Medical Methadone Maintenance: The Further Concealment

The physicians recruited for medical maintenance were the first doctors permitted to prescribe opiates for maintenance in private medical practice by the FDA and the DEA since the passage of the Harrison Narcotic Act in 1914. Prior to the establishment of methadone maintenance, physicians were harassed and incarcerated if they prescribed narcotic drugs for anything but the alleviation of pain.

In this chapter of the study the following will be discussed: the transfer of medical maintenance from an isolated project at The Rockefeller University to the private medical practices of internists at the Beth Israel Medical Center in New York City; the backgrounds of the physicians selected to treat the patients; physicians' theoretical concepts of addiction and methadone treatment; the applicability of medical maintenance to private medical practice: a presentation of theories of addiction as promulgated by the medical research scientist, Dr. Vincent P. Dole and by the sociologist Alfred E. Lindesmith. The theories of Dole and Lindesmith form an overall framework that incorporate of both medical research and sociological formulations. Lindesmith's theoretical writing intertwines prophetically with the findings of modern neuroscience in the mid twentieth century.

From Pilot Project to Private Medical Practice

Six physicians were involved in medical maintenance. The first was Dr. Marie E. Nyswander who established the pilot project at The Rockefeller University in 1983 and recruited the first twenty-three patients from clinics at Beth Israel Medical Center. In 1985, the patients were transferred to the hospital-based private medical practice of Dr. David Novick. Dr. Novick recruited four internists to continue medical maintenance and eventually 100 patients were placed within their medical practices. Dr. Novick indicated that he had problems recruiting physicians because of the prejudices and mythologies that abound concerning methadone patients and methadone maintenance treatment. However, the four physicians that were finally recruited were responsible professionals with specialties in internal medicine and general medical practice. Dr. Novick moved from New York City in 1992, but the program has been continued at Beth Israel Medical Center with the four physicians. Medical maintenance was conceived of as the final phase of methadone treatment -- namely the integration of methadone patients into private mainstream medical practice within the specialty of internal medicine and general medical practice.

In addition to his hospital-based medical practice at the Beth Israel Medical Center, Dr. Novick was associated with the research team at The Rockefeller University monitoring long term medical safety of methadone and its effect on liver, immune function and HIV infection. Novick was the first physician to treat methadone maintained patients in private practice within a major medical center. He also began to treat medical problems other than addiction within this patient group further integrating methadone maintenance treatment into general medical practice. Novick's philosophy about addiction, methadone treatment and the rationale for continued maintenance followed the writings of Dole, Nyswander and Kreek concerning the metabolic theory of addiction. He also contributed to this body of research and, therefore, became a link between clinical research and practice.

However, the practicing physicians who participated in the medical maintenance trials were practitioners without Novick's theoretical base and professional associations. The physicians are exceptional clinical professionals and represent the type of doctors who should be recruited. With the exception of one none worked in the methadone maintenance clinic system but they were employed on rounds as residents in the withdrawal wards caring for heroin addicts and seriously dysfunctional methadone patients. The physicians have active hospital-based medical practices with specialties in internal medicine and primary care. Methadone patients from the practices of the four physicians were interviewed and without exception the patients expressed a great deal of respect and admiration for the physicians and satisfaction with their services

A Modern Theory of Addiction

In this section, the theories of Dole and Lindesmith will be presented. Although these theories were developed within two different disciplines -- medical research and sociology -- they take into account biological and sociological factors that create an addictive disorder. Dole (1994) summarized as follows the metabolic theory of addiction from its evolution over the past 20 years:

"A modern theory of narcotic addiction is that the compulsive (and quite specific) craving for narcotic drugs is a symptom of deficiency in function of the natural opiate-like substances in the brain. To be sure, sociological and psychological forces enter into the making of an addict, but these factors determine exposure -- whether or not addictive drugs are available in the environment and whether a person chooses to experiment with them. In any person, with repeated exposure to a narcotic drug, the brain adapts and becomes pharmacologically dependent on a continuing input. In some susceptible persons -- fortunately a minority of the population -- the adaptation becomes fixed, and with the repeated use a regular input of narcotic becomes a necessity. The experimenter has become an addict. From this perspective methadone maintenance is replacement treatment, compensating for impairment in function of natural opiate-like substances."

With this statement, a modern theoretical theory incorporates social, psychological and biological components, each within a defined place. The overlapping of psychosocial and biological concepts is eliminated and a definite boundary is drawn. Eventually biological forces take over irrespective of the psychosocial elements that may be responsible for experimentation or initial use. The role of methadone is clearly defined as a neurological corrective but not curative regimen. It functions as a normalizer of deranged physiology not as a mood altering narcotic.

However, prior to the discovery of the endogenous opioid system, Lindesmith conceptualized an insightful observation that attempted to take into account undefined biological elements. For Lindesmith (1968: 95-96) addiction is:

"...reserved for those individuals who have the characteristic craving, whether it is in the form in which it is manifested during regular use, it exists in the abstaining addict impelling him to resume use."

Lindesmith (1968: 95-96) conceptualizes a theory of addiction that attempts to mesh biological and sociological phenomena with a conscious process of associating specific symptoms with a specific disorder.

"... the sheer physiological or biological effects of drugs are not sufficient to produce addiction although they are indispensable preconditions. .... Persons who interpret withdrawal distress as evidence of the onset of an unknown disease act accordingly, and, if they are not enlightened, do not become addicted. Persons who interpret the symptoms of opiate withdrawal as evidence of a need for the drug also act accordingly and, from using the drug after they have understood, become addicted."

However, Lindesmith's (1968: 95-96) theory appears to have an element of choice that is mediated by social circumstances of use that enters into the development of addiction:

"As the user applies to his own experiences and behavior the attitudes, symbols and sentiments current in society, he is faced with a problem of adjusting himself to the unpleasant implications of being an addiction a society that defines him as an outcast, pariah, and virtual outlaw. In his efforts to rationalize his own conduct, which he cannot understand or justify, and to make it more tolerable to himself, he is drawn to others like himself."

The above insightful statements of Lindesmith may have to be modified with input from current research in neuroscience. The changes within the central nervous system that are being unraveled appear to affect behavior on an instinctual level. While agreeing with Lindesmith about the outward organization of addictive behavior, this researcher is of the opinion that sociological and personal formations described as distinct addictive and learning behaviors are in reality sociological and personal behaviors created to meet the neurological and instinctual needs of a specific drug hunger. This has been shown in the methadone program and in medical maintenance. Socially rehabilitated methadone patients in this study have been able to change their lives and relinquish the social formations of addictive behavior with the proper prescribing of methadone that effectively relieves narcotic craving and withdrawal symptoms

Theoretical Understanding by Practicing Physicians

The conceptualization of theory influences the thought, attitude, behavior and, in the case of a physician, the prescription of medication, the amount and the duration of treatment. Optimally, physicians to prescribe methadone maintenance in private medical practice should have a firm grasp of the literature and how it evolved. However, this may not always be the case. Although there are review articles about methadone maintenance, the literature is scattered through many journals over a thirty year period and may not be readily accessible.

A major purpose of this section of the study is to obtain the practicing physician's conception of addiction, addicts and methadone treatment, prior to and after their acceptance of methadone patients within their private medical practices. None of the physicians were formally trained about addiction or methadone treatment since it is not taught in medical schools. Their conceptualizations will therefore be based on the empirical evidence presented in their medical practices and informal discussions with colleagues.

The four physicians agreed that the criteria set up for medical maintenance worked well as a screening device to identify patients who were appropriate for the program. When the physicians undertook the care of these patients they were employed and stabilized at appropriate doses of methadone. However, minor modifications in dose were prescribed for some patients (e.g., increases of about 5 or 10 mg/day). Also, patients who did not succeed in medical maintenance could be sent back to their clinics of origin without a break in treatment. This arrangement assured the treating physician of a backup system in the event that a patient proved to be inappropriate. The physicians' methadone prescriptions were filled by the hospital pharmacy, picked up by the physician, and stored in a special narcotic's cabinet in the doctor's office. Urine specimens were collected and forwarded for testing to the appropriate laboratory.

Physician 1

This doctor made the most far reaching changes in his thinking after undertaking the treatment of methadone patients in his private medical practice. Although he is an internist with a specialty in treating pulmonary disorders, his practice also includes patients with diabetes, epilepsy and HIV infection.

Prior to accepting the patients, this physicians's only experience with methadone patients was on the withdrawal wards of the Beth Israel Medical Center. On this service he saw only unemployed dysfunctional patients who were seriously abusing other drugs including cocaine and alcohol. His impression was that methadone maintenance "did not work as a treatment." He considered addiction "a matter of willpower," a "voluntary" condition and that addicts could "rehabilitate themselves if they wanted to." They were in his mind stigmatized people afflicted with "character disorders, ...liars, cheaters ...asking for methadone." He did not have too much respect for doctors who worked in this field as he considered it a "lower specialty." Although he harbored these conceptions, he was also sufficiently inquisitive to consider the hypothesis that addicts were "self medicating themselves" as an explanation for what he observed.

He was approached to participate in the medical maintenance project by Dr. Novick, a respected colleague in internal medicine. Despite his skepticism and apprehensions, he agreed to cooperate. He indicated that he did not feel that this would be a stigmatized project since it had the backing of Dr. Vincent Dole, whose high standing in the medical profession vitiated potential stigma. Initially, he agreed to accept four patients. They turned out in his mind to be "the nicest, most normal people you would want to meet. They were employed in a wide variety of jobs, some were more educated than others. They all seemed to be regular normal people." The patients were totally different from the dysfunctional patients he treated on the withdrawal wards. The physician than systematically studied the literature on methadone treatment from the 1960s to the present and integrated the theoretical concepts of the metabolic theory of addiction into his understanding of addiction disorders.

At the time of this study he was treating about 60 methadone patients in his private practice, and they "fit directly in." The methadone patients are like the usual patients he treats in internal medicine -- diabetics, epileptics, persons with hypertension except that the:

"Methadone patients as a group appear to have less psychological problems than the usual patients seen by me. They are comparable that they look and act the same. Some may have their ups and downs."

For those who may have psychiatric problems, this physician obtained the services of a therapist who understands methadone. "I had experiences with a therapist who did not understand methadone maintenance and when I referred the patient all the therapist wanted to do was to withdraw the patient instead of addressing the patient's emotional problems." This physician then is able to separate emotional problems from methadone maintenance and addiction because of his theoretical orientation. He also refers patients with special medical conditions to appropriate specialists. Again he is careful to refer to doctors who understand methadone. This clinician is cognizant of the bias and ignorance that physicians harbor and realizes that these attitudes can be reflected in the treatment that patients receive.

His patients are on doses as low as 20 and up to 100 mg/day. He states that patients are on individualized doses that are appropriate to them and there is no such thing as those on lower doses being better, or those on higher doses being sicker. In other metabolic conditions he prescribes a variety of appropriate doses. He stated that:

"The spouses of his patients do not understand this and in one case, the spouse was a nurse and insisted that her husband begin to withdraw. The dose was reduced from 80 mg/day to 50. The husband was a successful business man and could not function. He complained about sleeping and other problems related to an inappropriate dose. After a discussion with the wife, I restabilized the patient and the complaints disappeared."

If a patient is physically able to withdraw from methadone then this physician will assist the patient. If serious problems emerge during the withdrawal process he will suggest that the patient return to his or her regular dose. However, the physician indicated that because:

"Addiction is thought of as an emotional instead of a physical illness, there is a great deal of stigma attached to high doses or remaining on methadone. Several patients feel that they must withdraw even if this is an inappropriate decision. Even if they are told that continued addiction is a physical condition, they cannot accept this emotionally since they want to withdraw and get off of methadone.

Methadone patients are the most stigmatized of all the patients I treat. Some cannot tell members of their families, friends or employers. They accomplished remarkable things that they should be proud of but they cannot say anything about their treatment. The patients have overcome a terrible illness and they should be proud."

The physician has transformed his ideas about addiction from his years as a physician on the withdrawal service. The prescribing of methadone has been integrated into his private medical practice; addiction is placed as a chronic condition in the same conceptual framework as the treatment of other chronic conditions. He indicates that:

"...with any endogenous hormonal system, if a compound that either resembles the natural hormone or is the same is introduced (e.g., heroin) the homeostasis of the endogenous system will be adversely affected. Replacement therapy is indicated to make the patients feel normal such as with patients who have a thyroid condition or in a metabolic illness such as diabetes with insulin. A medication must be prescribed that restores the homeostasis. When I prescribe methadone, I am doing something to restore the homeostasis in the endogenous opiate receptor system. Methadone treatment itself fits in with what I do as an internist. Methadone maintenance is one of the most beneficial things I am doing in my practice."

This physician realizes that medical maintenance itself can be limiting even though the patients report once every 28 days. He feels that the next stage should be renewable prescriptions that can be filled in pharmacies. The program is still too restricting for patients who may want to or be required to go on long trips or relocate outside the state. He has:

"...reliable patients with careers who now are travelling long distances to pick up a monthly supply of methadone. Some patients may want to relocate to Florida or another state where there is no medical maintenance program. These patients should be treated like other medical patients and be allowed to fill prescriptions in pharmacies. Patients are now in medical maintenance for nine years. They may fly in to New York at tremendous expense to pick up a month's supply. The government regulations are hampering their freedom. They can be trusted with a two months supply of prescriptions."

He advised that five of his patients withdrew voluntarily from methadone. He is still in contact with three of the five, and they seem to be doing well. He is curious about the application of the metabolic theory since these patients do not appear to be concerned about drug hunger and are, so far, are living comfortably. He indicated that he would like, if possible to refer these patients to a posttreatment study of successfully withdrawn methadone patients at The Rockefeller University.

This physician is now lecturing on grand rounds to physicians in other services at Beth Israel and other hospitals about methadone maintenance. He related the following about physicians and methadone treatment:

"The average doctor does not know that successful patients exist and knows nothing about methadone maintenance, except a series of myths. I present the subject of methadone maintenance by debunking the myths. Most physicians if they know a patient is on methadone will attribute everything to the methadone. They do not understand pain medication. One patient planning to undergo cardiac surgery was told that he would not need pain medication since he was on methadone. One of my patients died from a stroke -- a cerebral aneurysm and before the final cause of death was determined, the death was attributed to methadone. I pushed the autopsy because I knew that this patient did not have a drug problem and that methadone was not involved as a cause in this death. Two other patients were heavy smokers -- one died from lung cancer - the other from acute infarction (heart attack). When I discussed their deaths with other physicians they blamed the methadone when both patients were prime candidates for the conditions that caused their deaths."

Physician 2

This physician has a specialty in internal medicine and primary care and earned a Ph.D. in Educational Psychology, concentrating on the problems of adolescent girls. In her medical practice at Beth Israel she treats a wide range of patients from young adults to the elderly with a preponderance of middle class patients over 50 who are interested in preserving their health. The practice is located in a Beth Israel satellite program located about twenty blocks from the main hospital.

Addiction was not part of the curriculum in either her medical studies or Ph.D. program. Her introduction to addiction was as a resident assigned to the withdrawal ward at Beth Israel Medical Center. There she treated dysfunctional drug abusing methadone patients. Her impression was that they were "lost souls, and she felt that "methadone was not effective." She did not formulate a theory of addiction at that time but expressed a compassionate feeling for the patients she was treating.

However, after being approached in 1985 by Dr. Novick to accept methadone patients in private practice, she felt it was a good idea and was willing to try it. She was not aware that Beth Israel had a large system of methadone clinics and knew little about the work of Dole and Nyswander. This physician relied on Dr. Novick's word that the patients were proper for private medical practice. She now treats six patients and indicates that the patients:

"... absolutely fit into my medical practice. They are exceptionally great patients. They are hard working with families and function on a very successful level."

As a psychologist she worked through an emotional crisis with one methadone patient. The patients have their own primary physicians. However, if problems should arise, she will make appropriate referrals. Since working with successful patients, she supports methadone maintenance. However, she does not actively speak at grand rounds or meetings but in private conversations defends methadone if there are misunderstandings about the medication. She is aware of the stigma that patients endure and the need to preserve confidentiality. She does not believe there is any stigma directed against her for treating methadone patients. If there were "it would not matter." Her patients receive methadone in the range of 20 to 80 mg/day. She advised that they entered her medical practice at these particular doses after years of treatment in the clinics.

This physician offered the following theory of addiction after initially considering the concept of an addictive personality: "There is a strong genetic component to addiction that predisposes people. This genetic predisposition is combined with emotional or psychological elements."

The physician emphasized the genetic and indicated that "individuals so predisposed must be careful. Emotional problems related to adult addiction were rooted in early childhood upbringing and taking drugs in adolescence to young adulthood was a way of coping. Methadone satisfies the genetic and at the same time the psychological elements that constitute an addiction."

The physician stressed, however, that her patients were emotionally stable, functioned well at diverse jobs and fitted into the middle class population that she was treating in her medical practice. While the endogenous opiate receptor ligand system was not included in her conceptualization, there was a recognition of a physiological component in the hypothesis about a genetic predisposition. Her recognition of patient functioning and stability and her instincts about theory concerning the physiological component of addiction give her an understanding that does not lead to further stigmatization of patients (e.g., character disorder).

In her conceptualization, methadone is regarded as "an ideal medication," since it addresses "the genetic as well as psychological components of an addiction." Also, psychological causes of addiction are not volitional on the part of the patients "but stem from unfortunate upbringing. With methadone, many of these problems are resolved" and the patient in her words is now able "to cope."

Physician 3

This physician graduated from medical school in 1980 and is an internist with a specialty in endocrinology. She is also chief of the diabetes service at Beth Israel. Addiction and methadone treatment were not included in her medical school studies. Her understanding about addiction evolved from her assignments at Beth Israel Medical Center (e.g., working on the withdrawal service and examining addicts who were entering the hospital for medical treatment). Initially, she felt that addiction is a "compulsion that could be controlled with willpower." Methadone was seen as an effective medication to withdraw addicts but she questioned the idea of long term maintenance: "Why can't patients take it (methadone) and then be drug free?" It was her impression that these ideas and questions were widely held sentiments among the other physicians in the hospital. However, in her mind this was not a moral issue. She concluded that some people were susceptible to opiate addiction and that it was a physical as well as a psychological problem.

She agreed to accept methadone patients in her private practice because she was a physician within the Chemical Dependency Service and was building her medical practice in internal medicine. Although she currently specializes in diabetes, the methadone maintained patients appeared to fit in with her practice. This physician states that her patients essentially fall into two categories -- those who regard her as a primary physician including one patient who is diabetic and the others who come only for methadone maintenance. This physician has withdrawn two patients from methadone maintenance but continues treating them for other conditions as their primary physician.

She observed that the methadone patients in her practice have gotten their "lives together" and that in general "they are no different than the other patients in her medical practice." Medical maintenance, in her opinion, "can fit into a general internal medical practice." However, the physician must have an open mind, be calm and not have be prejudicial towards the patients. She indicated that there is a great deal of prejudice against methadone and patients within the medical profession. She now regards methadone as a "wonderful medication" for opiate addiction and wishes that she had a methadone-like medication that was able to control appetite (excessive eating) within her diabetes practice. Although she sees differences in the analogy of comparing methadone to insulin, in general, she accepts the analogy since both medications are used to control chronic conditions without curing them. When confronted with the criticism of "just substituting one addiction for another," she did not accept that as totally valid. To her, the word "just" is misleading, "When prescribing methadone you are changing the patient's life." In a "physical sense, the patient is addicted but the outcomes with methadone are so different." She indicated:

"Some patients are living 'picture postcard' lives, except that they come in once a month for methadone. One couple has a successful business out of state and must get up at three in the morning once a month to drive to the hospital to get their methadone. They are forever thanking me for caring for them. They live in a city that has one program. They cannot risk exposure as patients by attending the local program, since exposure would ruin their business."

However, this physician is a great believer in therapy - one to one - and feels that with therapy more people would be able to withdraw from methadone. She believes that therapy should be integrated into medical maintenance especially for patients who wish to withdraw from the medication. She indicated that she successfully withdrew two patients very slowly over the course of a year. Both were in therapy She has approached the above mentioned couple about possibly withdrawing from methadone but they are not in therapy and she is uncertain about proceeding. This physician did attempt to withdraw a patient who was not in therapy but had to discontinue the procedure and restabilize the patient. Although she is aware of 12 step programs she feels that therapy is more effective.

The need for therapy is predicated on her belief that methadone maintenance has achieved a great deal for the patients. It has allowed them to rebuild their lives and resolve many of the emotional and social issues that caused them to use opiates. However, there may be "residual problems" that were not addressed and could be resolved in therapy thereby facilitating withdrawal. However, withdrawal should not be attempted until the patient has resolved many of the social and personal issues that may impact on drug use.

The physician indicated that in times of great stress some of the patients may resort to tranquilizers or use of additional methadone. The physician contends that therapy would help patients resolve emotional or other crisis without recourse to medication. At present, her belief is that change of dose should be mediated by a therapist whether a patient requests an increase, decrease or withdrawal.

The theory of addiction conceptualized by this physician combines psychological and physical components. She believes that, "a potential addict has an affective disorder which is relieved with drugs. The type of drug - be it opiates, alcohol or cocaine - is determined by social availability. If opiates are used then there is a change in the number of opiate receptors which can affect the endorphin output. Methadone essentially replaces the function of natural endorphins that were affected by the change in receptors. However, with a slow enough withdrawal, the receptors can be regulated to normal." In her conceptualization this process could account for euphoria, withdrawal and physical dependency.

She indicated that "narcotic craving is another matter." She does not believe that anybody has, as yet, unraveled the source of this crucial element in addiction. She compared drug craving to food hunger and indicates craving, "...probably stems from biochemical or electrical changes within the brain which nay be reversible," However, she indicated that the issue of "irreversibility has yet to be answered" and that further research is needed to understand this phenomenon.

The physician does not give lectures about methadone treatment on grand rounds since she has not made a systematic study of the literature. However, in private, if the matter of methadone should arise, she will inform physicians about her positive experiences with medical maintenance. She is aware of the stigma associated with the program and the biased attitudes towards patients among physicians. When she moved her methadone patients into a new facility, there was initial resistance which she describes as a case of "NIMBY." She also related that she has had to insist that adequate pain medication be prescribed to methadone patients who may be hospitalized. She indicated that sometimes there is a tendency to under prescribe opiates for pain relief if the physicians learn that the hospitalized patients are enrolled in methadone treatment programs.

She advised that the stigma against the patients and the program would be a drawback to enlist new physicians. However, she sees that medical maintenance is a very cost effective way for the government to treat chronic addiction. If the program were made financially rewarding to private practitioners this may help recruitment. For this physician, the treatment of medical maintenance patients has not proved to be more difficult than treating patients with other conditions in internal medicine and that "in most cases it is quite easy."

Physician 4

The fourth physician received her medical degree in 1964 and has worked at Beth Israel Medical Center in substance abuse treatment for about 23 years. Her past and present duties include working on the withdrawal service and as a physician in a methadone clinic. She is currently an administrative physician who is the acting director of the methadone clinic system at Beth Israel Medical Center. She is an internist with a specialty in hematology.

The five medical maintenance patients are her "private hospital based practice." This physician was associated with Dr. Nyswander in the establishment of medical maintenance at The Rockefeller University. Also, she has known several of the patients in her medical maintenance practice from the clinic system. She will not be able to expand her practice because of administrative responsibilities.

The physician operates her medical maintenance practice from her administrative office which is about six blocks from the main hospital. She has to pick up the methadone from the hospital pharmacy since it must be received by an authorized person with a narcotics' license. Until recently, she also hand delivered the patients' urine specimens to the laboratory. Despite these time consuming chores, she continues to participate since the physician-patient relationship gives her a great deal of personal and professional satisfaction although the financial remuneration does not cover the time and effort expended.

This physician is the only one who had clinical exposure to addicts while in medical school. She learned the technique of withdrawing addicts from heroin using methadone on her psychiatric rotation in her senior year. However, the school did not offer formal lectures in addiction or the use of methadone as a maintenance medication. She states that she initially thought that addicts used drugs as an environmental response to the lack of a structured life. It never occurred to her that this was a metabolic disease. From her early experiences in the wards she thought that there were many reasons for persons to become addicted:

"There was a void in their lives that they filled with drugs. Some stopped, others continued. Some were mentally impaired and started using substances -- something to allay the symptoms. They would continue to use, when withdrawn the psychiatric symptoms would reappear and they would get readdicted."

However, her concept of addiction has not changed radically over the years. She feels that addiction is multifactorial -- physical, psychological and social. Although she is aware of the metabolic theory of addiction and the possible involvement of the opiate receptor ligand system, she indicated that she "does not believe this theory holds across the board. Successful withdrawal without subsequent relapse would be difficult if not impossible and discourage many patients in good standing who would want to withdraw. It puts up barriers." In her experiences in the clinic she has withdrawn patients in good standing.

However, she does not know whether the metabolic theory is applicable to her patients in medical maintenance since she has "not attempted to withdraw them as they are fearful of the procedure." She sees that her patients are doing well and likens the methadone to an orthopedic "crutch" which allows them to function.

She has had success and failures in medical maintenance. For this reason she indicates that patients have to be carefully selected and monitored. The monitoring is essential. She states that as a physician treating methadone patients in private practice she "... does not just dispense methadone," but:

"... essentially offers the services of a clinic. I learn from my failures. One patient who did well in the clinic system and in an aftercare program became involved with cocaine while on medical maintenance. It took several visits for me to piece the problem together. The patient was late, missed appointments, appeared dishevelled. The urine bottle had to be felt because he might not submit the correct one. He was sent back to the clinic. I read his clinic chart a few months ago and unfortunately his situation had further deteriorated, as though he had never been in medical maintenance. This patient lost his job, family and became homeless. I had one patient who died that was morbidly obese - over 500 pounds -- with many medical problems. The cause of death was probably a heart attack.

The five remaining patients are doing well. Two work for the program and the others have a variety of jobs. Methadone maintenance has helped them tremendously. They were stabilized at a particular dose and in a particular life style when they came into medical maintenance. They are patients who can be treated successfully in private medical practice. One is an artist who developed a very successful business and expanded it while on medical maintenance. Another is a highly skilled construction worker who is able to work overtime on high scaffolds and teach in his union at night. The patients that I treat are able to function intellectually, emotionally and physically without impairment just like you and me. Nobody can tell that they are on methadone. My patients, except for one, are on standard doses in the range of 50 to 100 mg/day. Sometimes they request a raise if they have problems and I inform them that this might be good for the short run but that they should try to resolve their problems without an increase. Methadone provides a steady state of well being."

When asked whether the patients still have the same problems or associations they had when they first became addicted, she replied that these have been resolved. When asked why the patients need the methadone she indicated that, "... methadone is something for them to take everyday to function, like a vitamin." She indicated that the daily need for methadone might be related to the dysfunction of the opiate receptor ligand system. She realizes that patients are fearful of withdrawal. She encourages patients to think about it since they are nearing retirement and may want to relocate where there are no methadone or medical maintenance programs.

Confidentiality, however is a major issue.

"Patients who work for the program are not that concerned since they are accepted as methadone patients on the job. However, the others are fearful of telling members of their families, their employers and even their physicians that they are on methadone. Some of the patients will bring in an insurance form and if I treat them for other problems, I will put it down for reimbursement. Otherwise patients prefer to pay in cash. I cannot give my new business card to one patient since my position as assistant director of the methadone program is listed."

The physician, like the other doctors, is very involved in the medical and social problems that her patients present. If a patient is hospitalized she will contact the physician and explain about the use of methadone and pain medication especially if surgery is anticipated. She is now working with a patient and his physicians at another hospital regarding a future liver transplant operation. Also, if social crises arise, she recommends referrals to appropriate agencies. Although she is not the primary physician, she has tended to minor medical problems and has written needed prescriptions for infections, arthritis and other conditions.

The doctor was successful in withdrawing one patient who was on methadone for over twenty years. This patient had previously withdrawn from methadone, but developed an alcohol problem and was restabilized. The patient resolved his alcohol problem and subsequently underwent a second withdrawal about five years ago.

This physician is aware of the biases and stigma surrounding methadone maintenance and the patients. She advised that stigma:

"..is the reason that the program will probably never enter the main stream of internal medicine. Doctors do not realize that addiction is a disease and that addicts can be treated successfully in medical practice with methadone. Furthermore, the field is not sufficiently lucrative and few doctors that I have come in contact with have shown an interest."

She indicated that education has to start in the nursing and medical schools. In her opinion: "The physicians that provide medical maintenance should be internists with hands on experience, preferably with previous experience in the clinical system. Also, most importantly, they must understand the patient and not be biased. ... Medical maintenance may require more effort than other specialties in internal medicine since patients may need continued focus and support systems."

Discussion

As previously stated the four physicians interviewed in this section are the first doctors since the passage of the Harrison Narcotic Act in 1914 to treat legally maintained opiate dependent patients with methadone in private medical practice. While other physicians may have prescribed dolophines prior to the existence of methadone maintenance, the prescriptions were usually for withdrawal. However, some physicians in the 1950s did prescribe maintenance doses of dolophine as an alternate opiate to heroin addicts, but they did so without the current knowledge of medical research and evaluation. Furthermore, these attempts at early maintenance were usually aborted by the Bureau of Narcotics. An effective maintenance treatment for opiate addiction did not exist until methadone maintenance was conceived and a clinic system developed. However, this marginal highly regulated system, isolated from mainstream medicine, can be detrimental for the continued treatment of stable, working patients.

Several issues emerge in the interviews with the physicians:

None of the physicians were educated about addiction and methadone maintenance while in medical school. Only one physician learned about withdrawal procedures.
Socially rehabilitated methadone patients fit into a private medical practice in internal or general medicine.
All of the physicians were initially exposed to seriously impaired dysfunctional patients on withdrawal wards. Their view of addiction, methadone treatment and methadone patients was initially shaped by this experience. All now regard methadone as a medicine that can help transform patients from dysfunctional alienated addicts to successful productive individuals.
The doctors are fully aware of the social stigma that is levelled against the patients and the need for strict confidentiality. Also, they are aware of the stigma and ignorance within the medical profession itself. When patients are hospitalized they inform doctors about methadone and proper protocols for pain. While all educate colleagues informally, one physician has undertaken a major education campaign within his own hospital and other institutions. Stigma and ignorance about addiction and methadone treatment will be the most crucial factor in trying to recruit doctors to expand the program.
The physicians conceptualize different theories of addiction but regard methadone as an effective medication for the treatment of opiate addiction. They interweave methadone into their individual conceptualizations. However, dose level is adhered to irrespective of theoretical considerations. One physician has systematically studied methadone and conceptualized a theory that coincides with other replacement therapies in medicine. The remaining physicians conceptualized theories that incorporate genetic or neuroscience factors. However, these were cast with a patina of residual emotional or behavioral problems that were attributable to the condition of addiction -- a bland recasting of older psychological and social theories of addiction which included fear of withdrawal.

The psychiatric, affective and behavioral aspects of the conceptualized theories appeared to mesh into interpretations and observations of the patient's behavior and goals of treatment (e.g., withdrawal or continued maintenance). However, ten patients in medical maintenance voluntarily withdrew. Two physicians felt that these were their most stable patients psychologically while another physician indicated that dose or whether the patient withdrew did not matter: it was the functioning of the patient that was paramount, either on or off methadone. These psychiatric underpinnings within a theory of addiction inadvertently stigmatize patients who remain on a high dose or continue in treatment because of metabolic factors (e.g., weak will, fear of withdrawing, strength of character or motivation).

The final point is that irrespective of theory, the four physicians were intensely dedicated professionals who saw their primary mission as treating their patients with respect and dignity while assisting them in every possible way with whatever problems arose in the course of treatment. The physicians all had a great deal of admiration for their patients and worked hard to facilitate their continued rehabilitation.

Footnotes

This researcher assisted both Dr. Nyswander at The Rockefeller University and Dr. Novick at Beth Israel implement and evaluate medical maintenance. Novick graduated from medical school in the 1970s and indicated that when he was a student narcotics addiction, medical problems related to addiction and the use of methadone as a maintenance medication were not taught. He learned about addiction and methadone treatment as a physician associated with Beth Israel and The Rockefeller University.
Dr. Dole is referring to the endorphins and the endogenous ligands of the endogenous opioid receptor ligand system.
However, one of these patients when interviewed for this study about two years after withdrawal from methadone has experienced a disturbing dream about narcotics (two weeks prior to the follow-up interview, has trouble sleeping, has written music about heroin and came into social contact with a heavily addicted friend. These are indications that the craving for heroin appears to have persisted although this particular patient has not yet relapsed and is still in therapy.
One incident involved the AIDS death of the only son of a methadone patient who took additional methadone to assuage the grief of his son's death. The other incident involved a patient who took a tranquilizer to alleviate anxiety while driving in a hazardous blizzard to keep an appointment