News and recovery-oriented commentary about current controversies, emerging trends and research findings related to drug and alcohol addiction, treatment and recovery.
Thursday, October 16, 2008
More on Methadone
My recent post on methadone prompted several comments, some making really great points. I decided to post all of them so that they would not be missed. The last 4 comments are great, you can guess what I think of the first 2.
armme said...
Your still working on the idea that addiction is some spiritual malady. Your way of thinking is in the DARK AGES, my friend. Your idea of recovery will soon be a thing of the past. It will be like performing an Exorcism on mental illness...once thought to be the ONLY form of treatment, but now considered completely irrational.
Your still trying to stop drug use...when you should be focusing how to get the addict to live a better life. Your treating an illness of endorphin dysfunction by taking away the only thing that corrects that dysfunction with stability.
You can continue to offer people your "exorcism approach" or you can learn the science behind opiate addiction and realize stopping people from using drugs doesn't stop the disease.
Do you want to treat the disorder so these people can have a better life--or do you just want them to stop using drugs no matter HOW miserable they have to be to do so?
Sometimes, MANY TIMES, you can't have both. Not with opiate addiction.
Anonymous said...
"counseling", while possibly helpful to some who may need referrals to things like job training, childcare, housing options, etc, is NOT the answer to most hardcore addiction problems. Science has shown clearly that addiction is a brain disease, a disruption of the brain chemistry. That is not something you can repair with a few hours of talk therapy. If talk therapy (or meetings or group therapy) worked even fairly well for addiction, there would have been no need to come up with something else to treat it--but it didn't and doesn't. We don't treat ANY other legitimate disease this way. People with schizophrenia, bipolar disorder, clinical depression, etc--all brain chemistry disorders--may receive some therapy sessions but it is almost always in conjunction with MEDICATION, which does the actual work of repairing and restabilizing the brain. Why should addiction be treated differently--especially when it has been clearly shown that abstinence based treatment has an extremely low effectiveness rate for addicts and particularly for opiate addicts?
Anonymous said...
As a recovering IV addict for more than 35 years, I continue to be appalled by these guys who push needles, methadone maintenance, etc. with their well-meaning efforts to "help us." Thankfully, none of you were around when I got clean - only people who assured me that I could in fact get clean and live a happy life.
The expectation that people like me are largely unable to find lasting clean time undermines our chances - and makes the way for the "experiments" by psychiatrists and others - naltrexone, methadone (now at new and much high doses!), acamprosate - hell, the Chinese drill out our limbic system with a Makita.
The lie is exposed - we CAN recover.
Anonymous said...
I too am a recovering IV user. I had the experience of being on maintenance several times and also of doing 21 day methadone detoxes in California a few times. My experience when I was using was that every time the methadone kicked in, the urge for CRACK became overwhelming. My problem is that I am a drug addict who has an allergy to drugs. When I get drugs in my system I want more and more and more. There is not enough methadone in the world to make me happy, or to fix whats wrong with me. I could drink a ton of methadone and be close to death but still be crawling across the floor trying to find more drugs. It doesn't work for me. Recovery after many years of using and living the lifestyle was not easy, but it did get better, and the alternative was way worse. I am SO glad that I was introduced to a program of abstinence based recovery and that the system did not give up on me by relegating me to a methadone clinic for the rest of my life. I am also quite sure that my family, the courts and everyone else on the road is glad as well. Recovery has changed my life!
Anonymous said...
You are SPOT ON in describing the "study" practices of those who want the world to believe that methadone is a miracle. Thanks for stating it this way.
The belief that methadone maintenance has a higher success rate than abstinance-based treatments is another huge lie these people use. They want to compare the people taking methadone to the people who have tried abstinance, without holding the same goals for each method. The maintenance population as about a quarter of the success rate at remaining abstinant as the other group after leaving mmt.
I personally think that nearly every sample used in these studies has a bias, and it is meant to be that way. The people conducting these "studies" have something to sell, and I think people should keep that in mind. It's little more that advertising in a free market economy, IMO...
Dr Dave said...
Nice critical appraisal of another tired study that does not help move things on at all. I couldn't agree more that low expectations of what opiate addicts might achieve is fundamental in ensuring that they don't achieve more.
I'm a doctor who is also a recovering opiate addict. At no point was methadone suggested as a treatment choice (apart from detoxification). The expectation was that I would recover with the right sort (and duration) of treatment. Now I adopt the same high expectation of my heroin addicted patients. They get better and stay better in the main. Our service is filled with reovered addicts who infectiously pass recovery on to their peers. Okay, so my recovery capital is arguably much higher, but we can increase the chances of success with some simple interventions (linking into recovery communities, providing housing and employment solutions, giving aftercare and long term management plans which focus on the client self-managing). We do it. It works. People get better.
9 comments:
Anonymous
said...
Your remarks about methadone having a different criteria for success are, sadly, correct. Apparently, your indicators of success are only measured by a person not having any medications in their system--whether or not they are prescribed to treat a legitimate mental dysfunction. Simply abstaining from that (while smoking and drinking coffee--the drugs "allowed" by AA/NA) accounts for full recovery by those standards.
However, full recovery in the methadone program is defined differently--true enough. We define recovery as being restored to a productive, law abiding, responsible life--one that need not be spent suffering daily from severe depression, simply because other people cannot accept that what works for them may not work for everyone else.
How many failures of the 12 step treatment modality must one endure before they are "allowed" to try something else? Five? Ten" Twenty? Until they die? And why are they to blame when a program developed by a stockbroker with no medical or scientific background, and based on a religious cult, not updated in 70 years, fails to work for them?
First, as I said in the previous I'd welcome all clients being able to make an informed choice.
If I saw local methadone clinics producing the kind of recovery you describe, I'd have different feelings about them. They are all dosing clinics. I'm not sure what you mean by "allowed." Methadone clinics and outpatient treatment are the only forms of treatment that are available on demand in our region. And, these clinics serve poor addicts with no other options. They are places of despair.
Again, though, why do opiate addicted heath professionals have such high rates of success without methadone? When opiate addicts are offered treatment of the appropriate intensity and duration with long term monitoring and swift re-intervention, they do well.
And you know that the methadone clinic is a place of despair how? Have you visited recently> Worked there perhaps? I bet not. Have you even bothered to talk to long term compliant successful patients?
Where do you get the idea that healthcare professionals have a high rate of success? Just because they normally aren't offered MAT? It's not because it's not an option. I know quite a few medical professionals on methadone.
the ONLY goal of abstinance based treatment seems to be ABSTINANCE. That is the ONLY marker for success in studies of that modality. So tell me-how is it not TIRED and OLD that they aren't measuring success differently in those studies? Why not make the indicators be things that MATTER like re-united families, employability, happiness,etc etc. Do you really believe it matters HOW someone gets those things, as long as they get them? Why not make it about wellness instead of goodness/badness.
First, my comments were specific to clinics in my area. I'm open to the idea that recovery-oriented MMT clinics exist, but not in my area.
Second, I've twice said that I would welcome a system that allows the client to choose from MMT or recovery-oriented treatment of an adequate duration of intensity. I've also said that I'd feel differently about comprehensive treatment that includes methadone. This post from a friend who once worked in a program addresses this point: http://www.dawnfarm.org/2008/05/methadone.html
Third, I have never personally visited a methadone clinic, but I work with colleagues who have worked in methadone clinics, people who have been methadone clinic patients, I interview counselors who currently work in methadone clinics and are looking to get out, I drive by a clinic on my way to and from work and see everyone lined up for their dose, and I work with scores of clients who have previously been methadone patients. Admittedly, this is a biased sample, but at conferences, meetings, etc, I've never meet someone who's put forward a group of successful clients.
Fourth, who's talking about badness? I think the post just before or after this one questioned CADCA's use of those very words.
Fifth, I'll be the first to admit that abstinence focused does not mean recovery focused. There are a lot of crappy abstinence focused programs that are also places of despair. Abstinence focused does not equal good.
Sixth, there's a lot wrong with a lot of research but methadone research constitutes a special black hole when it comes to measuring wellness. The origins of federal research and support for methadone are not was not for treatment purposes, but for crime control.
To quote from an article in support of MMT, "The positive evaluations of MMT rest primarily on what it reduces and eliminates (e.g., heroin use, crime, HIV transmission) rather than on what it adds to the quality of individual, family, and community life. As a field, we know almost nothing about the pathways, styles, and development stages of recovery for MMT patients and their families. The absence of pathology tells us nothing about the reconstruction of character, personal identity, and interpersonal relationships within methadone-assisted recovery. People in stable, long-term, methadone-assisted recovery are as invisible in the research literature as they are in the larger culture."
I'm earnestly looking forward to this research and I'll post it when it arrives. In fact, if you want to send me some studies and a summary, I'll post that too.
BTW - Here's a post regarding AA and methadone: http://www.dawnfarm.org/2008/02/methadoneaa-link.html
You know licensed health professionals, currently practicing, on methadone? In what state?
Regarding your questioning health professional recovery rates: "physicians do not fit the typical, and erroneous, stereotype of addicts (i.e., poorly educated and from lower social classes); however, physicians have their own special risk factors, including easy access to controlled substances and, as a group, relatively high rates of alcohol consumption. Also, physicians entering addiction treatment report particularly high rates of problem complexity, e.g., family histories of addiction, multiple drug choices, co-occurring medical/psychiatric conditions, and other significant obstacles to successful recovery (Domino, Hornbein, Pollissar, et al., 2005).
Despite these risk factors, the documented long-term recovery rates for physicians are among the highest reported — between 70 percent and 96 percent (Talbott, Gallegos, Wilson, & Porter, 1987; Gastfriend, 2005; Domino, et al., 2005). "
I was in no way referring to what my criteria for success are. I didn't personally have a hand in any of the studies we are discussing. I was referring to the promotion that methadone has a higher success rate than abstinance-based program being a skew of the truth, at best. Because, the two modalities do not hold the same goals. If you say that success is simply gaining independence from a street-level drug dealer, then methadone treatments are far more successful. But if you say that success is becoming totally absinent from narcotics, then abstinance-based programs are far more successful. Just to say that methadone is more successful is, in my opinion, an attempt to "hand pick" what is used as criteria for being successful, unless it is noted what the term successful means for both modalities.
It's no secret what the relapse rates are for those in abstinence-based treatments, and it's also no secret what the relapse rate is for those both on methadone and those who have discontinued methadone treatment. The only secret seems to be what is considered to be successful by those two groups when the studies are conducted.
I've been inside the line of a methadone clinic many times, and the comment about it being a place of despair is much closer to the truth than the wonderful image that is so widely promoted today. It's not all roses, as you know I'm sure. I was astonished at the number of the patients at my clinic who did not like waiting in that line, or waiting at all, out of fear that what they were using on top of their methadone would hit them before they got the chance to take their dose.(And before you say they needed an increase, there were no problems at my clinic when one wanted an increase, nor was there a cap.)
If that is the type of methadone patient you are referring to when using the term wellness, or success, then we (you and I) have a fundamental disagreement, and in my experience, this group was by far the majority at my clinic.
The differences in what is deemed to be successful in the two modalities is not something that should be taken lightly. And to say studies have shown that one is more successful just because they hold a different criteria for success is immoral, and it is unethical to conduct a study comparing two groups when the criteria for comparison is not the same.
OK so your saying that the criteria for success in "methadone studies" is quote: black hole.
So tell me, what is the criteria of success in the paper you quoted about health care professionals? What is the indicator for their "success"? I'd be willing to bet its two things "abstinance" and "links to support systems". Talk about a black hole! NOW, take into account that the only way that these studies KNOW that the person is "clean" and "in support" is the person SAYS THEY ARE! There is no tangible way to rate success with the standards you picked: "has the persons quality of life been restored"? If a person on methadone said YES to this statement would you believe them? Why should we believe people on the other side then>?
The methadone treatment studies at least rate success by things that can be PROVEN: drug testing, absence of infection, treatment duration, interactions with the law. These compared to:"are you clean?" as the ONLY indicator of success in a abstinance based study? It's apples and oranges. What health care professional answering these questions is going to say "NO", even with anonymity promised. No wonder the rates are high--if they were at least doing weekly drug testing on these people for two plus years-then I could at least say the data was proven!!
I know practicing nurses and clinical scientists on methadone...and many more on suboxone. No, I don't know doctors on methadone-however (because of stigma) I don't imagine we ever WOULD know if they were or not. I also know a successful lawyer, a secruity guard for a hospital and have read news article about a cop on methadone.
The fact that you think it's out of the realm of possibility that a doctor could be on methadone shows how ignorant and bias of the treatment you are.
You have included people on your list of "how you know about methadone treatment" only people that would NATURALLY have a negative opinion of it. Why not talk to a long term patient? Or a long time staff member at a clinic? A clinic doctor? Better yet, talk to a new patient just getting their lives back--it's a pretty inspiring thing to see someone get well almost overnight.
It said methadone studies constituted a special black hole when it comes to measuring WELLNESS--the construct offered by the other comment. I also included a quote from an article advocating greater acceptance of MMT. It acknowledged this problem.
You also are making a lot of assumptions. I'm also open to the concept of drug assisted recovery. I'm happy for any addict that recovers, whatever their path.
I addressed a lot of your statements in earlier comments. I know people who have been on methadone and have worked in methadone clinics. I keep hearing about recovery oriented MMT, but it doesn't exist in my region.
What state's monitoring agency allows nurses to practice while on MMT?
I would also like to know what state's monitoring agency allows nurses to practice while on MMT. And as far as finding long term patients, that's an option. Or even clinic doctors, but they don't always know any more than anyone else, and use it as a secondary practice. But long-term clinic staff are extremely rare, as the turnover rate is enormous. If you want a real education on mmt, find a FORMER clinic doctor, and listen to what they have to say when their paycheck is not in any sort of danger.
9 comments:
Your remarks about methadone having a different criteria for success are, sadly, correct. Apparently, your indicators of success are only measured by a person not having any medications in their system--whether or not they are prescribed to treat a legitimate mental dysfunction. Simply abstaining from that (while smoking and drinking coffee--the drugs "allowed" by AA/NA) accounts for full recovery by those standards.
However, full recovery in the methadone program is defined differently--true enough. We define recovery as being restored to a productive, law abiding, responsible life--one that need not be spent suffering daily from severe depression, simply because other people cannot accept that what works for them may not work for everyone else.
How many failures of the 12 step treatment modality must one endure before they are "allowed" to try something else? Five? Ten" Twenty? Until they die? And why are they to blame when a program developed by a stockbroker with no medical or scientific background, and based on a religious cult, not updated in 70 years, fails to work for them?
First, as I said in the previous I'd welcome all clients being able to make an informed choice.
If I saw local methadone clinics producing the kind of recovery you describe, I'd have different feelings about them. They are all dosing clinics. I'm not sure what you mean by "allowed." Methadone clinics and outpatient treatment are the only forms of treatment that are available on demand in our region. And, these clinics serve poor addicts with no other options. They are places of despair.
Again, though, why do opiate addicted heath professionals have such high rates of success without methadone? When opiate addicts are offered treatment of the appropriate intensity and duration with long term monitoring and swift re-intervention, they do well.
And you know that the methadone clinic is a place of despair how? Have you visited recently> Worked there perhaps? I bet not. Have you even bothered to talk to long term compliant successful patients?
Where do you get the idea that healthcare professionals have a high rate of success? Just because they normally aren't offered MAT? It's not because it's not an option. I know quite a few medical professionals on methadone.
the ONLY goal of abstinance based treatment seems to be ABSTINANCE. That is the ONLY marker for success in studies of that modality. So tell me-how is it not TIRED and OLD that they aren't measuring success differently in those studies? Why not make the indicators be things that MATTER like re-united families, employability, happiness,etc etc. Do you really believe it matters HOW someone gets those things, as long as they get them?
Why not make it about wellness instead of goodness/badness.
Your making a lot of assumptions.
First, my comments were specific to clinics in my area. I'm open to the idea that recovery-oriented MMT clinics exist, but not in my area.
Second, I've twice said that I would welcome a system that allows the client to choose from MMT or recovery-oriented treatment of an adequate duration of intensity. I've also said that I'd feel differently about comprehensive treatment that includes methadone. This post from a friend who once worked in a program addresses this point: http://www.dawnfarm.org/2008/05/methadone.html
Third, I have never personally visited a methadone clinic, but I work with colleagues who have worked in methadone clinics, people who have been methadone clinic patients, I interview counselors who currently work in methadone clinics and are looking to get out, I drive by a clinic on my way to and from work and see everyone lined up for their dose, and I work with scores of clients who have previously been methadone patients. Admittedly, this is a biased sample, but at conferences, meetings, etc, I've never meet someone who's put forward a group of successful clients.
Fourth, who's talking about badness? I think the post just before or after this one questioned CADCA's use of those very words.
Fifth, I'll be the first to admit that abstinence focused does not mean recovery focused. There are a lot of crappy abstinence focused programs that are also places of despair. Abstinence focused does not equal good.
Sixth, there's a lot wrong with a lot of research but methadone research constitutes a special black hole when it comes to measuring wellness. The origins of federal research and support for methadone are not was not for treatment purposes, but for crime control.
To quote from an article in support of MMT, "The positive evaluations of MMT rest primarily on what it reduces and eliminates (e.g., heroin use, crime, HIV transmission) rather than on what it adds to the quality of individual, family, and community life. As a field, we know almost nothing about the pathways, styles, and development stages of recovery for MMT patients and their families. The absence of pathology tells us nothing about the reconstruction of character, personal identity, and interpersonal relationships within methadone-assisted recovery. People in stable, long-term, methadone-assisted recovery are as invisible in the research literature as they are in the larger culture."
I'm earnestly looking forward to this research and I'll post it when it arrives. In fact, if you want to send me some studies and a summary, I'll post that too.
BTW - Here's a post regarding AA and methadone: http://www.dawnfarm.org/2008/02/methadoneaa-link.html
You know licensed health professionals, currently practicing, on methadone? In what state?
Regarding your questioning health professional recovery rates:
"physicians do not fit the typical, and erroneous, stereotype of addicts (i.e., poorly educated and from lower social classes); however, physicians have their own special risk factors, including easy access to controlled substances and, as a group, relatively high rates of alcohol consumption. Also, physicians entering addiction treatment report particularly high rates of problem complexity, e.g., family histories of addiction, multiple drug choices, co-occurring medical/psychiatric conditions, and other significant obstacles to successful recovery (Domino, Hornbein, Pollissar, et al., 2005).
Despite these risk factors, the documented long-term recovery rates for physicians are among the highest reported — between 70 percent and 96 percent (Talbott, Gallegos, Wilson, & Porter, 1987; Gastfriend, 2005; Domino, et al., 2005). "
I was in no way referring to what my criteria for success are. I didn't personally have a hand in any of the studies we are discussing. I was referring to the promotion that methadone has a higher success rate than abstinance-based program being a skew of the truth, at best. Because, the two modalities do not hold the same goals. If you say that success is simply gaining independence from a street-level drug dealer, then methadone treatments are far more successful. But if you say that success is becoming totally absinent from narcotics, then abstinance-based programs are far more successful. Just to say that methadone is more successful is, in my opinion, an attempt to "hand pick" what is used as criteria for being successful, unless it is noted what the term successful means for both modalities.
It's no secret what the relapse rates are for those in abstinence-based treatments, and it's also no secret what the relapse rate is for those both on methadone and those who have discontinued methadone treatment. The only secret seems to be what is considered to be successful by those two groups when the studies are conducted.
I've been inside the line of a methadone clinic many times, and the comment about it being a place of despair is much closer to the truth than the wonderful image that is so widely promoted today. It's not all roses, as you know I'm sure. I was astonished at the number of the patients at my clinic who did not like waiting in that line, or waiting at all, out of fear that what they were using on top of their methadone would hit them before they got the chance to take their dose.(And before you say they needed an increase, there were no problems at my clinic when one wanted an increase, nor was there a cap.)
If that is the type of methadone patient you are referring to when using the term wellness, or success, then we (you and I) have a fundamental disagreement, and in my experience, this group was by far the majority at my clinic.
The differences in what is deemed to be successful in the two modalities is not something that should be taken lightly. And to say studies have shown that one is more successful just because they hold a different criteria for success is immoral, and it is unethical to conduct a study comparing two groups when the criteria for comparison is not the same.
OK so your saying that the criteria for success in "methadone studies" is quote: black hole.
So tell me, what is the criteria of success in the paper you quoted about health care professionals? What is the indicator for their "success"? I'd be willing to bet its two things "abstinance" and "links to support systems". Talk about a black hole! NOW, take into account that the only way that these studies KNOW that the person is "clean" and "in support" is the person SAYS THEY ARE! There is no tangible way to rate success with the standards you picked: "has the persons quality of life been restored"? If a person on methadone said YES to this statement would you believe them? Why should we believe people on the other side then>?
The methadone treatment studies at least rate success by things that can be PROVEN: drug testing, absence of infection, treatment duration, interactions with the law. These compared to:"are you clean?" as the ONLY indicator of success in a abstinance based study? It's apples and oranges. What health care professional answering these questions is going to say "NO", even with anonymity promised. No wonder the rates are high--if they were at least doing weekly drug testing on these people for two plus years-then I could at least say the data was proven!!
I know practicing nurses and clinical scientists on methadone...and many more on suboxone. No, I don't know doctors on methadone-however (because of stigma) I don't imagine we ever WOULD know if they were or not.
I also know a successful lawyer, a secruity guard for a hospital and have read news article about a cop on methadone.
The fact that you think it's out of the realm of possibility that a doctor could be on methadone shows how ignorant and bias of the treatment you are.
You have included people on your list of "how you know about methadone treatment" only people that would NATURALLY have a negative opinion of it. Why not talk to a long term patient? Or a long time staff member at a clinic? A clinic doctor? Better yet, talk to a new patient just getting their lives back--it's a pretty inspiring thing to see someone get well almost overnight.
Read the comment again.
It said methadone studies constituted a special black hole when it comes to measuring WELLNESS--the construct offered by the other comment. I also included a quote from an article advocating greater acceptance of MMT. It acknowledged this problem.
You also are making a lot of assumptions. I'm also open to the concept of drug assisted recovery. I'm happy for any addict that recovers, whatever their path.
I addressed a lot of your statements in earlier comments. I know people who have been on methadone and have worked in methadone clinics. I keep hearing about recovery oriented MMT, but it doesn't exist in my region.
What state's monitoring agency allows nurses to practice while on MMT?
I would also like to know what state's monitoring agency allows nurses to practice while on MMT. And as far as finding long term patients, that's an option. Or even clinic doctors, but they don't always know any more than anyone else, and use it as a secondary practice. But long-term clinic staff are extremely rare, as the turnover rate is enormous. If you want a real education on mmt, find a FORMER clinic doctor, and listen to what they have to say when their paycheck is not in any sort of danger.
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