A.T.F.
Volume V, #1. Winter, 1996
It has now been about 30 years since Drs. Vincent Dole,
Marie Nyswander and Mary Jeanne Kreek started publishing their revolutionary
research demonstrating the efficacy of methadone treatment for opiate
addicts. Over the years, Dr. Dole has been a prolific writer and frequent
speaker advocating the importance and benefits of methadone; his views
are widely respected and his opinions have often been quoted by others.
Since retiring several years ago, he has been reluctant to grant interviews,
so we were delighted when he agreed to share his views with our readers
about the present practice and future potential of methadone maintenance
treatment.
A.T.FORUM: It seems that, over the years, methadone has been more thoroughly
researched and written about than almost any other medication; yet, it's
still not completely accepted. How do you feel about that?
DR. VINCENT DOLE: It's an extraordinary phenomenon and it has come to
me as a surprise. From the beginning of our research with methadone we
were able to rehabilitate otherwise hopeless addicts that had unsuccessfully
been through all of the other treatments available. I expected methadone
would be taken up carefully by the addiction treatment community, but
with some enthusiasm. Instead of that, we've had endless moral and other
types of objections which are really irrelevant to the scientific data.
I was surprised, because my background in research had led me to expect
that the medical community was a critical but nonetheless objective group
that would respond to solid, reproducible data. Instead I find that we
still get the anti-methadone argument of substituting one addictive drug
for another. The fact that people, especially medical practitioners, would
dismiss the data as unimportant simply staggers me!
A.T.F.: Do you see such attitudes changing at all?
DR. DOLE: Yes, especially, outside the United States. I was at a European
methadone conference in France recently, and I learned about an extraordinary
increase in the application of methadone treatment throughout Europe.
The stagnation of our treatment situation in the U.S. is really looking
very foolish compared to the application of methadone treatment in Europe.
But, they don't have the same bureaucracy that tends to hinder us here.
A.T.F.: Do you believe that methadone might finally "come-of-age"
here in the U.S.?
DR. DOLE: I am hopeful and I see good progress. But, you must understand
that I'm not really so much concerned about recognition for or boosting
the importance of methadone because that, after all, is just one medicine;
I'm not to trying to market methadone as though I were some sort of celebrity
spokesperson. The most important principle to recognize is that addiction
is a medical disease. And, as a medical disease, it's the responsibility
of the medical profession to do the best they can to deal with it.
I feel that if one accepts the fact that addiction is a medical disease,
not just something due to misconduct or hedonistic behavior irresponsibility
or whatever else, then doctors have an obligation to evaluate available
and proven treatments - including methadone - and to consider those treatments
in the same framework as they would with any other diseases.
I would say 30 years from now that the current attitudes regarding methadone
as substituting one addictive drug for another and other negative outlooks
on drug addicts in general will seem pretty archaic. What's happening
today seems more like a carry-over of medieval attitudes that affected
much of the thinking toward mental illness in the last century.
A.T.F.: We've heard some arguments claiming that methadone is just a crutch
and patients in treatment must eventually give it up or they will never
recover from addiction.
DR. DOLE: That seems like a vague charge that has no answer. A crutch
is not a bad thing if you have only one leg, yet it's not nearly as good
a solution as it would be if you could re-grow your missing leg. Since
we can't regenerate a leg, why not use the crutch to get about and lead
more normal lives?
A.T.F.: What do you think about LAAM? [A longer acting formulation of
methadone.] It has been around for quite a while though it only received
serious attention in the last two years or so. [See A.T. Forum, Vol. 11,
#3.]
DR. DOLE: It was available at the beginning of our research, and I looked
into it at that time but decided it had no particular advantage over methadone.
In some ways, there were disadvantages, because LAAM's mode of action
was less well-defined.
Nonetheless, it's being promoted now for absolutely the wrong reason.
Mainly, the DEA and other control agencies like LAAM because they believe
its use can eliminate the need for any take-home methadone. Such a philosophy
could prove very detrimental to persons on lifelong methadone therapy
who, after a period of time, couldn't cope with clinic visits even several
times a week as opposed to daily. It would drive people out of treatment.
A.T.F.: There are still many clinics which have so called "low dose"
methadone policies. What are your reactions?
DR. DOLE: That's entirely contradictory according to the past 30 years
of research... yet, such clinics widely exist due to a combination of
ignorance and prejudice! They just do not understand the pharmacology
of methadone, nor do they subscribe to their mission of normalizing the
life functions of their patients to the extent possible.
A.T.F.: What about other clinics we've heard about who use methadone dosing
as a reward or punishment for compliance with program rules?
DR. DOLE: Again, that's a result of ignorance! My feeling is that the
problem comes, ultimately, from the fact that people just cannot accept
the change in their thinking to accept opioid addiction as a bonafide
disease.
A.T.F.: What about "Interim Methadone" [see A.T. Forum, Vol.
II, #1] that was introduced as a way to get people into treatment faster.
It doesn't seem to have gone anywhere?
DR. DOLE: It's been strongly opposed and I think wrongly so. In a perfectly
rational world, anybody who has the qualified need for methadone to allay
their opiate habit should be able to receive it. Some people need only
methadone, while others, in addition to the medication, have social or
psychological needs, or other complications that have to be looked at.
Federal and other authorities tried to put one-size-fits-all restrictions
on interim methadone by saying that after a certain time period every
patient must be placed in a comprehensive service program. That becomes
impractical and effectively put a straight jacket on interim methadone.
A.T.F.: Similarly, it seems the medical maintenance model has been fighting
an uphill battle.
DR. DOLE: Medical maintenance was something we started at least 15 years
ago when Dr. Nyswander and I were dealing with patients who had been in
methadone treatment for some time, were fully employed and responsible
citizens, and needed only a continued supply of methadone. I think part
of the battle over this has been due to existing programs which feared
their budgets and their rationales for operation would be questioned if
one could show good results by having patients receive methadone from
private physicians. In Europe, they are making much broader use of primary
care physicians for methadone delivery.
A.T.F.: Why have you been so reluctant over the past several years to
be interviewed by the press regarding methadone treatment issues?
DR. DOLE: I've seen the sensationalism in print and other media that seems
to appeal to the public. For example, if you had a methadone clinic serving
100 people, and 99 of them were doing quite well, and one rogue patient
goes out and robs an old lady, what is the negative and sensational headline
on the story going to be in tomorrow's newspaper?
A.T.F.: At some future time, do you believe methadone will be replaced
by more effective medicines or better treatment protocols?
DR. DOLE: I would think so, and hope so. Methadone is very valuable and
efficient in controlling a specific kind of addiction, namely opioid addiction,
and normalizing addicts in their life activities. But the emphasis should
be on the fact that you're controlling the disease; you're not curing
the disease. In time, and with full knowledge of all disturbances in the
neurohumoral systems in the brain, we may find ways to remedy and cure
or restore a person to "normal."
This leads to considerations of genetic engineering and various other
modulations of the brain control systems that may lead to actual cures
for addiction when knowledge permits. I don't think such solutions are
going to come in my lifetime, but I believe they will come.
A.T.F.: Could you summarize your thoughts about the next 30 years of methadone?
DR. DOLE: I've seen substantial progress regarding methadone maintenance
treatment as a modality, even more so in Europe where they're starting
with fewer of the bureaucratic burdens that we have here in the U.S.
I am optimistic about the future. A generation has passed since our original
research regarding methadone, and a new generation in the scientific and
medical establishment is coming forward with more open minds to teach
new medical students. At the same time, there are strong developments
in our scientific knowledge of brain chemistry and functions coming out
of laboratories around the world. My optimism comes from a belief that
goes beyond methadone, which is after all just kind of a first probe into
dealing with today's addiction problems. I believe we will be able to
uncover more substantial knowledge of what goes wrong in a person whose
behavior becomes addictive and pathological. I have confidence that experience
and the truth will bring us more rationally to ways of dealing with addiction
treatment, and that we're just now overcoming rather medieval attitudes
toward addiction and beginning to appreciate it as a medical disease.
[Due to space limitations, this interview with Dr. Dole was edited and
condensed. He also discussed advocacy groups, needle sharing programs,
the plights of addicts in prison, and other issues. For a complete, unabridged
transcript, see Interview with Dr.
Vincent Dole.]
Addiction Treatment on the Internet
The National Institute on Drug Abuse (NIDA) can now
be explored on the World Wide Web at: http://www.nida.nih.gov
A vast array of information is available including: "NIDA Notes"
issues, news of meetings, special reports, congressional activities, program
and grant announcements, and much more.
The National Alliance of Methadone Advocates (NAMA) has also gone electronic
and can be reached at: http://www.interport.net/~clueless/norma1.html
We thought the "clueless" part of the address was amusing, since
browsers will find a wealth of enlightening information, including NAMA
newsletters, their excellent series of educational papers and more.
Let us know if there are other internet locations that might be of interest
to A.T. Forum readers and we'll publish them in our next edition.
NAMA is also linked to many other methadone sites, and if you forget the
address you can search on methadone.
Straight Talk ...from the Editor
AMTA Conference a Success; MMT Stigma an Ongoing Challenge
The American Methadone Treatment Association (AMTA) Methadone Conference
in Phoenix last November was a great success, with 1,200 attendees from
30 countries. A wealth of important issues were raised which will become
the subject of many articles in this and future editions of A.T. Forum.
During the opening session, David Mactas, Director of the Center for Substance
Abuse Treatment (CSAT), mentioned that they were in discussions working
toward assuming the current responsibilities of the FDA regarding methadone
oversight. This may mean a move away from regulation and toward accreditation
of methadone treatment as recommended by the 1995 IOM report titled Federal
Regulation of Methadone. Mactas told us by phone in mid-December that
meetings were just beginning and it was too early to tell what the outcomes
might be. We'll follow this story in future issues.
One theme at the conference, echoed by a number of speakers including
Mactas, was concerns about the prevailing negative attitudes or stigma
associated with methadone maintenance treatment programs (MMTPs) and patients
in treatment. Then, just prior to publication of this issue, we received
a new and very insightful thesis on the subject by Herman Joseph entitled,
Methadone Maintenance Treatment: The Further Concealment of a Stigmatized
Condition.
We'll be addressing this topic in a future issue. But first, we'd like
to hear from readers - patients and treatment professionals alike - regarding
your own experiences in dealing with negative attitudes surrounding MMT.
As always, unless you specify otherwise, your responses will be reported
anonymously to protect your identities. (See also Follow-Up:
David Mactas of CSAT)
Be certain to include your phone number for follow-up and write or fax
us at:
A.T. Forum
1750 East Golf Rd., Suite 320
Schaumburg, IL 60173
FAX: 708-413-0526
Stewart B. Leavitt, Ph.D., Editor
P.S. The next AMTA Methadone Conference will be April 13-16, 1997 in Chicago.
Mark your calendars now.
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