How I Learned to Stop Worrying and Love Methadone
Just like ex-junkie Russell Brand, I used to believe that “maintenance” was as bad—if not worse—than active addiction. Here’s how I came to understand how fatally wrong I was.
Contrary to popular opinion, maintenance and abstinence can co-exist.
By Maia Szalavitz
British comedian Russell Brand has a bit of 12-step recovery under his belt—and so, like a lot of people who fit that description, he fancies himself an expert on addiction. In fact, he’s so sure he knows his stuff that he’s taken it upon himself to tell the British government what treatment method is best: abstinence-only—and no maintenance, please! Conveniently, this is right in line with a recent push by the UK’s Conservative government for an abstinence-focused recovery agenda.
Brand elaborated on his position while discussing a documentary about his addiction that’s set to air this month on the BBC, telling The Guardian, “Without abstinence-based recovery, I’m a highly defective individual, prone to self-centeredness, self-pity and self-destructive, grandiose behavior. But if I seek the company and fellowship of other addicts and alcoholics … then, one day at a time, I have a chance of living free from this disease.” As for maintenance, he sniffs, “We might as well let people carry on taking drugs if they’re going to be on methadone. Obviously it’s painful to abstain, but at least it’s hope-based.”
It turns out that study after study shows that when methadone prescribing increases, addict deaths drop. It is superior to abstinence-only treatment in terms of fighting HIV and overdoses, and many studies find it superior in cutting crime.
I understand Brand’s position well. When I first quit heroin and cocaine, I shared it. In 1992, I even wrote an op-ed for Newsday, declaring that people on methadone were as far from recovery as active heroin users. It was like replacing vodka with gin, I wrote elsewhere at the time.
But I soon learned that not only is this perspective wrong, it can be deadly. And why shouldn't it be? After all, simply having an addiction and recovering from it no more makes Brand—or me—an expert on the topic than being treated for a brain tumor makes him a neurosurgeon.
Here’s how I learned a tiny bit of humility and began to develop some actual expertise. In the early 1990s, I began conducting research for a book on the addict’s perspective on drug policy. As part of that work, I interviewed dozens of recovering and active addicts, trying to include the widest possible range of experiences. I also read lots of addiction-research literature and joined a supposedly “academic and scholarly” listserv about topics related to addiction—which, as it turned out, included some of the country’s leading addiction experts, plus a number of 12-steppers. What happened, as anyone who’s ever commented on a Fix article can surely relate to, was that the list rapidly turned into a battle royal over whether the “truths” taught in recovery programs were supported by data.
At first, I argued fiercely against methadone, claiming that when I’d tried it, it had simply extended my addiction by six months and left me with a more protracted withdrawal to battle through when ultimately I chose abstinence. Adding insult to injury, my methadone counselor had done nothing but recommend Narcotics Anonymous—where, of course, methadone isn’t considered recovery and where I would not have been allowed to share.
The experts on the listserv demolished my arguments with data. It turns out that study after study shows that when methadone prescribing increases, addict deaths drop. It is superior to abstinence-only treatment in terms of fighting HIV and overdoses, and many studies find it superior in cutting crime. The conclusion is clear-cut: Add a methadone program to your community and crime and addiction-related deaths fall; eliminate one and they rise.
The World Health Organization and the Institute of Medicine both agree that methadone maintenance (as opposed to detox, which is what I did) is the most effective treatment for opioid addiction. More recently, buprenorphine has been found to be a close second in terms of effectiveness, at least for those who don’t require high-dose maintenance. So it wasn’t that methadone had failed me—I’d just been placed in a lousy program that didn’t use it effectively. I was also wrong about my “replacing vodka with gin” analogy, because an opioid-dependent person can be tolerant and not impaired on a steady dose, which is not true for alcohol.
But the 180-degree turn in my thinking wasn’t just due to data. As I researched my book, I met people on long-term maintenance who I came to admire and respect. Indeed, one of the smartest people I’ve ever known, and one of the UK’s leading thinkers on addiction, has been on maintenance for multiple decades. But what really leveled me and made me deeply ashamed of my prior ignorance was when another methadone patient—who also ultimately became a leading recovery activist—told me a story about methadone myths that nearly destroyed her.
Lisa Mojer-Torres was a kind, brilliant woman who tried repeatedly to recover without methadone. She wanted to attend law school, but believed that methadone caused cognitive impairment that would preclude being able to do it effectively—so she didn’t enroll. Ashamed and self-hating after multiple rehab attempts (and believing that methadone prevented emotional growth as well), she eventually came in contact with methadone advocates who debunked—with data!—these self-defeating beliefs and encouraged her to try. Rather than suffering through another failed detox, she stayed on methadone and, before long, she had graduated law school and passed the bar in two states. Over time, she became a powerful advocate and attorney, as well as a loving wife and mother. Sadly, she died last year from ovarian cancer.
While it’s certainly possible for people with opioid addictions to thrive without maintenance, there’s no need to stigmatize the treatment for those for whom it works.
Russell Brand believes only abstinence offers hope. I’d like to hear what he would have said to Lisa—or to the millions of others now quietly working and living productive and full lives on maintenance. I’d also like to know what he thinks about the UK’s prior painful experience with putting time limits on methadone, which occurred just before AIDS hit the country in the late 1980s. Researchers found then that the limits produced both increased abstinence rates and increased death rates: perhaps an acceptable trade-off for those who believe addicts deserve a death sentence, but not so for those who believe that where there is life, there is hope.
Moreover, with HIV spreading rapidly via IV drug use, experts feared that continued restrictions would push the death rate even higher. Wisely choosing to reverse course, under Margaret Thatcher the country expanded methadone prescribing and began a needle-exchange program, policies that actually prevented an AIDS epidemic in British drug users. While HIV rates reached nearly 50% in American addicts in some cities, they never climbed above 1% in the UK. In contrast, Russia—which bans methadone—has experienced one of the worst epidemics in the world, with at least one million people infected with HIV. More than three-quarters of these cases are directly linked to IV drug use, while many of the rest are the result of sexual contact with people who were initially infected via dirty needles.
And yet here we are again, several decades later, engaging in the same misinformed debate, which often seems more about a puritanical vision of what’s “right” rather than what works. While it’s certainly possible for people with opioid addictions to thrive without maintenance—and while most of us prefer to be dependent on the fewest possible medications—there’s no need to stigmatize the treatment for those for whom it works.
Type 2 diabetics who have conquered their disease through diet and exercise don’t go around calling those whose disease is more resistant “defective,” nor do they demand that insulin be pulled from the market or used only for limited periods of time in order to force those weaklings to recover more naturally. If they did, no one would listen. We know that personal experience doesn’t trump medical expertise and that medicine should be based on research, not anecdote.
It’s time we recognized that the same is true of addiction. If we want to call it a disease, we’ve got to have the humility to recognize that, as AA’s own “Big Book” puts it, we are not doctors. Different approaches offer hope to different people. One size does not fit all, and different strategies may even be needed for the same person at different times of his or her life. Perhaps Brand will come to understand this when he reaches his seventh step.
I really liked this one.