Half a century ago, two medical researchers at Rockefeller University began investigating a new treatment for heroin addiction. A year later, the husband-and-wife research team, Vincent Dole and Marie Nyswander, announced that they had treated a group of twenty-two heroin addicts with a synthetic painkiller called methadone. In every way—finding and holding jobs, continuing in school, stabilizing their families—the patients showed marked improvement. Careful supervision and support was needed, but methadone seemed to offer a promising avenue of treatment for the epidemic of heroin use in America’s cities.
In response, the federal Bureau of Narcotics and Dangerous Drugs threatened to arrest the researchers. Treating addiction with addictive drugs, the BNDD reasoned, was simply drug use under another name.
Six years later, however, President Richard Nixon conscripted methadone into the national War on Drugs. Methadone maintenance offered an approach to addiction that could be expanded quickly, and federal funds for new methadone clinics flowed generously. By the mid-1980s, methadone “substitution therapy” had spread nationwide, and heroin simmered as a low-grade problem that was eclipsed by the explosion of crack cocaine, which was turning inner cities into war zones. But the pendulum swung again—President Ronald Reagan’s 1988 White House Conference for a Drug Free America questioned whether “methadone substitutes one addiction for another” and suggested that “a drug-free state is superior to all others.” A decade later, Mayor Rudolph Giuliani began to phase out long-term methadone treatment in New York City. “Methadone is an enslaver,” he said. Several months later he reversed his position, acknowledging that he had been “unrealistic.”
In some ways, these rapid shifts tell the story of methadone maintenance: both the government and the treatment community swing back and forth between recognizing its value and shunning it as just another form of drug use. It’s time, however, to finally come to terms with methadone. We need it as part of any strategy to cope with our national drug problem.
We are in the midst of another drug surge. After decades of domination by the stimulants—cocaine and, more recently, methamphetamine—hard-drug use has swung back to the opiates, both heroin and prescription pain relievers, such as Vicodin, Percocet, and, especially, OxyContin. “An urgent—and growing—public health crisis,” is how Attorney General Eric Holder described it last March. The potential good news is that once again we can manage our opiate problem with methadone and a newer, related drug, Suboxone.
By “manage,” I mean reduce the damage to both addicts and society. When on substitution therapy, studies have consistently shown, patients use less heroin, commit fewer crimes, and reduce their odds of contracting infections such as hepatitis C and HIV compared with those not taking methadone.
That’s especially important for users under supervision by the criminal justice system. Drug-diversion programs such as drug courts offer a chance not only to get problem drug users into treatment but to keep them there. Retention is critical: as a rule, between half and two-thirds of all patients drop out of methadone and Suboxone treatment within a year. Four out of five of those will resume their habits, and criminal activities, within three months. With approximately one-fourth to one-third of all heroin addicts passing through the U.S. criminal justice system each year, the gains from embracing substitution could be very large indeed.
But too many parts of the criminal justice system remain mired in the mentality that led the BNDD, now the Drug Enforcement Administration (DEA), to try to shutter the first methadone clinic. Many judges, prosecutors, and prison officials still believe that opiate addiction can only be treated with drug-free approaches that exclude clinically sound substitution therapies. That attitude needs to change.
According to the Centers for Disease Control, an estimated 2.1 million Americans are addicted to narcotic pain relievers. I’ve talked with dozens of them in my methadone clinic near the George Washington University campus in Washington, D.C. Some of the older addicts had been prescribed OxyContin (an extended-release, uncut form of the opioid oxycodone) for pain at first; the younger ones just pursued “Oxys” because they were looking for a pharmaceutically “safe” high. They bought them on the street for $20 to $40 each, cajoled doctors into writing them prescriptions, frequented “pill mills”—doctor’s offices or clinics that routinely overprescribe or mis-prescribe narcotics—or raided the medicine cabinets of unsuspecting relatives. No matter where they got it, they pulverized the pills into a narcotic dust and injected or snorted the powder, a potent dose of pure oxycodone.
But around 2010, the pills got scarcer. States began cracking down on doctors and pill mills. Purdue Pharma, the maker of OxyContin, came out with a crush-resistant pill. Meanwhile, inexpensive, high-purity Mexican heroin had begun flowing across the border in 2007 (it cost as little as $8 a hit), and many of my patients switched from pills to heroin. The pill-to-heroin sequence is common: according to one study, 80 percent of people currently addicted to heroin came to it by way of painkillers.
As one might expect, a precise count of people addicted to heroin and prescription narcotics is impossible to calculate. To that end, the federal government conducts an annual National Survey on Drug Use and Health (NSDUH). However, a team of drug policy experts recently wrote in the journal Addiction that relying on this estimate of hard-drug numbers is “hopeless: the great bulk of the daily and near-daily users who dominate consumption do not end up on the NSDUH-based statistics.” The national survey puts the number of heroin addicts during 2013 at 434,000. As for the population that is dependent on pain pills, the survey puts that number for 2013 at nearly 1.5 million. The painkiller number may be closer to reality: pill users lead more stable lives than heroin addicts and are easier to survey.
The American Association for the Treatment for Opioid Dependence (AATOD) reports that about 300,000 people are taking prescribed methadone on any given day and another 400,000 receive Suboxone. If there are indeed 700,000 people on maintenance treatment and if the NSDUH estimates are correct, then many people needing treatment are receiving it. Yet Jonathan Caulkins of Carnegie Mellon University and Beau Kilmer of RAND calculate the number of addicts to be about 900,000; in addition to the national survey, which is administered in person by field interviewers at respondents’ residences, Caulkins and Kilmer used information on arrestees. Add to that 1.5 million painkiller addicts, which is likely an underestimate, and you can see why it’s hard to gauge the extent of the treatment gap—the difference between how many people need substitution treatment and how many are receiving it. Clearly this gap exists, however: clinicians and researchers constantly bemoan the lack of adequate care. Some point to the well-documented diversion of Suboxone—that is, when patients receiving the drug resell it on the street—as evidence that there are too few treatment slots: recovering addicts who want the medication are seeking it elsewhere. In 2013, Health Affairs reported that fewer than 10 percent of all people dependent on opioids (both pills and heroin) in the United States are receiving substitution treatment.
There are pharmacological differences between methadone and Suboxone, but the most important difference is the manner in which patients receive them. By law, methadone must be dispensed in federally licensed clinics. Patients stand before a nurse and drink a cherry-flavored methadone solution from a little cup. Suboxone, however, can be prescribed by trained office-based physicians; patients get their pills at a pharmacy like any other prescription. Methadone and Suboxone work the same way: they occupy the brain receptors that would otherwise be filled by heroin or opioid painkillers. Both medications last twenty-four to thirty-six hours. That’s considerably longer than heroin, which users must inject or snort every four to six hours to stave off withdrawal—cravings, tremors, cramping, and agitation. Without treatment, opiate users will seek another fix, perpetuating the cycle of use. Methadone also blocks the euphoric effect of subsequent administrations of opiates—preventing the “high” many users seek—and, more generally, keeps the yearning, which Vincent Dole called “narcotic hunger,” at bay.
But methadone or Suboxone is not a short-term fix. According to Mark Parrino, president of the AATOD, “one to two years is generally regarded as minimum length of care for opiate addicts. Some people need many more years.” Toward the end of treatment, the focus is on slowly reducing the dose of methadone until a former addict can face life without the drug. As a rule, the longer a patient stays on methadone—and the longer the period of time spent weaning their dose down to zero—the more likely he or she is to remain drug free after leaving the program.
Yet methadone maintenance has always operated under a pall of suspicion. The clinics themselves are often unwelcome additions to a neighborhood. Patients may loiter near the premises; drug dealers ply ambivalent patients with Valium or cocaine as they come and go. Law enforcement officials and politicians have assailed methadone as a way of merely replacing one addiction with another. They are also concerned about methadone diversion. Meanwhile, some African American activists once condemned methadone maintenance as a lethal distraction from deeper social ills such as racism, poverty, employment, and housing.
Finally, many politicians and law enforcement officials are still skeptical of methadone because of patients’ stubbornly high rates of relapse to heroin. The outcomes are modest for several reasons. Not all people enter a methadone clinic with the goal of quitting. Some just want to avoid opiate withdrawal symptoms or placate a probation officer. Other patients drop out because, once they get off heroin, they begin heavier use of alcohol or other drugs like cocaine. A number seek what the Beat novelist William S. Burroughs called “the reduction cure”—they take methadone for a few weeks and then taper off rapidly, resulting in a lowering of their physiological tolerance level. The plan all along is to return to heroin use—but the lower tolerance makes them more sensitive to the effect of the drug. Thus, they need a smaller, and therefore cheaper, dose to get a good high.
Even patients who complete at least a year in a methadone clinic and taper off their dosage slowly over months, however, have about even odds of falling back to old patterns within the next year. Not surprising, perhaps: they still may lack job skills, are ill-equipped to resist drugs without the pharmacological safety net of substitution therapy, and return to familiar drug-soaked neighborhoods. As Vincent Dole himself said many times, “The stupidity of thinking that just giving methadone will solve a complicated social problem seems to me beyond comprehension.” Still, methadone patients almost universally use less heroin, commit fewer crimes, and are less likely to spread blood-borne disease via needles than those not in treatment. While many will continue to use drugs and alcohol, engage in crime, perpetuate contagion, and remain unemployed, it will be at a mercifully lower rate.
The lessons of the last fifty years are these: Virtually all addicts will use less heroin and commit less crime during even a brief exposure to opiate substitution treatment. If patients take methadone for only a few weeks or months, however, lasting results are nil. If opiate substitution treatment is to fulfill its promise, addicts must not only enter drug treatment but stay in a program for at least a year.
That takes leverage—and there’s no institution with more leverage than the criminal justice system. In particular, the roughly 3,000 U.S. drug courts are in a good position to help keep addicts in treatment through enlightened leverage of rewards and sanctions combined with substitution therapy.
The first drug court opened in 1989 in Florida’s Miami-Dade County under then State Attorney Janet Reno. The idea was to divert nonviolent drug users from incarceration through treatment. Today, Florida has more than 100 drug courts, California has over 200, and New York has about 170; Washington, D.C., has three. About 145,000 people participated in a drug court in 2013.
The long-standing hostility of the criminal justice system toward methadone has thawed only slightly. Providing methadone maintenance therapy requires that a jail or prison obtain a DEA license; most don’t. In Washington, D.C., for example, the jail system does not allow our patients to remain on methadone, but at least they use medication to help them taper off it. In Virginia, by contrast, detainees routinely go “cold turkey,” ensuring a miserable period of withdrawal. These approaches are nothing less than a prescription for relapse to heroin upon release a few days or weeks later. In Anne Arundel County, Maryland, some facilities will maintain patients on substitution therapy. But that is a striking exception. Sally Friedman, legal director of the Legal Action Center, a New York City-based advocacy group for people with substance use problems, told me, “We get a constant stream of calls from people who came before a judge and were told, ‘You have ninety days to be off methadone or you’ll be in violation of probation.’ People relapse and die because of these misguided orders.”
In the early 2000s, few drug courts allowed participants to be maintained on methadone. By 2012, however, the National Association of Drug Court Professionals recommended that medication should no longer be withheld from any offender. Even so, the culture has not changed enough: in a 2013 study published by the Journal of Substance Abuse Treatment, 98 percent of drug courts surveyed enrolled opioid addicts, yet fewer than half offered substitution therapy.
Drug courts typically work by offering nonviolent criminal addicts a bargain: if they plead guilty and complete a treatment program closely overseen by a judge, the court drops the charges against them. During the typical twelve- to eighteen-month drug court supervision, the addict-offender is required to participate in the program. If defendants miss appointments or test positive for drugs, drug court judges react with sanctions—swift and certain but mild—that graduate in intensity for repeated offenses.
Thus, a first-time violator might start with a stern warning and a fairly moderate sanction (e.g., a requirement to spend several hours or several days observing court sessions). Upon subsequent missteps, if there are any, the penalties escalate—perhaps cleaning the courtroom, attending an outside meeting like Alcoholics or Narcotics Anonymous, or spending one night, then several days, in jail. If the individual persists in violating the rules, he or she may be sent to more intensive treatment, if deemed motivated, or is returned to the docket to go through the standard adjudication. Rewards are also available to participants: fewer urine tests, less-frequent so-called status hearings with the judge, and other perks. This process of shaping behavior with penalties and rewards is called contingency management; a massive academic literature supports its effectiveness.
Drug court dropout rates are significantly lower than dropout rates of patients in methadone treatment. On average, two-thirds of drug court participants graduate drug free at eighteen months, while half of methadone patients not involved in the drug court system have quit their treatment program after one year. Compared with probationers undergoing standard probationary conditions, the rate of return to crime and drug use among drug court participants is about one-half to one-third lower. These reductions in recidivism persist for at least three years after
With participants less likely to bolt from treatment, methadone or Suboxone has time to stabilize them. But there is no one-size-fits-all approach to substitution maintenance. Let’s start with the addict-offender who is already taking methadone or Suboxone at the time of arrest. Without question, he or she should remain on the medication. Younger patients on methadone might be encouraged to consider switching to Suboxone over the course of several months: Suboxone is more convenient, less symbolically fraught, less lethal in overdose than methadone, and somewhat easier to taper off of.
But most patient-offenders entering drug courts are not already in substitution therapy. Drug courts are a good option for them too: the swift and certain sanctions alone often provide enough incentive to quit using illicit opiates. What’s more, the average opiate addict today has characteristics that signal a good prognosis. During the 1960s and ’70s, addicts tended to start using in their teens, were ensconced in a drug subculture, and used other substances. Today’s addict is more likely to be employed and older (in his or her twenties) at the time of first use of illicit painkillers, and to have the social and sometimes financial support of friends and family.
No doubt, however, a sizable subset of these participants will continue to submit positive urine tests. For them, substitution treatment makes good clinical sense. Practitioners must decide whether to advise patient-offenders to remain on the medications indefinitely or to taper off slowly during the final months of drug court. Older opiate addicts who have been through several cycles of treatment and relapse should seriously consider lifelong substitution therapy. Many patients in our clinic have been on methadone for up to a decade with no ill effects; as this article was going to press, I met a woman who has been doing well with methadone maintenance for the past twenty-seven years. Eighty-year-old trumpet player Jimmie Maxwell, who played with Benny Goodman, had been taking methadone for thirty-two years when the New York Times profiled him in 1997. But younger individuals who have been dependent on opiates for only a few years or less should probably consider abstinence as an ultimate goal.
Finally, participants need to be able to resist drugs after they graduate from the program. Relapse prevention, a proven strategy for avoiding situations that render addicts vulnerable to resuming use, teaches them to identify cues that reliably trigger a burst of desire to use drugs and alcohol. These can be the people, places, and things associated with their old lives, or internal cues, such as stress and boredom. Patients rehearse strategies for avoiding the cues if they can, and learn techniques to tolerate and reduce cravings when they cannot.
Half a century ago, long-term opiate substitution became a viable practice as the nation found itself in the midst of a blossoming heroin epidemic. Today, we know that substitution medications, relapse prevention skills, and other rehabilitation efforts can improve the lives of addicts, and save society both money and sorrow. The most promising arena for this effort is the criminal justice system: faced with the rewards and sanctions of drug court, participants are less likely to bolt. Although the criminal justice system is off to a slow start, merging these elements could be a winning prescription for our current opiate problem.