Happy birthday, methadone!(TEN MILES SQUARE) (methadone maintenance)

• Author: Satel, Sally

Maintenance therapy proved its value half a century ago. We need it today to combat a rise in opioid use. But many courts and prisons cling to a Reagan-era dust say no" mind-set.

Half a century ago, two medical researchers at Rockefeller University began investigating a new treatment for heroin addiction. A year later, the husband-and-wife research team, Vincent Dole and Marie Nyswander, announced that they had treated a group of twenty-two heroin addicts with a synthetic painkiller called methadone. In every way--finding and holding jobs, continuing in school, stabilizing their families--the patients showed marked improvement. Careful supervision and support was needed, but methadone seemed to offer a promising avenue of treatment for the epidemic of heroin use in America's cities.

In response, the federal Bureau of Narcotics and Dangerous Drugs threatened to arrest the researchers. Treating addiction with addictive drugs, the BNDD reasoned, was simply drug use under another name.

Six years later, however, President Richard Nixon conscripted methadone into the national War on Drugs. Methadone maintenance offered an approach to addiction that could be expanded quickly, and federal funds for new methadone clinics flowed generously. By the mid-1980s, methadone "substitution therapy" had spread nationwide, and heroin simmered as a low-grade problem that was eclipsed by the explosion of crack cocaine, which was turning inner cities into war zones. But the pendulum swung again--President Ronald Reagan's 1988 White House Conference for a Drug Free America questioned whether "methadone substitutes one addiction for another" and suggested that "a drug-free state is superior to all others." That same year, Mayor Rudolph Giuliani began to phase out long-term methadone treatment in New York City. "Methadone is an enslaver," he said. Several months later he reversed his position, acknowledging that he had been "unrealistic."

In some ways, these rapid shifts tell the story of methadone maintenance: both the government and the treatment community swing back and forth between recognizing its value and shunning it as just another form of drug use. It's time, however, to finally come to terms with methadone. We need it as part of any strategy to cope with our national drug problem.

We are in the midst of another drug surge. After decades of domination by the stimulants--cocaine and, more recently, methamphetamine--hard-drug use has swung back to the opiates, both heroin and prescription pain relievers, such as Vicodin, Percocet, and, especially, OxyContin. "An urgent--and growing--public health crisis," is how Attorney General Eric Holder described it last March. The potential good news is that once again we can manage our opiate problem with methadone and a newer, related drug, Suboxone.

By "manage," I mean reduce the damage to both addicts and society. When on substitution therapy, studies have consistently shown, patients use less heroin, commit fewer crimes, and reduce their odds of contracting infections such as hepatitis C and HIV compared with those not taking methadone.

That's especially important for users under supervision by the criminal justice system. Drug-diversion programs such as drug courts offer a chance not only to get problem drug users into treatment but to keep them there. Retention is critical: as a rule, between half and two-thirds of all patients drop out of methadone and Suboxone treatment within a year. Four out of five of those will resume their habits, and criminal activities, within three months. With approximately one-fourth to one-third of all heroin addicts passing through the U.S. criminal justice system each year, the gains from embracing substitution could be very large indeed.

But too many parts of the criminal justice system remain mired in the mentality that led the BNDD, now the Drug Enforcement Administration (DEA), to try to shutter the first methadone clinic. Many judges, prosecutors, and prison officials still believe that opiate addiction can only be treated with drug-free approaches that exclude clinically sound substitution therapies. That attitude needs to change.

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