The Methadone Program at 40
Ask the old hands what they think about the methadone maintenance program in Australia 40 years in and you’ll hear a good deal of pragmatism. “It’s like the electricity bill. You want light at the flick of a switch, you’ve got to sign up and pay for it. Simple as.” Ask the same people what they know about methadone itself, where it comes from or the chemistry behind it, and they shrug. “Who cares? You’re not hanging out. You’re not twitching. You can function.” And the bad part? “You put on weight. It makes you sweat. Rots your teeth. Keeps you tied to a clinic or pharmacy.”
Two old hands who dose at the pharmacy where I work (a couple, Danny and Carla) have been using since they were 18. They are in their forties now, have raised their kids (the eldest is at university), and keep a neat house in the suburbs. This is their third go at methadone and they think they’ll stick with it this time. Their bodies are older, so they want to take things easier from now on. Like the program itself, they’ve moved into middle age.
Beginning in a small clinic in western Sydney in 1970, methadone programs were slowly established around the country. The number of heroin addicts enrolled in the programs steadily increased, spiking in the first five years of this century. Curiously, the rising trend has now slowed, with the number plateauing at about 45,000.
Forty years ago, a nationalised program to benefit a handful of injecting outlaws seemed to have a snowball’s chance of surviving the heat generated by the prohibition lobby. Heroin addicts were a small self-regulating subculture. The game was played under the radar, between those who had and those who needed, mediated by those who could fix things. Addicts wanting to quit had to emerge from the shadows and check into a psychiatric clinic or charity dorm, or sweat it out on a bed. But the detoxification ritual, with its Biblical imagery of water drenching and cleansing, merely flushed away what was measurable in urine and blood analysis. Narcotic hunger, as it used to be called, gripped and hung on in some hidden corner, ready to be your friend again when everyone else had left town.
What was missing for the convert to sobriety was something to fill the void left by years of total absorption in the daily, hourly business of scoring. The 12-step programs opened their doors to injecting addicts, and some of the more motivated converts found what they needed there. However, the majority could only manage with a new drug, Huey Lewis style: one that didn’t make them sick.
Methadone changed the way addicts stepped down off the heroin express. Instead of a stopover in a transit lounge, the travellers changed platforms for a parallel line with quieter, more comfortable carriages. The introduction of a long-acting synthetic opioid – given once daily under supervision – addressed the toughest challenge to quitting: the intolerable doof doof of unsatisfied hunger.
Carla explains the difference: “Danny went back on methadone first, and I was going to try to stop [using heroin], but I just couldn’t do it. Then I noticed him when I’d come home. He was on the lounge, all comfy, and I’d be twitchy. The methadone had gotten into him, and so I decided then to try it too.”
In a strange way, twitchiness is an important clue to the puzzle of heroin’s tyranny. Before heroin, in the era of “opium maniacs”, Fitz Hugh Ludlow described the “painful tigerish restlessness” of addicts deprived of their drug for even a few hours. Ludlow (a writer with some medical training and an incurable addict himself) proposed a humane treatment-model of slow reduction with watered down doses backed up by a kind of health-spa regime of beef-tea tonics, steam baths, massage and fresh air. His long essay, published as a chapter in The Opium Habit by Horace B Day, written in a climate of escalating opium addiction after the end of the American Civil War, marks the point in history when addiction was reframed as a medical condition with social implications.
A century later, Dr Marie Nyswander, a psychiatrist working in private practice in New York, published The Drug Addict as a Patient in 1965. Nyswander’s own journey to a fuller understanding of “narcotic hunger”, the term she coined, owes much to her early exposure to the prevailing model for “curing” heroin addicts.
After medical school, Nyswander spent a year working at the Lexington Narcotic Farm, Kentucky, an establishment made famous in popular drug lore by William S Burroughs’ Junky. In 1948, Burroughs signed himself in, after trying, and failing, to wean himself off heroin on a self-administered dilution cure. “Lexington is not designed to keep the addicts comfortable … After eight days, you get a send-off shot of dolophine [methadone] and go over into population. There you receive barbiturates for three nights and that is the end of the medication.” Burroughs liked the food and the company at Lexington, but after release, when his final shot wore off, suffered withdrawal sickness that he cured with an over-the-counter paregoric mixture (an opium-based cough syrup). He “stayed off the junk for about four months”, then returned to old patterns of using.
Nyswander hated the us-and-them attitude of some of the Lexington staff who, she said, labelled addicts as psychopaths, treated patients like prisoners, and vilified anyone of colour. The “cure”, with its 90% relapse rate, was disappointing. She left before its research department, which went on to play a leading role in treatment advances, was established.
After Lexington, Nyswander trained in psychiatry, set up a private practice in New York City, and gave about a third of her time to treating addicts, mainly musicians, for free. Eager to try a Freudian analytical approach to treating addiction, she went out into the community, to Harlem and other districts, setting up clinics and talking to addicts. Some of the highly motivated musicians who wanted to beat their addictions so they could keep working responded to analysis but the street addicts – the larger group – remained out of reach. It was in the gap between the failed prohibition model and the unpromising psychoanalytical model that Nyswander (now collaborating with metabolic specialist, and future husband, Vincent Dole) identified her therapeutic target as narcotic hunger: what it was, what it meant, and how it grabbed and held on.
In the clinic she tried giving her patients controlled doses of opiates. Morphine wore off in four hours, heroin in two or less. She spent all day writing pharmacy orders, while her unhappy patients watched the clock, stayed in their pyjamas and cycled in and out of withdrawal. Then she changed two of her patients’ orders to methadone. In a 1981 interview Nyswander said, “Their behaviour changed dramatically. They got up, got dressed, stopped obsessing about drugs and even began going to night school.”
In 1965, Dole and Nyswander published a paper on their trial of methadone on 22 patients at the Rockefeller Institute in New York, which, together with subsequent papers, revealed their evolving thesis that narcotic addicts could be maintained on an inexpensive substitute drug (US 13 cents per day then, an average of A$6 per day now), breaking new ground. All that methadone maintenance has become in 40 years (both good and bad) builds on this foundation.
Methadone came to Australia after Dr Stella Dalton, a psychiatrist working with addicts in Parramatta, met Nyswander and adopted the methadone philosophy. The first official trial began in 1970 at Wisteria House, Parramatta. At Wisteria the patients slept in dorms, made their beds, kept things tidy and spent six weeks on high ‘blockade’ doses of methadone, with a view to becoming drug-free in a few years. Departing from the Dole–Nyswander model, Dalton initially favoured an abstinence-oriented program over indefinite maintenance, but soon encountered serious problems in attempting to wean her patients off methadone. In a newspaper interview she stated: “When I started I thought you could look to them being totally drug-free. I thought after three years you could take them off, but I tried this and it’s quite useless.”
Heroin was everywhere in 1977 when I was recruited by the then New South Wales Health Commission to be a drug educator, a sort of lay evangelist for reform in thinking about and attitudes towards addiction. It was after-hours work, in over-lit halls in front of anxious and often angry parents, or tired schoolteachers faced with another add-on to their in loco parentis portfolios. Drug snobbery was as prevalent then as it is now (most of the participants, including myself, smoked) and prohibition was the most common call to arms from the floor.
Attitudes to methadone were mixed. At the community level, there was warranted scepticism about giving addicts a substitute drug that had its own addiction profile; the ‘treating fire with fire’ metaphor didn’t hold, didn’t make sense. Many were looking for somewhere to place the blame. Hippies, I recall, were an easy target, despite their well-known green-drug preferences. Pushers were supposed to be loitering at every school gate, and police, politicians and lefties were pushing their own barrows. Educators had very little hard evidence to back up claims that methadone patients used less heroin, were less likely to be arrested and were more inclined to be considerate to their parents. (AIDS was still in the future.)
Parents and citizens knew very little about drugs and drug paraphernalia, and were confused by hyped media reports. Wisteria House was close to the hospital where I worked so I interviewed two of its graduates, Rob and Wendy, and put together an edited show-and-tell using the best technology at my disposal: a microphone and slide projector. They were a generous couple in their mid-twenties, already veterans of the illicit drug pharmacopoeia and, at that time, stable on methadone. In response to my questions about why they’d stopped using heroin, Rob said, “It gets to be one big hassle: knocks on the door, your family wipes you, your friends. You get to a point where you just want to stop.” Comparing the old cassette tape I made of their interview with one I made recently with Danny and Carla, I recognise common markers, such as the same professed reasons for starting and stopping. Rob and Wendy spoke of a future (beyond the cycle of heroin) that Danny and Carla have now lived. All four used the phrase “being able to function” as methadone’s biggest selling point.
The last thing Rob said on the tape was “My scene is dying off, long hair and that. There’s younger ones coming through, maybe they’ll handle it better.”
Some former opponents of methadone have mellowed over time, but there are still advocates of zero tolerance. Fewer than 50% of Australian pharmacies participate in the dosing program, citing image problems (regular patrons being turned off by junkies), personal prejudices about providing a service to addicts who “brought it on themselves”, safety concerns (threatening behaviour), and time and remuneration shortfalls. The counter-arguments, principally the ones about the greater good of the community, don’t wash and never will, so long as the perception persists that heroin addicts should be corralled somewhere distant from the backyards of decent citizens.
The distinction to be made is that clients who dose at pharmacies are methadone addicts, and are, in the main, trying to fit in. “Some straight people give us the look, but that doesn’t worry me too much,” says Danny. “The worst I ever got was from that chemist down south. He made us wait like an hour, with kids and that. You can’t say anything or you get kicked off.”
During my 20-odd years of handing out cups of methadone I’ve kicked a few people off the books: the bad eggs, the ones who play games. I know who’s cruising along smoothly, who’s got a foot on the slippery slope, who’s selling their takeaways and who’s due in court and not handling it. Being able to spot unauthenticity is no special gift; mothers do it all the time. If I don’t pick up on the signs myself, though, someone in the morning queue will give me a heads-up. Methadone clients are like any community that drinks from the same well. They notice, they talk, they network.
A valid criticism of maintenance therapy is that once a takeaway dose leaves the pharmacy or clinic it has the potential to become a tradeable commodity. Individual variation means that a client can go without a home dose in order to sell it, exchange it for heroin or save it up for the future. The black-market trade in takeaway doses makes it harder to argue for unsupervised dosing for selected clients.
What we service providers can contribute is structure, rules and small acts of kindness. We can micromanage for clients who have fallen behind in payments, or lost papers, or who need a word in their ear about personal hygiene. The transition to a functional life is easier for some; others carry their chaos around with them.
Methadone has been the mainstay of indefinite maintenance programs, but it is not the only drug in the cupboard. Substitute drugs borrow from heroin’s unique access to the brain and lower (or cancel, in the case of naltrexone) its reach. Heroin slips through the blood–brain barrier quick as a flash, aiming straight for opiate receptors deep below the cortex. The net result of a hit on these receptors is to dampen down or knock out the amount of significance the mind attaches to incoming signals. With a dampening of busy cognitive activity, the mind floats into a dreamlike state (the euphoria of early use). However, once this disconnecting effect moves into overdrive, the receptors lose their sensitivity, more drug is needed for less effect and euphoria is replaced by exhaustion. “When you are hooked,” writes Burroughs in Junky, “the effects of a shot are not dramatic. But the observer who knows what to look for can see the immediate working of junk in the blood and cells of another user.” As heroin levels recede, the nervous system repays the downtime episode with a heightened awareness of incoming signals, and the area of the brain that mediates urges is activated by a steep rise in stress hormones. Suddenly everything signifies. Hence the twitching.
Heroin itself has been used for maintenance in other countries and is still available by supervised medical prescription in the UK. Working in London in 1980, I dispensed daily heroin ampoules to a World War II amputee who’d developed his habit on hospital morphine and changed up to heroin in civilian life. It was a morning transaction conducted along very civil lines. That he was the one and only in a practice that had no methadone clients speaks to the limitations of implementing heroin maintenance to a broader community. I can’t vouch for his private life, but he was a polite man who wore a suit and hat and called me “ma’am”, and he had an unblemished decade-long record. He needed multiple ampoules (his daily supply took up a good deal of drug-safe space), as well as needles, swabs and a bottle of morphine mixture for what we would call ‘breakthrough’ today. The logistics of extending this service to many would be beyond most pharmacies or clinics, even with an ‘ideal’ client, and it is no surprise that heroin maintenance is a small, niche service.
Buprenorphine (Subutex or “bupe”) is a sublingual tablet also given once per day. It has a high affinity for the receptors that naturally derived opiates (heroin, morphine) bind to, so that by getting in first it takes up all the seating. Its efficacy compared with methadone and a placebo has been tested in clinical trials; it scores better in safety profiles, but it has not toppled methadone from the top of the popularity poll. Seventy per cent of pharmacotherapy patients prefer to drink their doses. Anecdotally, there is a resistance among older clients to taking a pill; most of the bupe clients in my area are young.
The number of methadone clients has recently levelled out, a trend linked by some to the war in Afghanistan. The heroin that gets out is of a poorer grade – the cheaper “brown stuff”. So-called “hillbilly heroin” – or legally prescribed high-dose oxycodone (OxyContin) tablets, dissolved and injected – appears to offer a better, cleaner hit. The evidence for diversion of legal drugs is convincing. (In one extraordinary case, a woman obtained valid prescriptions for over 10,000 80-milligram strength OxyContin tablets.) When large numbers of heroin users switch to OxyContin, the net result is a slowdown in the numbers recycling in and out of heroin addiction, which in turn leads to a decrease in methadone candidates.
At last year’s Festival of Dangerous Ideas in Sydney, Dr Alex Wodak, Australia’s leading anti-prohibition campaigner, spoke passionately in favour of making all drugs legal. It’s a bold idea, one that makes politicians run for cover and brings the majority of our citizens out in spots. What would happen if heroin was for sale in pharmacies? It wouldn’t be the first time. Cough mixtures containing heroin were once items on the retail shelf. Codeine, the poor cousin of heroin, is still on shelves. Dr Wodak’s work in reforming attitudes to addiction, fostering safe practices through needle exchange and engaging with experts from a variety of fields (lawyers, police, moral ethicists and psychologists) has taken the small canvas painted by the pioneers of maintenance therapy and enlarged it with bright and alluring colours. Making all drugs legal or, to restate the proposition, abandoning the war on drugs is the kind of radical brushstroke that invites a more diverse and representative audience into the viewing room.
William S Burroughs railed against prohibition to his dying day. “The war against drugs has united us as a nation. Bush or Reagan – take your pick. A nation of what? Stool pigeons? Informers? … Our pioneer ancestors would puke in their graves.” Yet even Burroughs, the great campaigner against government control of personal drug use, spent his later years in Kansas stabilised on government-issue methadone.
The Australian maintenance program has saved the lives of people like Danny and Carla. “If I wasn’t on methadone I’d be on some other drug. Reality didn’t fit with me,” says Danny. “Methadone works if you want it to.” Carla believes she’ll be on methadone for years to come: “I never liked an upper, speed and that stuff. I like a downer. I like being relaxed.” Danny jumped off methadone twice in the past, but couldn’t sustain it. He returned to heroin and did some jail time before he got to where he is now, comfortable in 24-hour stretches. If he’s late to the pharmacy for his dose, he feels wired, anxious.
At the end of the methadone story, you’re left with a tangle of loose ends. Relatively few people graduate from methadone college. Treatment termination usually happens because the client has gone back to their first love.
On a slow reduction schedule, Carla and others I’ve known have been able to get down to one millilitre (5 milligrams) per day, a dose considered safe to “jump off” from. In reality, that jump is a free fall into madness. “I couldn’t sleep, my eyes were huge, my heart was banging, I was going crazy,” says Carla. “I had to keep busy. I had a really clean house.” To cope, Carla had small sips of Danny’s takeaways, maybe half a millilitre every other day. Nothing she took, including Valium, conquered the insomnia.
Between them, they’ve come up with a proposal for termination treatment: “Keep the script open for a couple of months after you’ve jumped.” Pharmacies and clinics would need to have orders that allow the client to present (without censure) for a small, settling dose when needed. “I call my methadone liquid handcuffs,” Danny says. “If I go away for more than three days, I’ve got to make arrangements to dose at another pharmacy.” They are handcuffs he willingly wears. It’s a family friendly way of doing time.