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handcuffs addicts resentfully call it, with their
penchant for making things just a little more dramatic
than is necessary, but also reflecting the view that treating
heroin dependence with methadone is merely substituting
one addiction for another. The term refers to the fact
that methadone normally can be obtained only in one- or
two-dose amounts and thus requires drug users never to
be more than 24 hours from their source, severely limiting
their freedom of movement.
But
the phrase also acknowledges that the use of methadone
is closely linked to the confusion between drug addiction
as a criminal problem or a health problem.
One
of the reasons addiction is still not well managed is
that doctors do not want to manage it. With good reason.
Buried in the ancestral memory of the medical profession
is the aftermath of the Harrison Narcotics Act of 1914,
which made prescription of opiates illegal in the United
States.
Most
addicts then were middle-class white women, and doctors
attempted to continue to supply them.
The
authorities set about to make an example of these doctors,
and many were convicted, struck off or jailed. Pretty
soon, even the medical schools quietly ceased any discussion
of the treatment of addiction. Once addiction became
predominantly a problem of the black population, interest
in it fell away completely.
Today,
doctors who specialise in addiction are seen as─and
act as though they are─on the fringes of their
profession. (This is where you will find the doctors
who still smoke cigarettes.)
In
1914, as now, prohibition alone did not work. Addiction
became and remained a criminal problem.
Methadone
made it possible for that attitude to change by providing
a workable medical treatment for addiction. The drug
was developed near the end of World War II when Nazi
scientists, running low on morphine, developed it as
a form of pain relief. For a long time that was seen
as the extent of its usefulness.
If
any one person was responsible for discovering there
was more to it, it was Dr Marie Nyswander, the founding
mother of methadone maintenance treatment for the relief
of opiate addiction and author, in 1956 of The Drug
Addict as a Patient, a book which, as its title
made explicit, radically rethought the problem of addiction
and its treatment.
Nyswander
stumbled upon the effectiveness of methadone by accident.
She and Dr Vincent Dole had been working with addict
inmates in Lexington, Kentucky, trying to find levels
of an opiate─any opiate─that would maintain
them in some sort of equilibrium. The experiment seemed
to have failed, and her team decided to detox the patients
and end it. To achieve this they gave them high doses
of methadone.
And
a remarkable thing happened─the focus of the subjects'
days started to shift from obsessing about where their
next dose of drugs would come from. They began to talk
about hobbies, work, education and other interests.
The methadone had ended both their craving and their
need for a high.
Better
yet, it turned out, it also blocked their opiate receptors
so that heroin, or any other opiate, would have no effect
if taken. Methadone literally sits in the receptor and
stops the heroin getting in. It is this attribute which
makes it so effective.
There
are those who will say that the main difference between
heroin and methadone is that the former is illegal but
the latter is not. They have a point. Any drug that
can be used can be abused and methadone is no exception.
Despite the inferior quality of the stone that can be
obtained from it there are still people─drug experimenters
at the so-dumb-they'll-try-anything end of the spectrum─who
will take it `recreationally'. The difference between
its effects and those of heroin for the user is roughly
the same as that between calf's liver and foie gras
for the gourmet.
This
is how people abuse methadone. If you don't have a prescription,
you need someone who does to get it for you. They will
go to the chemist for their orally administered dose
and, by sleight of mouth, either dribble it into a phial
around their neck or go outside and expectorate it into
a container.
Most
would-be abusers swallow it. Some─doubtless seeing
themselves as purists─insist on injecting it.
This can cause large pullulating abscesses on their
arms due to the extra bacteria they have shot up along
with their treat.
But
for addicts on a responsibly managed methadone maintenance
program, the effect of the drug is in its own way as
much of a life-altering experience as heroin. It is
safe─when it hasn't been diluted with orange juice
and left where the kids can get it. (Although people
can overdose on methadone the risk is low because, unlike
street smack, it comes in reliably measured doses.)
Unlike heroin it tends not to increase tolerance so
that bigger doses are necessary to achieve the same
effect. It improves intellectual and sexual functioning,
allows people to have jobs and relationships, improves
general health, lets people experience emotions and
respond empathically to fellow humans, even restoring
the normal relationships which were sundered by addiction.
It allows people to feel pain, and to be prescribed
effective pain relief.
For
a portion of non-drug using members of society, methadone
is an acceptable treatment not because it improves the
lot of junkies but because it improves their own quality
of lives by reducing the crime committed to feed addictions
and, in the days before needle exchange programs, it
reduced the risk of HIV/AIDS transmission in the community
by obviating the use of needles.
Methadone
has indeed saved more lives than those of drug users─people
who weren't murdered in the course of burglaries committed
to feed habits, family members who weren't driven to
despair by addicted children or parents, children who
were born and raised by addicts who otherwise would
have struggled constantly just to maintain their habits.
Recently,
other pharmaceutical treatments─notably Naltrexone
and Buprenorphine─have been advanced as superior
remedies for addiction. They may indeed have the capacity
to end addiction once and for all. But as of now they
have their own drawbacks and await further research
and possible improvement.
Methadone
is not a cure. There is a high level of relapse into
opiate addiction from people who attempt to go off it
in any but a rigidly controlled manner. But at this
time, methadone, for all its failings, is still the
best hope an addict has of leading anything like a normal
life.
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