Methadone administration.
Methadone is used as a replacement for heroin, in treatments aimed at either abstinence (reduction cure) or maintanance. For the medicinal treatment of abstinence syndrome, it appears to work no less well than Librium. NOTE 17
The idea of substitution and withdrawal is not particularly modern: a royal decree given by the second King of Thailand in 1809 suggested a course of selftreatment for opium dependence consisting of gradually cutting down the daily dosage until complete abstinence was reached. NOTE 18
Supplying methadone to heroin addicts was discovered by Dole and Nyswander, and was based on a somaticmedical theory: heroin use apparently brings about a metabolic disorder which makes further use of heroin or other opiates a necessity. By supplying methadone, which should correct this disorder and block the euphoric effect of heroin, patients should be able to function normally. NOTE 19 NOTE 20 The results of treatment appeared to be impressive. NOTE 21 NOTE 22 NOTE 23 At last there was a medical treatment for heroin addiction aimed at improved functioning: methadone maintenance.
The rationale for this treatment was and still is that supplying methadone would reduce the criminality associated with heroin use and would enable heroin addicts to lead a socially productive life, or, as it was put in a recent Dutch methadone pamphlet, Methadone is intended to enable the user to function without the use of illegal substances and without the related risks such as criminality, infectious diseases etc.' NOTE 24
As has already been stated, people's expectations regarding the results of supplying methadone appeared to be surpassed by what actually happenned: Gearing's evaluation of Dole's program NOTE 22 NOTE 23 showed that 50 80 % of patients had returned to a 'socially productive' life.
Yet Trimbos NOTE 25 who, already in 1971, visited Dole & Nyswander's program in New York, had his doubts. Where addiction was the result of character defects, methadone treatment only masked the defects, and as such was only a cheap show of success. Dole and Nyswander rejected premorbid sociopathic behavior as the cause of the addiction and Trimbos felt more or less obliged to follow them in this opinion, impressed as he was by the data he was given, but he remained wary and missed 'attention to the sociogenesis of the addiction disease'. His doubt can be read between the lines. Besides, once the opiate receptors had been discovered by Kosterlitz in 1972, it was of course, easier to avoid the either/or position prominent at that time.
In 1972, Maddux and Bowdon NOTE 26 fired some sharp criticism at the methadone treatment. They state that 1) the replacement of heroin by methadone in itself is already regarded as a success, 2) the reduction of criminal behavior is not clearly demonstrated in the published data, 3) the stated number of those in work averages only 15% higher than in drugfree treatment programs, and it is in no way clear that this 15 is due to the methadone. They regarded the reports about the success of the methadone treatment both ambiguous and exaggerated.
Preble, NOTE 27 whose own field observations gave him a distinctly less rosy picture than the results presented by Gearing, showed that Gearing's figures originated from the programs and these results in turn were based on unverified information given by the patients themselves. Gearing had himself not checked how his patients were faring, and his findings, as such, were totally unreliable. Preble himself described the behavior of the socalled socially productive people as follows: "They pick up their methadone, get their welfare check and pay their rent, buy pills and drink booze", an image with which we in the Netherlands have become all too familiar in the eighties. Only 14% of the population investigated by him used the methadone as it was intended, that is, remained free from all other drugs, did not engage in criminal activity and were in work. Besides, Haddox and Jacobson NOTE 28 indicated as early as in 1972 that it is possible to predict whether or not the maintenance treatment will work, with the aid of psychological tests.
So far, we have the history of methadone administration in the US. In the Netherlands, we see a completely different development. Here too, in the late sixties, opium addicts were treated with methadone for the first time and this was extended to a regular program after the introduction of heroin in 1972, but in contrast to the American programs, it was a reduction program here, in which far lower doses were kept to. However, recidivism after completion of the cure turned out to be the rule rather than the exception, followed by readmittance to the program for another cure. This practice grew into a sort of zigzag pattern; no maintenance, but a series of gradual reductions of dosage alternated with sudden increases.
In 1977, the Stichting Kontakt Sentra from the HUK started up with a major 'low threshold' maintenance program for its clients, whom they already knew from years of observation.
'With this assistance, we hope to bring about circumstances in which the role of heroin in the addict's life will have less emphasis (humanizing), that the rhythms of the user's life will become more regular, whereby access for further help will be increased and all kinds of activities (work, living outside of Amsterdam, group outings, etc.) can be realized much more easily . NOTE 29 ' With the so called low threshold character of this program, it should be noted that this refers primarily to the demands made within the program itself of those taking part, while entrance to the program was extremely difficult, aimed as it was at only very problematic addicts.
The goals of this program were very different from both the maintenance programs in the U.S. and the gradual outpatient detoxification/resocialization.
The belief that a junkie taking methadone will become a respectable citizen a la Dole & Nyswander, which still appears to survive in some circles, was in any case, thrown overboard.
The treatment concept disappeared. Others suggested a new, equally medically oriented vision to take its place. It was based on the concept of 'selfmedication'. In this vision, the supply of methadone is seen as a remedy given according to phychiatric indication: methadone as an antipsychotic and/or major tranquilizer.
This is best illustrated in the principle of 'basic' administration, formulated by W.G. Mulder in the early eighties on epidemiological grounds. This became the guideline for Amsterdam's methadone policy. Come, swallow and go, was the motto, combined at the most with elementary medical care. There was no place for other sorts of intervention aimed at rehabilitation within this system, and if clients wanted that, they had to look for it elsewhere. Amsterdam politicians have translated this (most unmedically) as the principle of 'Do ut des', I give in order that you shall give, with which is meant that the junkie gets his methadone in order that he will behave more sociably.
The mistake in this thinking is that the junkie on the one hand wishes to alter his behavior, while it has long been clear that heroin use gives meaning to the life of the addict NOTE 30 NOTE 31 , and on the other hand, the expectation that the proffered methadone can come close to the desired heroin. But the junkie who finds his way to a methadone program does not do it out of desire for treatment which aims at a change in behavior which he himself is also striving for, but as a pharmacological emergency intervention, to which he goes only when he is unable to survive independently. He does not want to stop with the dope, but he cannot be it for a longer or shorter period continue the way he has been carrying on: he is too old, too tired, to weak. NOTE 32 NOTE 33
Both the outpatient detoxification programs and the programs aimed at only the most extremely problematic drug users have in common that the supply is seen as only part of a total treatment aimed at rehabilitation. It is ironic to note that precisely what they are attempting to prevent with the low threshold 'basic' administration is taking place here in the Netherlands. But in the abovementioned article by Preble NOTE 30 and in an article by Soloway NOTE 32 , the effects of large, open methadone maintenance programs were already made clear in the seventies. Under these circumstances, the administration of methadone is merely a palliative. Just about all that was described at that time took place in the Netherlands in the eighties. He who will not learn when told, must learn by experience.
Giving methadone to addicts in all its various forms is still regarded as medical treatment, pharmacological intervention. Practice gives us another view. 'Basic' supply without a structured treatment program aimed at rehabilitation is not treatment at all.
Who continues to prescribe a medicine if it turns out not to work? There is little doubt possible about the fact that in a considerable proportion of methadone clients, methadone use does not lead to the significant social rehabilitation described by Dole & Nyswander.
On top of this, practice teaches us that supplying methadone entails 'for life' in the majority of patients. Not that there would be anything against this if it worked, but we see that it doesnot.
There is even a poorly thougtout pronouncement by a Dutch court that methadone is an addict's right. Each Dutch citizen of course has a right to medical facilities and these rights are laid out in the statutes for medical insurance. Medical insurance companies however, quite rightly refuse to pay for (the more or less 'basic') methadone programs, as methadone supply in the Netherlands is not usually a medical treatment. Methadone is provided by the government as a subsidized stimulant for every junkie.
Another model worth considering is combining supply with reform: methadone will be given as long and only as long as the patient stays on the straight and narrow. This would be a rational application of the 'Do ut des' principle, according to the American model of Dole & Nyswander, but subject to strict individual control. If someone fails on a program such as this, that is, gets into trouble with the police, he would have to wait for, for instance, 2 years before being allowed to start again. We are no longer dealing with medical treatment, but with functional behavior seen from the eyes of the upholders of order. The number of participants in such a program would not be much more than 5% of the present methadone clients.
In 1984, De Mug, (a Dutch paper for the jobless) NOTE 34 suggested that methadone be used purely as a medicine, thus treatmentoriented. We can safely assume that no more than 10% of the present number of patients would be eligible for this. In any case, giving methadone remains a possibility as part of an integrated treatment in which concrete goals and checkpoints have to be reached at a certain time. In the case of failure, the methadone might be quickly phased out.
'Basic' administration as a medical function is now being extended as bait, particularly in relation to AIDS, but then one is tying people to a longlasting pharmacological chain from which it is more difficult to get free than it is from heroin. It would be more logical with regard to AIDS, just to legalise heroin. Taking part in a methadone program does not appear in any way whatever to increase one's sense of responsibility and that is after all the main point where the HIV problem is concerned, not to mention resocialization.
Of course, methadone or morphine can be administered intravenously as a palliative treatment (for instance to addicted AIDS patients), but this is also possible with heroin.
The reader could be forgiven for thinking that this writer is opposed to methadone. That, however is not the case. He is just as much or as little opposed to methadone as to heroin or other drugs. Even though the original goal of administering methadone, that of rendering property crime unnecessary for the procuring of opiates, has not been reached to a significant extent with large numbers of addicts, the legal, medicalized provision of methadone has not only had a positive effect on the heroin market, but also on the impact of the AIDS epidemic.
No, this writer is against the hypocrisy in the foundations of methadone administration. The inevitable conclusion is that methadone administration in the Netherlands has in many cases, no medical or scientific aim, and is thus in conflict with the opium law, and is in fact maintained in order to undermine the law.
This is, of course, a serious matter. This writer has pleaded before for the abolition of the opium law NOTE 35, as the penal approach to the misuse of substances has not proved itself to be an unmixed success. Addiction is bad enough without turning the addict into a criminal. This observation compels us to ask whether we are indeed happy with the 'uneasy concensus' between doctors and the keepers of order who, for the greater part, decide what form the present methadone policy will take. It's fine to pick holes in the opium law, but abolish it then, or if that isn't possible due to 'international' consequences, at least admit that you are circumventing the law by, for instance, removing all the rigmarole around handing out the drugs: give each junkie a credit card to take to the local pharmacy for his desired portion instead of to a drug 'helper'. And let him pay for his credit card noone gets his kicks for nothing.
Opiate antagonists
The problem of addiction led to the search for substances with the painkilling effects of morphine but without its addictive effect. The first result was nalorphine, an opiate antagonist which can thus be used for the treatment of an acute overdose of opiates. This material blocks the opiate receptors, so that they cannot be stimulated by opiates. It must be applied with care: an overdose provokes an acute withdrawal syndrome among opiate addicts! All the same, nalorphine also proved to have some effect as an opiate agonist and was thus subjected to further research.
The next substance was a full antagonist: naloxon. This genuine antagonist has virtually no effect except after the use of opiates. Soon afterwards naltrexon was developed. This substance has the same effects as naloxon, but it is more suitable for oral application and is effective for a longer period. These substances completely block the effect of opiate agonists without any appreciable sideeffects. The substance is virtually nontoxic. If naltrexon is administered in sufficient doses (120 mg 3x week), the effects of heroin are completely countered. The pharmacological basis for naltrexon therapy which is proposed in the US and is also being considered in the Netherlands is thus beyond discussion. Since the blockade is competitive, high doses of heroin can overcome the naltrexon. However, this seems pointless: such large amounts of heroin are expensive, and it is easier to take naltrexon once than simply to carry on using heroin. There is therefore no point in naltrexon maintenance for those who do not want to live a clean life, but it is useful for those who do. Naltrexon can protect this group against unforeseen situations in which they might give in to sudden temptation (the return of an old friend from the scene, etc.).