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Recovery-oriented Methadone Maintenance, part 5

Bill cites a methadone advocate making an important distinction--treating dependence vs. treating addiction.

The stigma attached to methadone is also shaped by the expectations of methadone treatment as a system of care. Methadone advocate Walter Ginter comments on such expectations:

Patients, former patients, staff, policy makers, and the public expect the methadone treatment program to treat addiction. While that is a reasonable expectation, it is not what Opioid Treatment Programs (OTPs) do. OTPs treat opiate dependence, and they do it very well. Most patients on an adequate dose of methadone do not continue to use opiates. However, opiate addiction is more than dependence on opiates; it is dependence combined with a series of behaviors. OTPs (with a few exceptions) do not treat the behavioral aspects of addiction. The behavioral aspects are not treated by a medication but rather by counseling, therapy, peer recovery supports, and 12-step groups. As long as well-intentioned people go around saying that “methadone is recovery,” it is going to continue to be misunderstood. Methadone is a medication, a tool, even a pathway, but it is not recovery. Recovery is a way of living one’s life. It doesn’t come in a bottle.547

Recovery-oriented Methadone Maintenance, part 4

Bill summarizes criticism of MM as follows:

Critics of medication-assisted treatment, many of whom were competing for cultural and economic ownership of the problem of heroin addiction, alleged that MM: 1) substitutes one drug/addiction for another; 2) conveys a societal attitude of permissiveness toward drug use; 3) fails to address the characterological or social roots of heroin addiction; 4) cognitively, emotionally, and behaviorally impairs MM patients; 5) is a tool of racial oppression and genocide; 6) is financially exploitive; and 7) as a result of these factors, is morally unacceptable.

He later states:

We concluded in the first two articles that it was time we as a country and a professional field stopped debating the morality of methadone maintenance and focused our energies instead on elevating the quality of methadone maintenance treatment.

I didn't see where another kind of objection is addressed. What about the concern that MM is a manifestation of stigma? That it's based on the premise that drug-free recovery is not possible for opiate addicts (or, certain kinds of opiate addicts)? That it's a form of treatment that doctors never use for their addicted colleagues? That it's born from the failure of drug-free treatment of inadequate intensity, duration and quality and, when we choose to address those inadequacies, outcomes for opiate addicts are very, very good.

Whenever I'm talking with a professional helper about a loved one, one of my first questions is, "What are our options?" followed by, "What would you do if this was your child/parent/spouse?" That's where we determine the ideal course of action and second best options. I'd like to have this conversation with people who have been exposed to the best of both approaches to treatment.

Recovery-oriented=Soviet-style?

Seems the recovery movement in the U.K. has hit a nerve. PeaPod reports:

Writing in SCANbites (not the latest fast food on offer at McDonald’s, but the newsletter of the Specialist Clinical Addiction Network) he [Dr Colin Drummond] rails against what he sees as a politically motivated attempt to force doctors to practise in non-evidence-based ways.

He is ambivalent about the recovery agenda. Praising its potential on one hand, but worried that at its worst “it can be an ideological dogma, imposed by a vociferous minority driven by hegemonic, or, worse, financial motives; a stone’s throw from simple minded translation into daft new Soviet-style targets for treatment delivery”.

Hegemony means the predominant influence, as of a state, region or group over others. A bit like the influence of psychiatrists, say, over the addiction field. 

Recovery-oriented Methadone Maintenance, part 3

Bill White on efforts to broaden the definition of recovery:

Consistent with Newman’s and Dole’s views are definitions of recovery that focus on health and functionality without reference to cessation of medical use of methadone. The examples below illustrate such definitions:

Recovery is the process of pursuing a fulfilling and contributing life regardless of the difficulties one has faced. It involves not only the restoration but continued enhancement of a positive identity and personally meaningful connections and roles in one’s community. Recovery is facilitated by relationships and environments that provide hope, empowerment, choices and opportunities that promote people reaching their full potential as individuals and community members.194

Recovery is a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles.195

The process of recovery from problematic substance use is characterised by voluntary sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society.196

Stabilized MM patients would meet these criteria for recovery if they were demonstrating progress toward increased health and functionality. The “sustained control over substance use” in the UK recovery definition is broad enough to include multiple pathways of alcohol and other drug (AOD) problem resolution—traditionally defined abstinence, decelerated patterns of AOD use that no longer meet criteria for a substance use disorder, and medication-assisted recovery—as long as the other criteria of health and positive community participation are met. Similar in spirit to the UK definition were suggestions to the authors from some methadone patients that a broadened definition of recovery is needed.

The only way we will ever be able to move addiction treatment to a chronic disease model is if we take the “abstains from alcohol and other intoxicating drugs” out of the recovery definition, or at least stop making it the deciding factor for the status of being “in recovery”… I think we need to make it one of many goals rather than the focus. This would help us achieve the focus of every other chronic disease treatment: QUALITY OF LIFE and the reduction of symptoms…We have got to stop thinking of recovery as ALL or NOTHING.”

Personally, something about the patient's statement is more compelling than any of the others. I think a lot of people in drug-free recovery would be open to thinking about abstinence as a goal when defining recovery. "One of many" may be a problem because it makes it sounds like it would reduce abstinence to an item on a checklist when, for many of us, without abstinence there is NO recovery--an insufficient, but necessary condition for recovery.

With abstinence being so central to our recovery, it certainly feels like defining recovery as something for which abstinence is not necessary leaves it feeling like an incomplete definition. One of the factors that binds us together is the shared experience of searching for chemical solutions to our addiction problem and having to face the reality there is no chemical solution to our problem. If someone can find one, our hats are off to them, but their experience and our experience are qualitatively different. Not better or worse, but different. The journey may be similar, but it's not the same. Does that make any sense?

This isn't to dismiss recovery-oriented MM, but is it realistic to expect people in drug-free recovery and medication-assisted recovery to identify as one community? We might get there, but we've got a long way to go and a lot of mental barriers to navigate. Many of those barriers were created to protect our recovery and our identity as recovering people. I associate stigma with "otherness". Addicts have long faced being defined as "the other" and recovering people have constructed our own positive sense of otherness. We talk about "normal people" and that we different from people who manage to moderate or find recovery through faith communities. Would embracing MM patients erode this protective differential identity? It also begs the question, why have MM patients been unable to create their own communities of recovery?

The Big Picture on marijuana

The Big Picture (one of my favorite blogs) has a marijuana gallery.

Warning--if you're recovery is a little shaky, you might want to skip it. A few images of people using marijuana.

Recovery-oriented Methadone Maintenance, part 2

Here Bill describes the devolution that troubled early advocates of MM:

The regulation and mass diffusion of MM in the 1970s and 1980s was accompanied by changes in treatment philosophy and clinical protocols. The most significant of these changes in terms of recovery orientation included a shift in emphasis from personal recovery to reduction of social harm; increased preoccupation with regulatory compliance; widening variation in the quality of MM programs; the reduction of average methadone doses to subtherapeutic levels; arbitrary limits on the length of MM treatment; pressure on patients to taper and end MM treatment; the erosion of ancillary medical, psychiatric, and social services; and a decreased emphasis on therapeutic alliance between MM staff and MM patients. The definition of recovery during this period shifted from a focus on global health and functioning to an almost exclusive preoccupation with abstinence—then defined as including cessation of methadone pharmacotherapy. The public face of MM became defined by the worst MM clinics and the least stabilized MM patients.

Recovery-oriented Methadone Maintenance

Bill White has a new monograph out on recovery oriented methadone maintenance (MM). There's something in it please everyone and something in it to anger everyone. He takes the position that MM is an essential part of the treatment continuum but is hard on MM in its current form.

I'm very busy with a couple of projects but I plan to try and post some highlights every day for the next several days. Here's the first.

Here Bill descibes the disappointment of methadone pioneers at what they see as a devolution of MM:

Dr. Dole later spoke of the “stagnation of treatment” that occurred throughout the 1970s and 1980s.87 He was particularly incensed at the depersonalization of MM and the loss of partnership with patients in MM: “the contempt with which many regulators and program administrators have treated their patients seems to me scandalous.”

The strength of the early programs as designed by Marie Nyswander was in their sensitivity to individual human problems. The stupidity of thinking that just giving methadone will solve a complicated problem seems to me beyond comprehension.

Dole was not the only early MM pioneer who criticized the evolution of MM in the 1970s. In 1976, Dr. Robert Newman, who led the expansion of MM in New York City, declared:

Methadone maintenance treatment, with its unique, proven record of both effectiveness and safety, no longer exists. One can only hope that it is not too late to reassess that which has been cast aside, and to resurrect a form of treatment which has helped so many, and which could help many more.90

Other critics, including Dr. Stephen Kandall, concurred with Newman and further argued that:

Political forces reduced methadone to an inexpensive, stripped down way to “control” a generation of addicts without having to provide essential rehabilitative services… 91

Tab Dump

• Rangers Use Ginger Ale in Celebration as Way to Include Josh Hamilton
• The Marijuana Number That Was Too Good to Check
• I lost ten years of my life as a middle class, NHS sponsored drug addict...
• Shelter alters its handling of substance abuse