ill, the causality of the problems within first five groups are perceived to be the result of the affected individual's behavior. This reflects the belief that the affected persons brought the problems on themselves.
| Methadone Patients (n=58) | School Teachers (n=23) | |||
|---|---|---|---|---|
| Rank Order | Group | Stigma Scores | Group | Stigma Scores |
| 1. | Heroin & Cocaine Addicts | 4.63 | Heroin & Cocaine Addicts | 4.48 |
| 2 | Persons with Serious Criminal Histories | 4.32 | Persons with Serious Criminal Histories | 4.44 |
| 3. | Methadone Patients | 4.29 | Persons with HIV/AIDS | 4.43 |
| 4. | Persons with HIV/AIDS | 4.25 | Mentally Ill and/or Retarded | 3.90 |
| 5. | Homeless People | 3.73 | Methadone Patients | 3.69 |
| 6. | Gays and Lesbians | 3.42 | Gays and Lesbians | 3.52 |
| 7. | Minorities (People of Color) |
3.37 | Homeless People | 3.45 |
| 8. | Mentally Ill and/or Retarded | 3.24 | Alcoholics | 3.34 |
| 9. | Alcoholics | 3.00 | Minorities (People of Color) |
3.23 |
| 10. | Physically and Sensorially Disabled | 2.33 | Physically and Sensorially Disabled | 3.04 |
Overall, Table 1 reveals a similar pattern of perceived social stigma among methadone patients and teachers. Active heroin and cocaine addicts are perceived of as having the greatest social stigma, followed by persons with serious criminal histories. These two groupings probably are the most stigmatized in the United States and methadone patients have histories both of heroin addiction and serious crime.
With methadone the stigma was transferred from heroin addiction to methadone treatment. The public is ignorant and does not know how to treat the methadone patient: Are they still addicts in the sense of heroin addiction? Are they methadone 'addicts,' or are they cured? The confusion has resulted in a transfer of stigma and image from the heroin addict to the methadone patient. The order of Table 1 reflects the attitudes of the public. Methadone treatment is highly stigmatized following the primary deviance of heroin addiction and criminality. Thus, the perceived degree of social stigma is slightly less than that of the heroin/cocaine addict and those with criminal histories.
In both groups gays and lesbians rank sixth with the physically disabled ranking tenth. Stigmas perceived as behavioral have greater rankings than stigmas that are perceived as not under the person's control. Teachers on the other hand regard persons with mental illness and retardation as highly stigmatized. This may be a function of their role in their school. Students with serious mental illness and retardation are known in the school setting and referred by teachers to special education which is a stigmatized classification for a student. Methadone patients, on the other hand, may perceive of mental illness and retardation as less stigmatizing since it is not regarded as volitional. Furthermore, mentally ill and retarded persons may not be a part of the methadone patient's social circle while school teachers may have daily contact with mentally disabled or retarded students who are marginalized within the school system.
Persons with physical and sensory disabilities are ranked last or were given the lowest stigma score by the patients and teachers. The acquisition of a physical disability may be perceived as beyond the person's control or responsibility and, subsequently, there is a degree of compassion for persons so affected. However, prior to this century and modern science persons with physical or sensory disabilities were a highly stigmatized group. The disabilities were seen as a visible moral failing and a mark on the affected person's parents and family.
Interrelationship Among the Invisible Stigmas of
Homosexuality, Emotional Disorders and Methadone Treatment
The results in Table 1 suggest that methadone patients may be more socially stigmatized than homosexuals. To further investigate this possibility, four methadone patients (1 white gay man, 1 Latino gay man, 1 black lesbian and 1 Latina lesbian), who also harbored the invisible stigma of homosexuality, were interviewed. The Latino gay man advised that he identifies with the gay culture and participated in the Washington March for Gay Rights in 1993. He also attended the final ceremony of the gay games in Yankee Stadium in June of 1994. He advised that he could never see himself marching in a parade for the rights of methadone patients. Also, he never reveals his status as a methadone patient in casual social relationships but does inform a prospective partner in an extended relationship. At work he is accepted as a gay person. He works as a medical technician, considers himself to be skilled and creative "like many gays." At work his supervisor illegally searched his locker and found a bottle of methadone. She did not report this finding to the administration, since the search was illegal. As far as he is able to determine, nobody at his job knows that he is a methadone patient except his supervisor. He is of the opinion that the stigma against methadone patients is greater than the stigma directed against gays which is greater than the stigma directed at Latinos.
The two lesbians indicated that when they are employed, they quickly learn who the "girls" are at work. However, they never reveal their status as methadone patients since they feel they will be the first to be blamed in the office if anything is stolen or "disappears." The Latina lesbian is also HIV positive. In order of stigma, the two perceive HIV infection as the greatest social stigma, followed by their status as methadone patients, having a lesbian sexual orientation and lastly their minority status.
A white gay patient with degrees from Ivy League universities advised that methadone is very stigmatized within certain organizations of the gay community and AIDS activist organizations. He is a member of ACT-UP and indicates that there are people within ACT-UP who do not accept methadone treatment as valid. He met another methadone patient in ACT-UP and was told not to reveal his treatment status to anyone because of the stigma that is directed to the program and possibly to patients. Also, at the Gay and Lesbian Center on West 12th street in New York City, the major treatment recommended for drug addiction is a 12 step program. He advised that gay advocates of the 12 step programs reject methadone maintenance as a treatment for addiction. Also, he is involved in mental health volunteer groups and indicated that methadone is also viewed with suspicion since the philosophy of 12 step programs has penetrated these services. He is currently in therapy for a depression disorder and had to educate both the therapist and the psychiatrist at a well known downtown hospital about methadone maintenance. Although he has improved with time in methadone treatment, the psychiatrist still regards him as an addict.
As a member of the gay community he states that he has never felt more stigmatized since entering a methadone program. At the present time, he is living with a companion but has not informed him of his enrollment in methadone treatment because of the stigma and possible personal rejection. However, he has informed his companion about his depression and enrollment in psychotherapy. Both are regarded as "legitimate:" depression and psychotherapy are socially acceptable.
A female patient in medical maintenance with a diagnosed emotional disorder has similar comments about the interrelationship of stigmas. She has attended 12 step programs as an adjunct to therapy although she does not abuse alcohol or other drugs. She unknowingly informed the participants that she was a methadone patient and was immediately confronted since methadone was incorrectly considered a mood altering drug. She was not permitted to participate in the meeting and left the group. She embraces some of the principles of 12 step programs and found another group to attend without informing the participants that she is a methadone patient. In addition to medical maintenance, this patient is under the care of a therapist for panic attacks and is medicated for severe anxiety.
When questioned about the possible relative stigmas of methadone treatment and psychiatric treatment with anxiety relieving medications, she advised that methadone is the much greater stigma. She has confided to friends that she is in therapy and is prescribed medication. However, she never tells friends that she is a methadone patient since they have no understanding and only know about methadone from the negative media presentations. Her friends regard methadone treatment as a "legal high" and methadone patients as "legal junkies." For this patient, therapy for anxiety with medication is socially acceptable without serious social stigma. She related that:
"Television and the media present positive images of recovering alcoholics and drug users in drug free programs such as TC'S (therapeutic communities). Methadone is never positively presented on TV. There are TV commercials for therapeutic communities in the media, ....TV commercials about condoms, but where are the methadone commercials? Even AIDS is more acceptable than being a methadone patient. .... There has been a lot of education about AIDS. It does not have the stigma that it used to have, and people appear to be a little more understanding."
Since she attended AA programs and has met alcoholics, she indicated that the current social stigma for alcoholism is low: "There is an acceptance that this is a medical condition. Participation in treatment for alcoholism such as the 12 step program or treatment for drug addiction in a therapeutic community is considered admirable."
Overall, elementary school teachers, a non-stigmatized group may have less of a perception of the social stigma directed against methadone patients since they are not known to be members of that stigmatized group. To test the hypothesis that elementary school teachers may be less perceptive than methadone patients of the social stigma directed to methadone patients, the stigma scores were tested for significance. The t score (t=1.16, p>.05, df=79) did not reach significance. The hypothesis for this particular sample was rejected. There is, however, a tendency in the direction of the hypothesis since teacher's scores do have a lower ranking than the scores of methadone patients for social stigma directed to methadone patients.
Interrelationship Between the Stigmas of
Methadone Treatment and Alcoholism
Interestingly, alcoholics who can be functionally impaired from drinking have a lower stigma score and ranking than methadone patients. This pattern was noted by Dr. Norman Gordon1 (1973) who observed that discriminatory attitudes against methadone patients seem intractable. The following extended quote, although written in 1973, accurately reflects the patients' predicament concerning disclosure of their status as methadone patients in 1994.
"...it amounts to a prejudiced set of attitudes, in which unfortunate experiences are extended to embrace even those who are attempting to turn their backs on a sordid past. The attitudes seem amazingly intractable to reason, despite the impressive records that methadone patients have shown by giving up lawbreaking activities and self-destruction and turning to society for help with their addiction. These attitudes were nowhere more apparent than in two hearings before a semi-public body which this writer attended as an expert witness.
... In both cases, the patients involved had worked successfully for periods of time while they were heroin addicts, with only relatively minor negative marks on their records for occasional absenteeism. They both received on-the-job promotions. Quite accidently, they were discovered to be methadone patients, and as soon as that happened, and for no other reason, they were suspended from their jobs. It should be emphasized that both individuals had voluntarily entered methadone treatment because they had become tired of the heroin-seeking rat race. The reason given for the suspensions was that no person can be employed who consumes narcotics without the permission of the organization's physician, and he would not give such permission. The argument given against permission was two fold. On the one hand, the fear was expressed that the individual might cease taking methadone and then revert to heroin, leading to employment of a potential criminal. On the other hand, the notion was expressed that since methadone as well as other narcotics are chemicals of unknown consequence to the body, the individual's behavior might be unpredictable. Yet, at the same time, this particular employer maintained a sizable facility for the treatment of employees who were alcoholics, and alcohol when consumed prior to important psychomotor tasks is known to lead to impairment. Yet no employee who confesses to having an alcohol problem and seeks treatment is summarily suspended. Here we find the apparent inconsistency in attitudes: one condition leads to the branding of its victim as a social outcast and an employment risk. Even when faced with the detailed findings of our extensive research, the attitude could not be changed, and the suspensions were not lifted."
Mr. Stanley Novick (1994), the president of NAMA and a former methadone patient, reports that 12 step programs (Narcotic Anonymous and some Alcohol Anonymous groups) usually discriminate against methadone patients. He reported that local AA and NA groups regard methadone as a mind altering drug and will allow methadone patients to observe meetings but not actively participate. However, the national AA accepts methadone as a legitimate medication. This attitude, however, has not filtered down to local groups. Mr. Novick has been instrumental in attempting to organize 12 step programs for methadone patients known as Methadone Is Recovery. Also, Methadone Anonymous and Methadone Awareness groups are forming throughout the country because of the stigmatizing and rejecting attitudes of established 12 step groups to methadone patients.
Dr. Enoch Gordis (1991), director of the National Institute on Alcohol Abuse and Alcoholism, reported that there was a considerable amount of stigma against methadone patients in alcohol treatment programs throughout the country. Dr. Gordis has made the following observations about the interrelationship between alcohol treatment, 12 step AA programs and methadone maintenance:
"Also at issue is a topic that has been of interest in recent years with so much polydrug use the relationship between methadone maintenance and 12 step recovery programs. In my opinion, there has been an unwarranted philosophical obstacle set up by many alcohol treatment programs that require methadone-maintained alcoholics to withdraw from methadone use before receiving treatment for their alcoholism. Doing so places the methadone-maintained individual at clear risk for relapse to narcotic use and represents a misunderstanding by alcoholism treatment programs of the pharmacology of methadone. Methadone maintenance is consistent with drug-free 12 step programs and should not be an obstacle to alcoholism treatment."
The problem that Dr. Gordis related in 1991 has not been resolved by 1995. In 1992, the New York State agencies devoted to funding drug and alcohol treatment merged. Treatment programs for alcoholism known as Alcohol Treatment Centers refuse to treat alcoholic methadone patients unless they withdraw from methadone. To address this problem, a pilot project was planned in 1994 to introduce a policy change that would permit alcoholic methadone patients to be treated at certain centers without withdrawing from methadone.
A patient in medical maintenance who has been employed for about 10 years in the personnel department of a major corporation in New York City advised that she cannot reveal that she is a methadone patient because attitudes of rejection and suspicion would arise. She knows this from conversations and meetings in the office. Furthermore, she will probably never get a promotion if the company were aware that she is a patient. Although there is an Employee Assistance Program (EAP), it addresses problems mostly related to alcohol. Drug abusers are regarded with suspicion since they may have acted illegally in the past. Alcohol is considered legal and is readily available. Furthermore, there are persons at all levels of the corporation who have alcohol problems. Alcoholics are given every chance before they are fired. Alcohol relapses are tolerated and alcoholics can get promotions even if they are not completely sober but are participating in a program and showing progress. This is not the policy directed to drug addicts. Addicts may be referred to treatment and be in treatment, but if there is a slip up then the company tries to get rid of the employee. Methadone is seen as just another drug. It also implies that the employee must have done something illegal such as past use of heroin or committed crimes to obtain money for drugs. Even if doing well a person with a drug abuse history, especially heroin, will probably never get a promotion. The patient participates in management discussions and indicated that excuses will be found to either dismiss the employee or prevent promotions.
An example of the stigma that is experienced by methadone patients in traditional AA and NA 12 step programs was relayed by a methadone patient in good standing who is also a recovering alcoholic. He related the following after revealing to an AA member that he is a methadone patient.
"On the 18th of August, 1994 I attended an AA meeting. At a previous meeting I shared in front of the whole room that I was back on methadone. I was trying to be honest. It was a big mistake. I was immediately blackballed by my friends and other people in the room. Then at the current meeting, I shared with another member who had history of alcohol, heroin addiction and pills that I was currently on methadone. He was also on methadone for a period of time. He then insulted me by saying that he could never do what I am doing presently because if he were on methadone he would use other drugs. He stated that he is using on a self medication basis codeine #4, narcotic for a back problem. He considers himself clean and sober but he regards me a failure because I am on the methadone program. I have clean urines, am writing articles for local newsletters and have been given increased take home medication since the program is beginning to trust me. However, the people at AA whom I have helped in the past and never judged are now stigmatizing me, insulting me to my face and talking behind my back. I am going to find another group that is more accepting."
Another example of the relative stigma against methadone patients in comparison to alcoholics was relayed in an interview by an active member of the squatters movement on East 13th Street. This methadone patient in good standing is a graduate of a major university, is a writer and former college instructor. He is on the patient advisory board at a local hospital and has helped edit several neighborhood newsletters. In an argument with neighbors about policy of squatters talking to the media, he was insulted by being called a "junkie" by active alcoholics who were members of the squatters movement and were aware of his enrollment in a methadone program. His persona is one of a neatly groomed, sober, intelligent and literate individual.
In oral histories conducted by this writer in the 1980s of Russian immigrants who were enrolled in methadone programs in New York City, it was reported that the stigma of opiate addiction was greater in Russia than being an alcoholic. The immigrants were addicted to opiates in the former USSR where possession of opiates is illegal. Alcohol is available legally and alcoholism, although widespread, is treated medically. The interrelationship of the relative stigmas of alcohol and opiate dependency appear to be the same in both the United States and the former USSR.
Discussion
The perception of social stigma directed towards methadone patients was examined in relation to other stigmatized groups. In the two samples that were interviewed, methadone patients and a contrasting convenient sample of elementary school teachers, the trends of perceived social stigma against methadone patients is high. The rank ordering of the stigmatized groups is similar for both the methadone patients and the school teachers.
The perceived social stigma against methadone patients is ranked within the cluster of the highly stigmatized groups heroin/cocaine addicts, persons with serious criminal histories, persons with HIV/AIDS. In this cluster persons may be considered by the public and the media as responsible for the onset of their problems and conditions because of their behavior. Methadone maintenance therefore may be related in the public's perception to other major stigmas such as AIDS and criminal behavior that are associated and transferred to methadone itself.
There are about 115,000 methadone patients in the United States. They are currently being organized into advocacy groups by NAMA. Many are poor, distrustful of the medical profession, the government and fearful of retaliation in demanding quality treatment with dignity. The powerlessness, stigmatization and marginalization is reflected in the perceptions of patients with two or more invisible stigmas. Thus, patients with two or more stigmas regard their enrollment in methadone treatment as the greater.
Perhaps the most ironic trend is that the perceived social stigma is less for an alcoholic who may be severely impaired than for a methadone patient who may be functional. The lower perceived stigma of alcoholics in society may be attributed to their current organizational networks, political influence and educational strategies that transformed the public's understanding of alcoholism from a highly stigmatized condition to what is now considered a legitimate disease. Furthermore, treatment programs for alcoholics usually do not accept alcoholic methadone patients since methadone as prescribed in maintenance treatment is incorrectly regarded as a mood altering drug.
Neuroscientists have identified receptor sites and endogenous ligands, but a cohesive theory of addiction has, as yet, not been formulated. While a complete understanding of physiology does not exist for other recognized medical conditions (e.g., diabetes, epilepsy, alcoholism), medical treatments that have proven viable but less effective than methadone are accepted as legitimate. The perception of methadone as less than treatment marginalizes and stigmatizes this effective therapeutic intervention.
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Last Update: March 15, 2001 |
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