We have all heard highly negative views on methadone clinics, from patients, families of patients, law enforcement, the political establishment, and even physicians or other healthcare providers. Common criticisms of methadone clinics include (depending on whether it comes from patients, law enforcement or healthcare providers):
- It’s just legalized heroin.
- Methadone is a terrible drug – it gets into your bones; getting off methadone is even harder than getting off heroin.
- You were addicted to heroin; now you’re addicted to methadone – what’s the difference?
- It is not real recovery if you still need to take an opioid.
- Methadone clinics are just a den of crime and attract more crime to the area.
Of course, everyone is entitled to her/his own opinion, but opinions need to be evidence-based, especially when espoused by healthcare professionals. With the burgeoning opioid epidemic, as a society, we cannot afford to discard a highly effective treatment based upon ill-informed prejudices. As the medical director of a methadone clinic, my greatest frustrations have been barriers to recovery placed by patients’ families, prosecutors, parole officers, primary care providers and clergy. Most often, these well-meaning people simply do not “believe” in methadone clinics due to things they may have heard, or bad experiences they may have had.
The truth about methadone clinics is that they are highly effective; considered by many experts to be the “Gold Standard” of medication-assisted therapy (MAT). Methadone clinics have more than 50 years history and can be found in almost every continent. Endorsed by the World Health Organization, methadone clinics are accepted even in very conservative societies such as China or Iran. Outside of aspirin, I do not know of any other medication that has been continuously studied for more than 7 decades.
Studies over the decades consistently show four major benefits of methadone therapy.
- Mortality rates plummet, not only from overdoses but also from criminal violence, accidental deaths from impairments, deaths from medical complications such as sepsis or heart valve infections, and finally, death from suicides.
- Lower rates of arrests and incarcerations
- Reduction in new cases of HIV and Hepatitis C
- Many patients are able to return to function, becoming contributing members of society again.
The last point is actually easy to prove: call up any methadone clinic in the world and you will find almost all methadone clinics open their doors by 5:00 or 5:30 am. What other medical offices have such hours? The early hours are not for the benefit of insomniac clinic staff but because patients need to dose then get to work. In many busy clinics, the first hours of opening are reserved for working patients who are required to show proof of employment.
One might ask, “If methadone clinics work so well, why the stigma?” I believe the reasons fall into several categories. One set of reasons pertains not to the therapy but to the people we serve. By necessity, patients at methadone clinics include marginalized individuals unaccustomed to following rules. Criminal activities emerge if clinics are not adequately managed. However, most newer clinics, aware of the potential for criminal activity, safeguard their clinics well enough to promote a positive, healing, low-crime environment. Keep in mind that any clinic treating addictions, whether or not they utilize methadone, would have a similar patient base with potentially the same problems. The only option would be to not offer treatment for addiction, which would drive up crime in the greater community.
The second set of reasons relate to the long-term nature of methadone maintenance therapy. People who do well at methadone clinics remain in therapy for years, not uncommonly for decades. Just as we put diabetics on insulin indefinitely, so duration of methadone therapy is indefinite. I caution prospective patients interested in methadone therapy not to sign on unless they are prepared to engage in long-term treatment. Problems arise when patients stop attendance abruptly, triggering severe opioid withdrawal symptoms. Reasons for sudden discontinuation of therapy range from incarceration, to financial/transportation difficulties, to patients getting tired of the routine. Withdrawal symptoms from methadone can be protracted and as intense as with heroin, leading these patients to feel they have merely switched heroin addiction for methadone addiction. Patients do become physically dependent on methadone, but dependency is not addiction. Insulin-dependent diabetics need their insulin, but they do not rob gas stations or lose their children to Child Protective Services; we find nobody in jails or prisons serving time for “insulin”. As mentioned above, patients enrolled in methadone clinics enjoy much lower rates of incarceration. Methadone maintenance therapy is not an addiction.
As an addiction doctor, I utilize all three medically assisted treatments (methadone, buprenorphine, naltrexone) on a regular basis. Of course, methadone isn’t right for everyone and I have seen good success with office-based treatments using buprenorphine or naltrexone. However, I have also seen many patients who respond only to methadone, after failing both buprenorphine and naltrexone. I urge all stakeholders in the opioid crisis, from healthcare workers, law enforcement, legislators, patients, family members and other support systems to better understand methadone therapy. Please do not deprive patients of this important, sometimes crucial treatment option out of misinformation.
I wrote this essay to fight the stigma of methadone clinics, but also as part of a broader effort to help fight the stigma of addiction more generally. Anyone who has ever struggled with an addiction (think of someone trying to quit smoking) knows how hard the struggle can be. Shaming and marginalizing addicts does not help. The opioid epidemic has touched too many of us personally, perhaps affecting close family members or even ourselves. Every addict is someone’s son or daughter, parent or sibling. They have a disease that can be effectively treated. Methadone clinics are not right for many patients but can be a very effective tool in our fight against opioid addiction. We cannot afford to lose this important option to stigma or prejudice.