The Clinic System Does More Harm Than Good

By Regina Walker 02/09/15

A response to Percy Menzies' Professional Voices piece last week, Opioid Addiction Treatment Should Not Last a Lifetime.

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"I really don't care if people use drugs. I don't want them to suffer from it." —João Goulão, President of the Institute on Drugs and Drug Addiction

It's my belief that misinformation is worse than no information—and with that in mind, I'd like to rebut some points contained in an article recently published on The Fix, "Opioid Addiction Treatment Should Not Last a Lifetime," by Percy Menzies. I read the piece and felt that it called for a response due to some significant errors in matters of fact—not matters of opinion—though I disagree with many of Mr. Menzies' opinions, as well. While I certainly wouldn't call myself an expert, I am a clinician and social services professional with many, many years of experience in both direct treatment of substance abuse clients, as well as in the formation of treatment policies and goals in substance abuse treatment.

Despite decades-long and widespread consensus among addiction professionals that the clinic system does far more harm than good, we remain, ironically, addicted to it.

The thrust of Mr. Menzies' story is that long-term, medication-based treatment of opioid addiction is a misplaced approach, which merely substitutes one addiction for another. This conclusion is mistaken, in my view. He also claims that drugs used to treat opioid addiction—specifically, methadone and buprenorphine—promote opioid addiction; as we shall see, however, the facts do not support such a claim.

Mr. Menzies asserts, first of all, that the history of Vietnam veterans disproves the disease theory of addiction—that addiction is a life-long, chronic disease requiring ongoing treatment. He writes that many Vietnam veterans were able to return to a substance-abuse free life upon returning from Southeast Asia and that this is clear evidence that long-term medical therapy is based on a misunderstanding of opioid addiction. One must, however, distinguish between physical dependency and addiction. Physical dependency is physiological, not psychological; anyone exposed to a physically addicting substance over a period of time, will become physically dependent. An alternative perspective on the experience of Vietnam veterans is offered by NPR science journalist Alix Spiegel, who wrote, in "What Vietnam Taught Us About Breaking Bad Habits," that:

"It's important not to overstate this, because a variety of factors are probably at play. But one big theory about why the rates of heroin relapse were so low on return to the U.S. has to do with the fact that the soldiers, after being treated for their physical addiction in Vietnam, returned to a place radically different from the environment where their addiction took hold of them."

It's possible, then, that the veterans did not suffer from the disease of addiction, but rather, became dependent on opioids due to environmental circumstances—at least, in many cases. Rather than being genetically predisposed to suffer from the disease of addiction, they instead became, for environmental reasons, physically dependent, but in the absence of a true genetic predisposition, were able to resume a drug-free life. If this is the case, then we can see that there are really two categories: the person who becomes, for environmental reasons, physically dependent, and the person who genuinely suffers from the genetic predisposition to the disease of addiction. If this is the case, then different treatment approaches are necessary—in the former case, physical detoxification and removal from (for instance) the stressful environment of combat; in the second case, long-term therapy that may have a medical component.

Menzies says of buprenorphine—a drug used for pain treatment, as well as the treatment of opioid withdrawal, and for long-term maintenance therapy— "[It is] being abused and diverted," and that despite its use, "we have not seen any substantial drop in the use of opioids and heroin."

Both statements are true, however, interpreting them is a little tricky. Many prescription drugs are abused and diverted, including blood pressure medication, psychotropics like Elavil and Seroquel, asthma inhalers, and others. Though buprenorphine is abused and diverted doesn't mean it is ineffective if used as intended nor does it mean buprenorphine contributes substantially to opioid addiction.

For instance, one critical difference between buprenorphine and heroin is that buprenorphine generally doesn't produce tolerance; Hendrée E. Jones, Ph.D. of Johns Hopkins University School of Medicine writes that, "Once a maintenance dose is achieved, it should not routinely require adjustments, as patients maintained on buprenorphine have not clearly demonstrated tolerance for the medication."

It's erroneous to suggest that treatments for opioid addiction should prevent an increase in new addictions, as Mr. Menzies claims—he appears to be mistaking treatment for prevention. He says that, "The introduction of buprenorphine should have made a significant dent in the rates of opioid abuse," but this is nonsensical. Should the use of insulin prevent new cases of diabetes? Indeed, Menzies seems unsure what he's actually suggesting—at one point writing, "There is no doubt that opioids like methadone and buprenorphine are highly effective in not only keeping patients off heroin, but also in preventing blood-borne infections like HIV and hepatitis C," while saying previously, "More long-term opioid prescribing.  And now we are going to see a lot more heroin coming to this country."

How can drugs that are "highly effective . . . in keeping patients off heroin," promote the "veritable tsunami of heroin" he says confronts us? 

There are other errors in matters of fact in his story. For instance, he claims that "benzodiazepines" (i.e. Klonopin, Valium) "were promoted and used for the treatment of alcoholism," but this is untrue; benzodiazepines are used for acute detoxification not for long-term maintenance. Perhaps, one of the most glaring errors is his assertion that "Methadone has worked well because of the clinics," that it is only thanks to the tightly controlled environment of clinic dispensaries that methadone has been effective.

Sadly, however, in the United States the clinic system has done more harm than good.  A study from 2000 in the Mount Sinai Journal of Medicine says, "“From the beginning of MMT, the program has been stigmatized by the belief that methadone treatment merely substitutes one drug for another. This belief blurs the crucial differences between an active heroin addiction and the use of methadone in a maintenance program. Gordis cites methadone maintenance as an example of a soundly researched medical program about which misperceptions and biases have had an adverse impact on implementation.” In the same study, the authors note, "Long-term methadone maintenance is a medically safe, nontoxic treatment with minor, mostly transitory side effects, found mainly during the induction phase of treatment. In general, the overall health status of patients improves after spending time in treatment.”

Methadone treatment via the clinic system subjects clients to an array of regulations and barriers that have nothing to do with the therapeutic value of methadone maintenance, for which there is overwhelming evidence of effectiveness in preventing relapse to heroin, as well as the abuse of other controlled substances. "Patients" are required to present at the clinic in person six days a week, initially—no calling in sick. Do you have the flu? Is there a blizzard? Tough luck. If a patient is unemployed, they must come later in the day as the "early medication" time period is reserved for employed patient.

Far from "working well because of the clinics," methadone works in spite of the obstacles to its effectiveness created by the clinic system–not only is your daily schedule dictated by the clinic's inflexible dispensing schedule, while you're there you get to stand in line with active addicts that are often buying and selling drugs. Addiction professionals tell patients to stay away from "people, places, and things." In my experience, most methadone clinic programs with which I've been professionally involved had people you shouldn't be around, with things you should avoid, in a place you shouldn't be, in abundance.

In 1998, the National Institutes of Health issued a consensus statement on the treatment of opiate addiction saying that "opiate dependency is a brain-related medical disorder, which can be treated," and that "stigmas and misunderstandings about addiction and methadone treatment are barriers to expanding treatment." It also stated that current regulations are "overly intrusive." Despite decades-long and widespread consensus among addiction professionals that the clinic system does far more harm than good, we remain, ironically, addicted to it—with all its potential to increase relapse rates, and to make using methadone effectively unnecessarily difficult for clinicians and clients alike.

I do agree with Mr. Menzies that there is much amiss in our treatment of addiction—but not the issues he claims.

Regina Walker is a regular contributor to The Fix. She recently wrote about the life and suicide of Audrey Kishline, the founder of Moderation Management, as well as an appreciation of the life of Ernie Kurtz.

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