Saturday, February 4, 2012

Musings about Methadone

I know plenty of folks who have been helped by methadone, but it also has a lot of critics.  Among the criticisms is the 'bureaucratic jungle' of regulations that surround methadone dispensing.  A lot these regulations are aimed at preventing the diversion of the medication.  In the piece below --  based on data from my dissertation -- I look at how some of the regulations surrounding methadone impacted the lives of people trying to adhere to those regulations.  I haven't had time to do an analysis of this data yet, so what's below is purely descriptive at this point.

If you're looking for a little more analysis and critique, tons a great stuff has been written about methadone.  I'm a big fan of Fraser and Valentine's book, Substance and Substitution.  Also check out Melissa Bull's work, like Governing the Heroin Trade.  Other scholars, like Bourgois and Bergschmidt, have done some nice Foucauldian analyses of methadone as a system of control, and Gomart has a couple of pieces on the productive capacities of methadone. For a recent on-the-ground look at New York City's opioid treatment system, check out a report published last Fall by Voices Of Community Advocates & Leaders (VOCAL), one of my favorite advocacy groups.

The Methadone Rat Race
Methadone treatment programs vary across the country but most share a requirement of daily attendance, directly observed dosing, and interventions or sanctions for failure to show up, having a “dirty” urine (a sign that someone has used drugs other than methadone), or refusing to participate in different aspects of the program, like counseling. Participants in the BHIVES study described that, because the way in which it is regulated and dispensed, complying with the requirements of methadone treatment was often difficult.  Rather than fostering a sense of being in a medical treatment that restores one’s “normal” functioning, they reported that the rules governing methadone disrupted their daily life in significant ways and in, some cases, contributed to relapse.  

For example, Jane[1] describes in detail how the restrictive methadone clinic hours and regulations, which require daily attendance at a specific time, combined with the fear of methadone withdrawal, can lead to relapse:

It would be the worst feeling in the world to get up and know I had to come to this fucking clinic and drink that methadone. … So you're coming this way, and you keep looking at your watch and it, it's getting close to that time and you got 30 minutes … and then when you get off the bus you got five minutes.  You're running up the stairs, you waiting for the elevator, it doesn't come, so you run up the stairs, you're breathing and you step up to the window and they closed.  They won't give it to you. … They say, ‘well, I'll bet you'll be on time tomorrow morning.’  You know, and then you have to wait until seven o'clock the next morning and ... so you either ran out of methadone, and you're actually sick.  So you go do something and you get you some money to get you some dope and especially if you don't have any money you gonna go and do something to get you some money to buy some heroin.  Then you have to go into that rat race.

Dana also found it difficult to get to the methadone clinic everyday, and when she missed her appointment, she used heroin to avoid withdrawal.  This only compounded her problems at the clinic because at her clinic, “if you have dirty urine, you either start rapid detox, or you go up 15 milligrams.”  She described how every time she “slipped up,” her methadone dose was increased to the point where she was terrified of ever being able to get off it.[2]  These kinds of struggles led Dana to conclude that she wanted to get out of methadone treatment and try buprenorphine because she was tired of “lying and trying to beat urines.”  

Even those who were able to comply with the requirements of their methadone treatment, talked about the ways in which daily attendance at the clinic disrupted their lives and made it difficult for them to work or travel.  Carl was one among many who noted that the methadone regulations, especially the requirement of daily attendance, prevent people from “having a life.”  He says:

With the methadone program, you have to go down there each and every day and that could be a hassle if you are trying to have a life.  You know, if you got a job or something, you have to work your schedule around going to pick up your methadone.

Similarly, Jesse explained that ,methadone helped him control his drug use, but having to go to the clinic interfered with his work as carpenter. 

Other people talked about how methadone prevented them from traveling or visiting family out of town.  These kinds of experiences are consistent with Bull’s study of methadone clinics in which she concluded that the regulations governing methadone impede clients “from making certain types of decisions about their daily lives, even when such decisions are considered to be of positive therapeutic value – such as working or visiting family” (2008: 163).

While several participants had successfully used methadone to stop or control their opioid addictions at least for a time, only one felt that mandated daily attendance and the highly structured environment of the methadone clinic were helpful.  This individual talked about how the structure of daily attendance was important to helping him avoid boredom and maintain sobriety.

[1] Pseudonyms are used throughout to protect the identity of participants.
[2] Some clinics increase doses when someone relapses on the theory that the individual must not be receiving enough methadone to effectively block the craving for heroin (see for example, Caplehorn et al. 1993).

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