Medical Methadone Maintenance:
The Further Concealment of a Stigmatized Condition
by Herman Joseph, Ph. D.

Drs. Nyswander & Dole

The Transformation of Stigma from Heroin Addiction to Methadone Treatment
While Dole and Nyswander were implementing their research, sharp and acidic criticism was directed at them from various professional and governmental interests. This early criticism has not abated, extends the prejudice associated with heroin addiction and is the foundation for the stigma that now encompasses methadone treatment. Extensive clinic regulations enacted during the 1970s by the Drug Enforcement Agency, the Food and Drug Administration, state and local authorities to control methadone treatment are in essence extensions of federal, state and local laws and drug policy enacted since 1914 (Harrison Act) to control heroin addicts and the process of addiction. This section describes examples of governmental action and the portrayal of methadone treatment in the media that has helped to create and then enhance the stigma associated with it. However, the stigma associated with methadone maintenance is derived from the perceived transfer of deviance associated with heroin addiction. The theoretical underpinnings of labelling and the concept of tertiary deviance as conceptualized by Miller (1974) will be discussed in the initial section of this chapter followed by examples of stigma in the media.

The Labels and the Concept of Tertiary Deviance
Drug addicts as a deviant group have always been defined with denigrating labels. Foster, Dinitz and Reckless (1972) state the following about labels and makes the connection between labeling and the Goffman concept of stigma as a 'spoiled identity' in the following excerpt:

"The labelling hypothesis maintains that being publicly identified as deviant results in a "spoiled" public identity. It contends that being labelled "deviant" results in a degree of social liability ... which would not occur if the deviance were not made a matter of public knowledge. It further suggests that the social liability incurred by being labelled "deviant" has the ultimate effects of reinforcing the deviance."

Lindesmith (1940) commented that heroin addicts appeared to be grouped into a label known as "Dope Fiends." The picture is of a totally depraved individual entrapped by a drive that is the generator of cruel single minded behavior without conscience. He also indicated that heroin addicts are labelled with an assortment of terms many of which are contradictory but all of which add to their stigmatization (e.g., passive psychopath, aggressive psychopath, narcissistic, dependent, childlike, sociopath, constitutionally immoral, hysterical, neurasthenic, weak character and will, self-indulgent, introspective, extroverted, pseudo-psychopathic delinquent, essentially normal).

The connection between labeling and deviance was made by Becker (1963) in the following statement:

"..that social groups create deviance by making rules whose infraction constitutes deviance... The deviant is one to whom the label has been successfully applied; deviant behavior is behavior that people so label."

Social labeling is then a prime phenomenon in the conceptualization and definition of primary and secondary deviance. Miller (1974) extends this concept to create a third category of deviance known as tertiary deviance to explain the stigma associated with methadone maintenance in relation to heroin addiction which is defined as secondary deviance. Prior to the passage of the Harrison Act of 1914:

"...there were apparently hundreds of thousands of primary deviants, individuals addicted to a drug that was morally acceptable in society. But they functioned as individuals addicted to opiates, not as a special subgroup of addicts (Miller, 1974)."

With the passage of the Harrison Act, Miller asserts that:

"...its interpretation by the Narcotics Bureau, the societal reaction which effectively criminalized the deviant behavior resulted in secondary deviance. Since narcotics were no longer freely and legally available one type of pre-1914 addict developed ... a secondary deviance pattern which shifted their self-image and their behavior patterns to a criminal subgroup identity."

The secondary deviance of narcotics addiction in the United States was contained within the criminal subculture that addicts were forced into to obtain money for heroin. Miller (1974) indicates that methadone maintenance, a response to the secondary deviation syndrome, was found to be a pragmatic solution to the criminal activities and transmission of infection but in itself did not resolve the initial philosophical debate over the use of narcotics in maintenance treatment or the behavior involved in the primary deviance of opiate use. As Miller (1974) indicates a dichotomy exists with tertiary deviance since:

"The solution to secondary deviation abuses is made both legitimate and illegitimate simultaneously. Moreover, the stigmatization of tertiary deviance solutions (such as methadone maintenance) indicates that the original ideological debate over the primary deviation has not been resolved."

Miller cites Nelkin (1973: 150) about the stigmatization of the methadone patient:

"... as a marginal man, isolated from his/her own community and stigmatized by the larger society as a threat to the social order."

Miller further states that the stigmatization in tertiary deviance will be continued:

"Tertiary solutions almost automatically guarantee that ideological debate will continue and that the tertiary solution will remain under assault by interested moral entrepreneurs."

The stigma of the primary deviance (heroin addiction) is continued but in a lesser state. With methadone as a treatment medication, an ambivalence is created in the public's attitude towards patients. As Miller (1974) states:

"Are they cured or are they still patients? Community opposition to methadone maintenance programs (especially in transition neighborhoods) must be understood in the light of this societal ambivalence."

Addicts themselves have adopted labels for and social concepts about their behavior. These concepts were usually developed in the larger society observing behavior that was deviant and perceived as endangering social values. The labelling is related to the observation by Helmer (1975) that perceptions of drug addicts are embedded in class and racial stereotypes and mythologies that promote minority oppression within a given society. The perceived characteristics of the drug abuser reflect the attitudes towards stigmatized racial and socioeconomic groups and constitute class conflicts especially in times of economic crisis. The two most common terms to describe drug addicts are dope fiend and junkie. Both dehumanize addicts and define a deviant stigmatized subgroup.

In nineteenth century United States, opium was associated with orientals and in particular the Chinese. Heroin, during the first part of the 20th century, was usually associated with the poor white ethnic and immigrant groups while cocaine in the late nineteenth century was associated with poor blacks. Exaggerated accusations of cocaine-induced black crime in the late and early 20th century prevailed among whites.

In the United States, therefore, the terms dope or drug fiend and junkie evolved from a confluence of class and racial stereotypes (e.g., indentured Chinese laborers, poor white ethnic and immigrant groups and poor blacks). These groups were perceived as potentially threatening to the socioeconomic status quo especially in times of economic crisis (Helmer, 1975). For example an upper class female opiate addict would not be considered a "drug fiend" or "junkie" but her drug using counterpart in the urban slums conjured up subhuman class and racial fantasies.

One theory about the evolution of the term "dope fiend" is reportedly rooted in behavior caused by cocaine. Cocaine is a stimulant but heroin and opium narcotize the user. Technically, cocaine is not a narcotic but is so classified under the Harrison Act. The possible paranoid ideations of the compulsive and heavy cocaine user evolved into the term dope fiend around the turn of the century (Kleber, 1988). The criminal behavior of a heroin addict to obtain money for drugs after withdrawal merged in the public perception with the cocaine induced behavior. Subsequently, the label of the dope fiend which originally applied to a cocaine addict was also applied to the heroin addict.

Furthermore, the opium den of the 19th century was seen as a den of inequity, and its patrons regarded as moral degenerates. The association of these dens with Chinese traffickers and poor smokers who were indentured laborers imported to work in mines and on the building of railroads further intensified racial and class fears. The Chinese laborers were paid less than white workers and this economic exploitation exacerbated tensions between the two groups. Also, as opium smoking entered the white marginal world of con men, gamblers and prostitutes, the opium dens and smokers became stigmatized and were targeted with restrictive local legislation (Courtwright, 1982).

Brecher (1972) describes nineteenth century America as a "dope fiend's paradise."

"Opium was on legal sale conveniently and at low prices throughout the century, morphine came into common use during and after the Civil War, and heroin was marketed toward the end of the century."

In describing opiate addicts in a 1916 survey of the New York City Jail known as the Tombs, addicts were referred to as "hypodermic fiends" or "sniffers." In 1919, in the case of United States vs Doremus, Dr. Doremus was convicted of prescribing narcotics to a "known dope fiend," Myers alias Ameris. The ethnic surname and the term "dope fiend" used in describing Myers reveals that the social prejudices targeted to immigrant, white ethnics and opiate users were even reflected in the language of the Supreme Court (Courtwright, Joseph and Des Jarlais, 1989).

In Victorian and turn of the century British literature (e.g., the Fu Manchu stories) the Chinese drug users were described in subhuman terms and as oppressing and seducing white women. Opium dens become palaces of evil where upper class men become enslaved to opium. The patrons of opium dens were described in dissolute terms reflecting the concept of degeneracy (Parssinen, 1983). An example is the role of opium and the opium den in the Oscar Wilde novel, The Picture of Dorian Gray. Dorian Gray is an upper class Englishman who is an habitue of the opium den and is driven by his insatiable craving for the drug. The den and the use of opium are symbolic of the dark, hidden and perverse side of his nature. While Dorian Grey retains his youth, his portrait ages reflecting his degeneracy and the use of opium (Wilde, 1977). Dickens also uses the opium den as a symbol of degeneracy in the upper classes in his novel, The Mystery of Edwin Drood (Parssinen, 1983).

In 19th century Victorian literature, upper class opium users were described as alien to the human race with an emotional coldness reserved for the monster and vampire literature of the period (e.g., Mary Shelley's novel Frankenstein). In this context, the dope fiend evolves from the degeneracy of the upper classes, the loss of human attributes and the overpowering craving for opium that leads to the descent of the upper class addict (Parssinen, 1983).

In 1922, the British novelist Aleister Crowley wrote, Diary of a Drug Fiend, which describes the addictions to cocaine and heroin acquired by a young naive couple traveling through Europe on their honeymoon. The novel, contrary to the title, does not describe "depraved," oriental or poor ethnic addicts. The plot deals with addiction within the British upper classes. Although the book describes the effects of cocaine and heroin sniffing in lush overblown prose, the novel is essentially a moral warning against the use of narcotics.

The term dope fiend therefore evolved from the experiences of two drug using cultures:

1. The British Victorian upper class opium smoker patronizes the barbaric Chinese operated opium dens (palaces of evil). The Chinese opium smokers are described in subhuman terms such as in the Fu Manchu stories while the upper class opium smokers are described as degenerating into less than a human state.

2. In the United States the term "dope fiend" evolved from the racial and class stereotypes of poor blacks using cocaine and poor whites from the lower and immigrant classes using opiates.

The class and racial contexts of the term dope fiend reflects the country of origin, the use of drugs by different class and racial groups, the type of drug that is used, and the perceived effects of the drug and environment in which the drug is used.

The term, "junkie" evolved within the first two decades of the century and its origin is not completely understood. Courtwright (1982) indicates that word is derived from the junk that addicts sold to obtain money to buy drugs. Stimpson (1973) states that the word is derived from the type of ships known as junkers that the Chinese drug traders used to transport opium.

Within the addict community, however, the terms have evolved to describe a definite addict class hierarchy. The narrator, "Sam," an upper class methadone patient in the book, Addicts Who Survived, relates the following, intertwining the two terms junkie and dope fiend:

"I was not yet a "junkie" - the commonly accepted convention of the dope fiend, the man lurking in the street with a dirty hypodermic in his pocket, who shoots up in a doorway, Mine was a private problem. I wasn't a "junkie." I was a "narcotic addict," if you please, or some other pretty, polite term. All the while not realizing -- or perhaps realizing, and not even admitting -- that I was a "junkie," as I realize today and admit (Courtwright, Joseph and Des Jarlais, 1989: 76) ."

In Sam's mind the drug fiend or junkie is at the low end of the status scale beneath the concept of the more sanitized term narcotic addict. Howe (1957) indicates that the term dope fiend probably evolved from pulp fiction and the combining in the public's perception the effects of excessive alcohol consumption with those of narcotics. Waldorf, however, states that the dope fiend identifies with the "culture of the streets." The definition is narrowed to a particular urban subculture.

"What are dope fiends? They are for the most part urban addicts who are overwhelmed by their addiction and must hustle on a sustained and continual basis to support their drug needs. The combination of uncontrolled drug use and regular hustling -- in juxtaposition with the larger culture's mores, laws and values about drug use -- causes the development of a social identity distinct from addiction which in a larger social context is seen as the addict subculture. Those addicts who somehow do not identify with the subculture are not, according to addicts, dope fiends; those who do, are dope fiends (1973)."

According to Waldorf, the addict subculture has therefore taken a concept developed to describe what is perceived as compulsive, degenerate behavior by the greater society and transformed it into a concept that encompasses a set of values and mores accepted on the urban streets.

Burroughs (1953) titles his autobiographical book, Junkie, a term used by addicts themselves to differentiate the behavior on the streets of heroin users.

Opium smokers in the 1920s and 1930s looked with disdain on heroin addicts - needle injectors. Several had to make the painful transition from opium smoking which was associated with atmosphere and class to heroin injection when opium was not longer available in the United States after World War II. As one opium smoker remarked in Addicts Who Survived, "When I became a junkie I lost my life" (Courtwright, Joseph and Des Jarlais, 1989). Heroin addicts especially those labeled as junkies were stigmatized as the lowest stratum of opiate user.

Labeling has shifted from the heroin addict to the methadone patient. A specific set of labels has developed to distinguish the methadone patient and the medication. For this study the term "methadonian" coined in the 1970s will be used to denote labeling. There are other terms such as "legal junkie" which is obviously denigrating. Methadonian is more subtle. It connotes an alien that uses methadone and, in a sense, removes the patient from the human race. The term methadonian not only demonizes the patient but also denigrates the medication. The stigma therefore enters the molecular makeup of methadone.

The origin of the term is not known. According to NAMA, the term methadonian appeared first on the streets in the 1970s and then in the media. It may have been used initially by working methadone patients to describe dysfunctional methadone patients. Thus a hierarchy of patients may have evolved early in treatment - those who were compliant, were employed and had normalized their lives in contrast to patients who were unemployed, still engaged in street activities, loitering and using a variety of drugs. This labeling may parallel Sam's narrative related above that the pejorative terms junkie and dope fiend are used in a special context to describe poor disheveled street addicts in contrast to the heroin addict who was "more responsible."

Functional methadone patients in medical maintenance consider themselves medical patients. However, according to NAMA, there are patients who prefer to use the word methadone client instead of patient (National Alliance of Methadone Advocates, May 1994).1 This "demedicalizes" methadone maintenance. The position of NAMA is that the word client denigrates methadone patients by removing the biological component of addiction: the patient is no longer a legitimate medical patient treated for a legitimate medical condition. The term methadonian, however, has been broadened to include all patients, derides the biological component of addiction and the patient's need for methadone to function normally. Patients irrespective of their adjustment are placed within a stigmatized subgrouping with the distinct label of methadonian.

Two health care workers who are patients in the medical maintenance program reported that the term is used in hospitals where they work and the classes they attend by nursing staff and physicians in private conversations to describe methadone patients. They indicated that the term is another manifestation of stigma. As one indicated:

"I hear it all the time where I work in classes-in the hospital. It is very stigmatizing."

A patient who owns a business in a suburban community near Manhattan had the following reaction to the term, its sociological implications and its effect on him as a hard working productive person:

"I saw a program where Geraldo Rivera stated that someone would succeed like a methadonian on methadone. I've seen the word methadonian on signs and walls in my community and heard it in conversation. Someone in the community writes signs about methadonians. They want to put us in a subculture. In this day and age, it bothers me that I've got to hide myself. I'm being put down for this (being a methadone patient), for trying to help myself, I don't stick needles in my arm -- it just isn't fair."

Bruce Stepherson (1994), a former methadone patient who is open about his treatment, acquired a master's degree and is now the Director of AIDS Outreach and Prevention at National Development and Research, Inc. (NDRI) sums up the connection and meaning of labeling for heroin addicts and methadone patients as follows:

"The forces mentioned above (intellectual, academic, political, religious, social, moral, cultural) have been effective in convincing communities, as well as users, and former users that they have "no value." This is evidenced by the fact that drug users are "demonized" and presented as being "nonhuman" by the media and the non-drug using community at large. One only needs to look at the language used to refer to drug users, words like 'dope fiend' and 'methadonians' as proof of this fact. This conscious demonization serves to further isolate and marginalize users."

The Role of the Bureau of Narcotics
From the first clinical research procedures with methadone maintenance in 1964 at The Rockefeller University, the Bureau of Narcotics perceived the theoretical and clinical work as a threat to its anti-maintenance position. In 1966 the Bureau published a pamphlet for the treatment of narcotics addicts by physicians. The following excerpt summarizes the Bureau's attitudes and philosophy:

"It is well established that the ordinary case of addiction yields to proper treatment, and that addicts can remain permanently cured when drug-taking is stopped and they are otherwise physically restored to health and strengthened in willpower."

This quote conveys the belief that willpower is sufficient to prevent relapse and effect a permanent cure after medical withdrawal. Yet at the time this pamphlet was published, all available studies showed that the majority of addicts relapsed after withdrawal in hospitals and extensive therapeutic interventions.

The belief in "cure by willpower" implies the absence of metabolic dysfunction, the persistence of a weak will and the need to control behavior until the will is strengthened. Thus, addicts who continue to relapse or continuously use narcotics are weak willed. This rationale constituted for the Bureau a theoretical basis to continuously control an addicted "irresponsible" population through criminal sanctions, legal statutes and commitment. The proof of their irresponsibility was of course their drug use. In contrast, the metabolic theory of addiction and the idea of methadone maintenance, the medicalization of an addictive disorder, challenged the concepts and philosophy promulgated by the Bureau to maintain power: methadone maintenance threatened to replace the primary deviance and stigmatization of heroin addiction. In a letter to the Yale Law Journal dated January 6, 1969, Donald Miller, Chief Counsel to the Bureau of Narcotics and Dangerous Drugs wrote about methadone maintenance:

"The Bureau does have a vital role ... to alert society as to the possible pitfalls and to caution against mass acceptance of a theory which could adversely affect our society by increased addiction.
Will there be any deterrence when potential users are assured that there will be no ill consequences from drug experimentation; indeed that addicts may even receive preferential treatment?

What will be the result of having no social stigma against addict proselytizers in our communities?"

The Bureau therefore perceived methadone maintenance as a medical sanction for continued narcotics addiction, hence a deviancy to be stopped. The concept that continued addiction can be treated successfully as a medical condition was discerned not only as lessening the social stigma of addiction but as a threat to the Bureau's philosophical approach and power. Their approach to solving the heroin addiction problem adopted since the passage of the Harrison Act included as a goal "enforced abstinence" which was impossible for most addicts to achieve. Other strategies the Bureau employed were the supporting of legal statutes and criminal procedures, harassment of physicians who prescribed narcotics, institutionalization of addicts including imprisonment and prolonged confinement to specially created prison-like hospitals. These goals and tactics essentially maintained and increased the social stigma and deviancy associated with addiction.

The next strategy was to stop the clinical research on methadone maintenance. The Bureau adopted a policy of intimidation and harassment. However, Dole had obtained not only the backing of the administration of The Rockefeller University but recruited the counsel at the university to study the legality of research on maintenance. It was found that there were no substantive legal issues or laws to prevent the establishment of research on narcotic maintenance, including methadone.

An agent from the Bureau of Narcotics appeared at his laboratory peremptorily threatening legal action and arrest if the research continued. After learning that the legalities had been researched and it was possible to lose in court, the Bureau discontinued its open threats of legal action and announced instead that Dole was "conducting a very limited set of research studies with their authorization and under their control." However, the Bureau continued its harassment, but covertly. Agents infiltrated the clinics where the research was being conducted. Records were stolen and false rumors were spread. Attempts were made to discredit Dole and Nyswander, even intimating they were liars. Nyswander was followed. Her activities including vacation plans were reported to the Bureau by an unknown surveillant. Many years later under the Freedom of Information Act, Nyswander obtained a censored record of these activities. The file was the size of the Manhattan telephone book.

In 1970, a representative from the Bureau of Narcotics visited the editor of the journal Federal Probation2 and demanded that an article that was being considered for publication by this writer and Dr. Dole, not be published. The demand was made when the article was not yet completed or titled. However, the Bureau appeared to know the contents. The editor of Federal Probation who informed this writer of the incident refused to surrender to the Bureau's demands, and the article was eventually published.3 It was a social, neuroscience and statistical clinical review of the program. Included were the methadone programs's philosophy, history and outcome statistics which detailed the successes and failures for first five years of its implementation. The article stated that the narcotic craving or drug hunger experienced by heroin addicts was symptomatic of a metabolic alteration in the central nervous system and may persist for long periods; perhaps even for the duration of a person's life. This concept was threatening to the Bureau. The metabolic theory of addiction would diminish the psychopathic or character disorder theory upon which the stigmatizing punitive approach of the government was based.

Clearly, the thousands of addicts whose lives have been restored through methadone maintenance may have never been given the opportunity were it not for the stature of Dr. Dole and his tenacity to continue with the work. Very few scientists would even consider standing up to the Bureau of Narcotics and risk their career or even possible imprisonment

The Drug Enforcement Administration (DEA) is the successor of the Bureau of Narcotics. The philosophy of the Bureau has been continued through the DEA which concerns itself with the diversion of methadone. The responsibilities of the DEA include storage of medication and the architecture of the clinic to minimize diversion. However, DEA agents have testified before Congress as recently as 1994 intimating that methadone was responsible for countless deaths. This viewpoint is contrary to scientific evidence and will be discussed later in this chapter. Other harassment tactics of the DEA include entrapment of patients (e.g., undercover agents pretend to be an addict in withdrawal and beg patients for their methadone). These strategies result in oppressive clinic regulations which all patients must adhere to. Programs fear their licenses to dispense methadone will be revoked if they are cited for violations. These oppressive tactics of control also create an atmosphere that stigmatizes the program and the patient. Miller's concept of tertiary deviance - that stigmatization is continued since the primary deviancy of heroin addiction has not been resolved - applies to the perception of patients by the DEA.

The Role of the Media in the Development of Stigma
In this section selected examples of articles in magazines, journals, books, newspapers and television programs that promoted a sensationalized negative view of methadone treatment and contributed to stigma will be reviewed. There are many more examples but the following exemplify the type of attacks that have appeared over the past three decades. The vitriolic attacks from various sources reflected Miller's (1974) contention that methadone maintenance is viewed as an "ideologically deviant rehabilitative therapy." Irrespective of the intentions of the critics, the ultimate effect of the criticisms stigmatizes patients: the "deviant rehabilitative therapy" has become a "rehabilitation without honor."

Magazines, Journals, Books, Newspapers, Television
Bayer (1978) reviews the incessant attack on methadone treatment in the popular literature. He reports that by the 1970s the majority of the articles published about methadone were unfavorable attacks upon methadone, the patients and the work of Dole and Nyswander. Included in his analysis are attacks on methadone during the 1970s by the author, William Burroughs, who by 1981 became readdicted to heroin, entered methadone maintenance and has remained a patient in good standing to the present. He was interviewed as a methadone patient in the book, Addicts Who Survived (Courtwright, Joseph and Des Jarlais, 1989). Although Burroughs may be considered a successful methadone patient who has produced books and acted in the film, Drug Store Cowboy, while being maintained on methadone, he has never published a disclaimer to the article published in the New York Times on November 11, 1977 entitled, Heroin Maintenance: Methadone Kills You Faster than Junk.

Bayer (1978) analyzes a complaint lodged against New York Magazine with the National News Council concerning the publication of an article written by a free lance writer, Blake Fleetwood, entitled Psst, Kid ... Wanna be a Junkie? Try Methadone. This article grossly misrepresented the methadone program and the medication. It was a supposed exposÚ of a privately run methadone clinic in lower Manhattan. The article was inaccurate about methadone as a medication and highly stigmatizing to patients. The opinion of the National News Council favored the magazine since the magazine was not considered a scholarly journal, was presenting advocacy journalism and printed several letters in rebuttal to the article in subsequent issues. However, one of the members of the National News Council, Sylvia Roberts, who dissented from the majority opinion wrote following:

"The article moved from the writer's personal experiences to a general indictment of all methadone programs. The argument was totally one sided; no arguments in favor of methadone were included.....

The article leaves the impression that methadone patients are "junkies" who are so continually "stoned" that they cannot hold jobs. Methadone alone may not be the answer to the nation's addiction problem, but there is substantial evidence that methadone therapy has helped many patients function productively. By labeling methadone patients as unreliable "junkies," the article contributes to a stereotyped image that makes it difficult for even the most motivated patient to obtain a job....

In our judgement, the damaging impact of so one-sided an article cannot be undone by subsequent publication of letters to the editor."

One of the earliest magazine articles to attack methadone treatment appeared in the New Republic (August 13, 1966) entitled, Stoned on Methadone by Louis Yablonsky. Yablonsky (1965) was the author of a book Synanon, The Tunnel Back promoting an abstinence oriented treatment. The New Republic article described a methadone patient interviewed for it as a "mummy man." In the September 16, 1966 edition of The New Republic, the patient wrote a letter to the editor refuting Yablonsky's description, indicating that he was normal and working. This was the first known attack in print in which proponents of abstinence oriented therapeutic communities portrayed a negative, biased image of patients on methadone.

A major attack was launched by Edward Jay Epstein in the 1970s in his book, Agency of Fear, and in an article written for the magazine, The Public Interest (Epstein, 1975). Epstein attacked the central metabolic hypothesis of Dole and Nyswander's work, their initial reports and the effectiveness of methadone maintenance treatment. Epstein never contacted Dole for information in preparing either his book or article. For the rejection of the metabolic basis of addiction and effective methadone dose, Epstein relied on the opinions of a Stanford University professor, Avram Goldstein, who subsequently entered neurological research in the addictions after Dole predicted the existence of opiate receptors. Goldstein organized methadone programs in California, was the codiscoverer of a group of opioid peptides known as the dynorphins and subsequently shared a Lasker Medical Award. Today, Goldstein does not reject the idea of a metabolic basis of an opiate addiction and has indicated that considering the advances in neurological research there is a strong basis for the Dole-Nyswander hypothesis (Goldstein, 1994). While Goldstein initially felt that methadone dose was "irrelevant," he has subsequently changed his mind and believes in higher rather than lower doses and that patients should receive adequate doses of methadone.

Epstein also relied on the work of Drs. Irving Lukoff and Paula Kleinman of the Columbia University School of Social Work for the evaluation of methadone treatment. Lukoff and Kleinman evaluated a program that was created by administrators of the VERA Institute of Justice and funded through the National Institute on Drug Abuse (NIDA). The program, the Addiction Research and Treatment Corporation (ARTC) services the black community in central Brooklyn and conducts clinical research. The VERA Institute of Justice developed a poor and dangerous research design concerning dose. Initially, low inadequate doses of methadone were prescribed to a poor addicted black population. At the time the ARTC program was designed by the VERA Institute of Justice, high doses (e.g., over 80 mg/day) were already known to be more effective than lower doses in the treatment of heroin addiction. Despite the protests by Dr. Dole and others to the head of the proposed board of ARTC, former Attorney General Katzenback, the program was implemented with this questionable design. The initial low dosing schedule with a cap of 40 to 50 mgs/day did what was predicted - high rates of heroin use among patients and high drop out rates. Over the years, ARTC was cited by then known as DACC (the Drug Abuse Control Commission) because of the number of patients using heroin who were prescribed low doses of methadone. It was during this period of low and ineffective doses that Lukoff and Kleinman did their evaluation, found minimum effectiveness, and dubbed methadone treatment a modest hope (Kleinman and Lukoff, 1975; Kleinman, Lukoff and Kail, 1975). Unfortunately, this publication has been used throughout the years to demonstrate that methadone is ineffective (See Appendix, "Methadone," United We Win).

After the initial evaluation which showed poor results, ARTC was audited regarding its dose policy by the New York State Drug Addiction Control Commission (DACC). When confronted, ARTC modified its policies and began to prescribe adequate doses of methadone and has openly admitted the error of prescribing low inadequate doses as recommended by the misguided research protocols of the VERA Institute of Justice (Primm, 1995; Scro, 1994).

Unfortunately Epstein (1975) regarded the expansion of methadone treatment simply as a means for controlling crime. During the time of expansion of methadone treatment, the jails of the inner cities were filled with heroin addicted men and women. Also, there were serious public health issues related to heroin addiction such as:

1. The leading cause of death in New York City among young persons 15 to 35 was related to the use of heroin.

2. A drug related hepatitis epidemic was in progress; the virus was transmitted by heroin addicts through the sharing of contaminated needles.

The potential for methadone to address the serious public health crisis and criminal activity related to heroin addiction were totally omitted by Epstein in his attacks. Also, Epstein believed the reports about excessive "methadone related deaths" from medical examiners without questioning the validity of their conclusions or the contexts of the reports. Methadone findings on autopsy were considered as the cause of death irrespective of factors such as trauma, accidents and the presence of other toxic drugs. Methadone when used correctly within a clinical situation is nontoxic. Such misleading autopsy reports have been used to denigrate the effectiveness of the program and its potential.

Contrary to what Epstein reported in his writings the following was noted in New York City during the years 1971 through 1973 when an additional 19,900 patients were admitted into treatment bringing the total enrollment to about 30,000:

1. Drug arrests decreased by about 24,900 arrests or a decrease of 1251 arrests per 1,000 admissions to methadone maintenance treatment (Joseph, 1988).

2. Property crime complaints decreased by 77,000 or a decrease of 3,869 complaints per 1,000 admissions to methadone maintenance treatment (Joseph, 1988).

3. Serum hepatitis cases transmitted by contaminated needles decreased by about 1,500 cases or a decrease of 75 cases per 1,000 admissions to methadone maintenance treatment (Joseph, 1988).

4. Drug dependent deaths decreased by 324 deaths or a decrease of 16 deaths per 1,000 admissions to methadone maintenance treatment (Community Treatment Foundation and The Rockefeller University, 1974; New York City Department of Health, 1974).

By the above four important measurements, methadone maintenance was effective in New York City. The major impact of methadone maintenance on public health and crime in the period 1971-1973 may be criticized as an anomaly unique to New York City at the particular point in time and unrelated to methadone. However, between 1976 and 1980 about 8,000 addicts were treated with methadone in Hong Kong, and an 85% decrease in drug related incarcerations were reported over a four year period. This is a decrease of 287 incarcerations per 1,000 admissions to methadone treatment.

Methadone maintenance was the only treatment for heroin addiction that could produce such dramatic results in public health and crime reduction. Dr. Jerome Jaffe, appointed in 1971 as director of the Special Action Office for Drug Abuse Programs recognized that methadone maintenance was the only treatment that could be expanded to achieve massive reductions in addiction related crime, disease and deaths. He therefore recommended the expansion of methadone treatment. Epstein's contribution was to create a climate of confusion and misinformation about methadone. His writings not only contributed to the stigma of the program and the patients, but also to a reduction in support for the only addiction treatment program capable of producing meaningful results in public health.

The attacks on the integrity of Dole and Nyswander remain to this day casting doubt on their theoretical conceptualizations as well as the effectiveness of the program. An example of this may be found in a current college textbook entitled Drug Abuse, An Introduction by Howard Abadinsky (1989). Although Abadinsky supports the concept of methadone maintenance, his descriptions of Dole and Nyswander's concepts trivialize their initial careful research. For example, he writes that:

"Dole and Nyswander (1966) intimated that they had discovered the "magic bullet:" methadone blocked the effects of heroin."

Dole and Nyswander never stated or intimated that they had discovered a magic bullet for addiction and both knew that antagonist drugs also blocked the effects of heroin. On a more serious level their integrity as researchers is questioned:

"The figures given out by Dole and Nyswander were deceptive: the rate of "cure" attributed to methadone was better explained by the screening mechanism used - older and more motivated addicts were preferred - and the fact that unsuccessful cases were simply dropped from the program and the final tabulations."

The initial criteria for the program in its first phase of research targeted a group of heroin addicts without complicating conditions. Methadone maintenance as a treatment for heroin addiction was in the development stage and other serious conditions (e.g., alcoholism, barbiturate abuse and mental illness) would complicate the outcomes. A clear demonstration concerning the effectiveness of methadone maintenance for heroin addiction was needed before admitting patients with serious co-morbidity. The premature admittance to a research protocol of subjects with complicating co-morbidity would vitiate the results and cloud the findings about either the effectiveness or ineffectiveness of methadone treatment.

The first group of patients was restricted to heroin addicts without serous co-morbidity, between the ages of 20 and 40. Heroin addicts comprising this group entered methadone treatment with an average of 12.5 year histories of addiction; multiple arrests, convictions and incarcerations; several attempts at withdrawal including admissions to the U.S. Public Health Hospital in Lexington. Once methadone maintenance proved its efficacy in reducing heroin use with this initial group of heroin addicts, applicants with histories of polydrug abuse and alcoholism were admitted as well as pregnant addicts and addicts with serious mental problems. Also, the upper age limit was removed and the lower age limit was reduced to 18. However, programs were not funded to treat all of the patient's social, medical and personal problems. For example, addicts with the dual problems of alcoholism and heroin addiction were admitted. The methadone program attempted to treat both conditions but an effective medication for the long term treatment of alcoholism has as yet to be developed. Furthermore, 12 step programs such as Alcoholics Anonymous refused to accept methadone patients as full participants in their meetings. Many of the health problems that methadone patients evinced and the subsequent deaths in methadone treatment were caused by chronic alcoholism developed prior to admission to the program (Joseph and Appel, 1985).

Abadinsky questions the use of the term narcotic blockade to describe the effect of methadone in blocking the euphoria of heroin and other opiates. He indicates that there is no blockade effect but only cross tolerance. This is reported in the text as follows, again implying that Dole and Nyswander are deceptive:

"Eventually, the bad news came out. Methadone was not the "magic bullet." Indeed there was no blockade but simply cross tolerance. .... In fact it was discovered that methadone patients, even those taking high daily doses, were often abusing heroin as well as other drugs. And, while methadone maintenance was designed for heroin addicts, the problem was often one of polydrug use."

Dole described the creation of the blockade effect by the induction of tolerance in major articles including the seminal, "Narcotic Blockade" in 1966. At high doses of methadone, the euphoric effects of heroin are blocked if the patient self administers heroin. The term, narcotic blockade, describes perfectly the effect that the patient experiences. Cross tolerance is implicit in the elementary definition of any narcotic drug, namely cross tolerance to morphine. Dole who is one of the foremost narcotic pharmacologists in the world is fully aware of this phenomenon. In this instance Abadinsky has unknowingly overstepped his expertise. Also, from the beginning of the program, polydrug abuse, especially alcoholism, was recognized as a major problem and was noted as such. More recently in the late 1980s and early 1990s the problem of cocaine/crack addiction has created many serious problems for patients and the program. With the emergence of the cocaine/crack epidemic, patients who injected cocaine would combine the cocaine with heroin. This combination known as "speedballing" was reported for patients at all doses. However, for patients receiving high maintenance doses (e.g., over 70 mg/day) the practice of "speedballing" and use of heroin was significantly less when compared to patients maintained on lower doses (Hartel, 1994). Recent advances in the technology of measuring blood levels of methadone have shown that there is a group of patients who metabolize methadone rapidly and may need extremely high doses to feel correctly stabilized without the occurrence of withdrawal symptoms. Also, as of 1994 there were no long term successful chemotherapeutic interventions for alcohol, cocaine/crack or nicotine addiction that are comparable to the efficacy of methadone for opiate addiction. Talk therapies for polydrug use have had limited success but nevertheless have been employed in some methadone programs with very modest gains.

Alcohol treatment programs and Narcotics Anonymous (NA) discriminate against methadone patients. Methadone patients are either refused treatment in alcohol treatment facilities or told they must detox before they can be considered. For example, in 1994 the homeless shelter for men on East 3rd Street in Manhattan refused to medically withdraw alcoholic methadone patients from alcohol. NA considers methadone a "drug" and methadone patients are not allowed to participate (share) in 12 step groups.

Newspaper Articles
Newspaper articles attacking methadone appear periodically in daily newspapers and neighborhood publications. There are many examples of newspaper articles and in actuality the majority present only the negative side of methadone treatment, or in order to appear "fair-minded" present a basically negative article with comments that some persons are helped by the program.

The Village Voice has published two major articles that attacked the concept of methadone maintenance. Although purporting to attack unscrupulous physicians, the articles presented a stand against the concept of maintenance and again equated primary deviance (heroin addiction) with methadone treatment. The first of these articles published on November 24, 1975 by Douglas Garr entitled, "How MD's Gross Methadone Millions." Although rightfully exposing unscrupulous physicians, the article distorts methadone as "synthetic junk." Methadone is therefore presented as another drug of abuse akin to heroin but even worse as a synthetic as opposed to a "natural opiate." Here Garr demonstrates his ignorance of pharmacology because heroin is a semisynthetic opiate which in the opinion of the reporter is probably better than methadone. Again, this concept further stigmatizes patients by vitiating the qualities of methadone that make it such an effective medication. The second article was published on April 5, 1988 by The Village Voice as a cover article entitled, "Hooked: The Madness in Methadone Maintenance" by Jim Landless. The article described methadone patients as methadonians, a demeaning term for compliant and productive patients. The article includes isolated statistical information with questionable interpretations. Methadone is described as giving patients a "buzz." This is refuted by scientific evidence and probably refers to patients who are abusing alcohol, cocaine or benzodiazepines since correctly stabilized patients report feeling normal on their stabilized doses. The article not only tries to debunk the program medically and politically but adds by its negative posture and sensationalism to the stigma and shame that compliant functioning patients experience as methadone patients.

Our Town, a Manhattan weekly, in the September 23, 1993 edition highlighted the loitering problems created by unemployed methadone patients with serious mental disturbances and polydrug use problems. The story entitled "The Methadonians," by Justin Brown, featured a homeless, physically and mentally ill, unemployed, Vietnam veteran who was alleged to be a patient. While highlighting serious problems among patients, the news media wrongly blames the methadone programs for the lack of extensive community social services to help this visible and dysfunctional population. Employed patients feel stigmatized by the visibility of the loitering, unemployed, mentally ill, homeless patients. Working patients usually report early in the morning or late in the afternoon for their medication on their way to or from jobs. However, the picture on the front page of Our Town showing a dysfunctional mentally unstable patient (primary deviancy is accentuated) creates an illusion that surrounds the programs and adds to the stigmatization and marginalization of functional patients. The publicity and stories lessens the distance between primary and tertiary deviance. Hence both groups (the primary and tertiary deviants) are highly stigmatized.

On January 4,1995, Newsday published a "Profile of Patrick Perri," a policeman on the beat in the South Bronx (McKenna, 1995). The policeman described methadone patients in the most negative terms - methadonians, unemployed, dishevelled, loiterers, urinators on the streets, drug users and dealers. The newspaper did not temper its story with images of methadone patients who were employed, supported their families and were responsible with their medications. Furthermore, the policeman did not describe how he was able to identify untreated addicts from methadone patients.

Documentaries and Television
The documentary, Methadone: An American Way of Dealing, was produced in the early 1970s by the socially conscious film producers, Julia Reichert and James Klein. The film was shown in art film series at the Whitney Museum and the Museum of Modern Art, in movie theaters and on public television across the country. It was photographed at a program called BUDA in Dayton, Ohio in a style called cinema veritÚ. The film discredited methadone treatment placing the treatment within locus of the primary deviancy of heroin addiction and substance abuse. The picture, therefore, became a source of great stigma for patients who were doing well in treatment. The following is a summary of this writer's contacts and correspondence with officials in the state of Ohio, the newly appointed director of the program, one of the patients who participated in the film and groups of patients who protested.4

The state hired an individual from New York City who made false claims about his experiences with methadone treatment. The program was clinically and financially mismanaged and this person was fired. During his tenure he invited the producers into the clinic to shoot this documentary without the permission of state authorities. However, there were many problems with the program because of poor management. Nevertheless, several patients did benefit from the medication and unfortunately cooperated with the producers of the documentary. The result was a distorted picture of methadone maintenance. As an example of the tactics employed, one successful patient invited the producer into his home. He was told to lie down on his living room couch and was interviewed in a reclining position. This position gave the audience the impression that the patient was sedated from the methadone. Furthermore, in a verbal agreement with the producers, according to the patients, the film was not to be shown in Dayton to preserve their confidentiality. The film was shown in Dayton, thus breaking the agreements and promises of confidentiality, which caused serious problems for patients who participated in it. When the producers were confronted with this breach of confidentiality, they did nothing and the distribution of the film was continued. In New York City, methadone patients attended the showings at the Higher Ground Cinema (a movie theater), the Whitney and Modern Museums to present their side of the methadone story. Authorities at the museum were contacted by the Chief of the Ohio Bureau of Drug Abuse requesting that they discontinue showings because of the distortions that were presented (Zwissler, 1975) (See Appendix for letter). A group in New York City called the Committee of Concerned Methadone Patients and Friends (CCMP) mounted protests at the Whitney Museum and the Higher Ground Cinema where the film was shown (Carlo, 1975). Successful patients distributed literature about the background of the film and talked with movie goers to demonstrate that the film portrayed a false and prejudicial image of methadone treatment and especially harmed patients (See Appendix). The film was distributed nationwide, and shown on television despite the protest from patients, officials and programs.

The following is an excerpt from a letter by a former patient in the BUDA clinic to the State of New Jersey Division of Narcotic and Drug Abuse Control requesting that the film not be shown in New Jersey. The patient was medically withdrawn from methadone and appeared to be doing well (Stroud, 1975):

"I can testify that methadone was a successful factor in my rehabilitation from the drug culture. Prior to my admission to the Dayton clinic, all other attempts to become drug-free had failed. An agreement was made with the film makers that the film would never be shown in the Dayton, Ohio area. I personally have witnessed the screening of the film in this area on two different occasions. This film reflects a negative image of methadone clinics in general, and the Dayton Ohio clinic in particular, and it should not be used to demonstrate the quality and effectiveness of these programs. This film has proven to be extremely detrimental to my image in the community and to my progress and survival and has caused me a great deal of mental anguish" (See Appendix).

The nationally televised news program, "60 Minutes," aired a program on February 21, 1993 about unregulated and privatized methadone clinics in Harris County, Texas. Physicians were operating programs without proper services, patients were selling the medication and a woman claimed that her two sons died as a result of methadone overdoses. A transcript of the television show (60 Minutes, 1993) and an internal unpublished report (Barrett, Luk, Parrish and Jones, 1993) concerning drug related deaths in Harris County, Texas prepared for the Center for Disease Control (CDC) in Atlanta were obtained for this study.

A review by the CDC of 91 deaths where methadone was detected upon autopsy in Harris County, Texas found that 85% of the supposed methadone-related deaths were due to polydrug use and other substances (i.e., cocaine and alcohol) (Barrett, Luk, Parrish and Jones, 1993). Furthermore, about 80% of the decedents were not even enrolled in methadone treatment in Harris County and the enrollment status of the remaining decedents could not be verified with certainty. In many of the cases low amounts of methadone were found. The overwhelming majority of deaths where methadone was detected occurred within a population of untreated addicts with serious polydrug problems. Other causes of death among this group of untreated addicts included trauma, AIDS and natural causes.

"Methadone mentions" at autopsy have remained constant from 1987 to 1992. However, polydrug toxicity increased in 1990 and 1991. In comparison to the national statistics, "methadone mentions" in autopsy reports did not increase during the period 1980 through 1991, but "heroin mentions" in the same period increased by 193%. However, "60 Minutes" did not mention the substantial increases nationwide for "heroin mentions" or "polydrug mentions" in autopsy reports.

A former patient interviewed for the segment claimed that methadone "left him with nerve damage and nervous tics." "60 Minutes" neglected to investigate this claim and to report the 30 years of research which demonstrate that long term methadone maintenance is safe. There is no medical evidence that methadone causes nerve damage or nervous tics. The patient displayed an intense hatred for the clinic which he claims "enslaved him." The former patient also allowed the producers of the show to hide a camera in a fake arm cast in order to film in the clinic without the knowledge of staff or patients. The former patient was attempting to show that "anyone" could enroll in the program, but the effect was unfortunately to breach the confidentiality of the patients shown. Patients shown on the program without their permission have initiated a class action lawsuit against the producers of the segment, "60 Minutes" and CBS.

The "60 Minutes" program was poorly researched and inferred the most injurious stereotypes about methadone patients, programs and the medication itself, emphasizing that it was "developed by Nazi Germany." Methadone was described as "more addictive than heroin" and doses were referred to as a "daily fix." The history and philosophy of methadone programs were distorted. The problems presented on the television show, however, reflected indifference by the state to properly regulate programs and discipline physicians who inappropriately prescribe methadone and mismanage programs. Texas has privatized all methadone treatment, and unscrupulous physicians have opened programs without adequate regulation. The methadone program shown on television was mismanaged, subsequently closed and the patients were transferred to other more reputable programs. Employed patients who have benefited from the program were interviewed and indicated that methadone helped stabilize their lives. The general attitude portrayed by the producers contributes to the stigma of methadone treatment and could be summed up in the following final statement of the telecast:

"The one thing methadone does achieve? It hides the unsightly problem of addiction from public view. They made it (addiction) legal and declared victory."

The statement incorporates a basic premise of the concept of tertiary deviance as defined by Miller (1974):

"Tertiary deviance implies that societal legitimization of the new behavior patterns is incomplete. ... Moreover, the stigmatization of tertiary deviance solutions (such as methadone maintenance) indicates that the original ideological debate over the primary deviation (heroin addiction) has not been resolved. ...the ideological debate will continue and ... the tertiary solution will remain under assault by interested moral entrepreneurs. "

Methadone patients, therefore are portrayed nationwide as "hidden addicts." Moreover, in this program, the differences between methadone treatment and heroin addiction are minimized. Methadone patients were portrayed as unreliable and devious, akin to heroin addicts rather than productive and responsible individuals.

NAMA protested to the producers of the show and many individual patients called the station. One of the patients who called and was interviewed for this study stated that she was treated coldly and with indifference. She could not discuss the issues with one of the assistant producers and the producers refused to return her calls for further discussion. Another of the patients interviewed for this study, a professional musician, saw the show; his reaction was one of anger indicating, "I wanted to smash the television set." As of 1995 NAMA still receives letters from methadone patients across the country commenting about the destructive effect that "60 Minutes" has had on their lives.

Therapeutic Communities
No stronger criticisms of methadone maintenance have been voiced than those by adherents to a drug-free, abstinent oriented philosophy. Directors of abstinent oriented programs attacked methadone for two reasons 1) competition for funding, and 2) a series of ideological concerns most of which were based on a simplistic conception of the pharmacology of methadone and ignorance about the biological factors in addiction. Leaders of therapeutic communities may be considered in Miller's conception of tertiary deviance as moral absolutists or moral entrepreneurs. More than any other group, they have transferred the stigma from heroin addiction to methadone maintenance. While methadone is seen in Miller's conception as a tertiary deviance, the adherents of drug-free programs regard methadone as problematic as the use of heroin. Therefore it has become aligned with the primary deviance of heroin use. Howe (1973) expresses this relationship based on a fundamental misunderstanding of the pharmacokinetics of methadone maintenance as follows: "Since methadone is a substitute for the pleasure of indulgence in heroin, its use must be equally wrong ..." The concept of "pleasure of indulgence" implies that in the United States there is a boundary of acceptable pleasure and that the euphoriant effects of opiates are considered a vice, not a legitimate pleasure, to be condemned. Simrell (1970) sums up this attitude which existed in the 19th century:

"The problem (narcotic abuse) had elements of ordinary vice; that is socially disapproved form of pleasure....

As a vice, narcotic abuse was largely identified with opium smoking and opium dens alien to American concepts of legitimate pleasure."

Therefore, the support for the drug free approach and therapeutic communities from the moral entrepreneurs is rooted in American social and cultural history. Nelkin (1973: 150) also expresses this phenomenon concerning American attitudes towards drug abuse within the 20th century:

"...rooted in a tradition that placed great value on abstinence, will power, postponement of gratification, and self control, as well as a strong moral taboo against any drugs that alter moods or weaken individual self-mastery."

Methadone as prescribed in maintenance therapy does not alter mood or weaken self mastery. On the contrary, the patients in this study were able to achieve impressive goals while maintained on methadone. The refusal of moral absolutists to recognize this or to take the effort to understand the pharmacokinetics of methadone maintenance raises doubts about their sincerity for rehabilitation of large numbers of heroin addicts. A more realistic concern would be competition for funds and a diminution of their power if methadone should prove to be successful. Therapeutic communities were never able to demonstrate a large percentage of "cures." However, a few graduates, estimated at less than 10 percent of the admissions, were able to live without relapsing to opiates. Many graduates became staff members of the therapeutic communities thus reinforcing their abstinence. DeLeon (1984) in a study of 7 therapeutic communities showed annual retention rates of 9 to 15 percent for all admissions.

Some of the criticisms of methadone treatment included statements by directors of therapeutic communities such as Dr. Judianne Densen-Gerber, founder of Odyssey House who indicated that "Methadone is a Lie" (Markam, 1973) and a statement published by Lennard, Epstein and Rosenthal (1972), "Methadone permits the illusion of a solution."5 These statements add to the stigmatization of the program, the providers and ultimately to the patients themselves. Again the tertiary deviance that Miller (1974) ascribes to methadone treatment actually becomes with these statements closer to the primary deviance of heroin addiction in the minds of the drug free moral entrepreneurs. Miller (1974) sums up the drug free criticisms of methadone maintenance treatment as follows. Answers to these criticisms will be given after each criticism is stated:

1. "Maintenance treats the symptoms of addiction, not the underlying social-psychological disturbances involved."

Answer: Methadone maintenance is medical replacement therapy for a deranged physiology created by use of heroin. The current neuroscience investigations have uncovered a complicated endogenous opioid system that is currently being investigated for its role in a continued opiate addiction. Methadone maintenance does not preclude the identification and resolution of underlying social-psychological disturbances that contribute to an addiction. Both the medical and social aspects of addiction can be addressed while patients are maintained on methadone.

2. "A legal addiction is an unacceptable substitute for a illegal addiction."

Answer: Methadone as prescribed in maintenance therapy acts as a normalizer rather than a narcotic. It is orally effective and does not produce mood swings, tranquilization or narcotic effects. The patient is able to function in every physical, emotional and intellectual capacity without impairment. Methadone patients can obtain college educations, perform all types of intellectual and physical skills, marry and raise families. Methadone does produce dependency as do other medications prescribed in medicine. For many addicts the alternative to methadone maintenance is continued illicit use of heroin, criminal behavior, jail and premature deaths.

3. "The methadone illusion encourages the nation to presume that human problems can be solved by chemical means."

Answer: Methadone maintenance addresses only the physical derangement that is produced within a newly discovered endogenous opioid receptor ligand system. Methadone is not a curative procedure, it is corrective for the time that the patient is prescribed the medication. The human problems that lead to addiction in society must be solved by human means (e.g., prevention programs, solution of poverty, racism and availability of drugs). Methadone maintenance does not preclude addressing the social and human problems that lead to addiction. Methadone maintenance addresses only the medical condition caused by abuse of heroin.

4. "Methadone diversion will create a series of street addicts whose primary addiction is to methadone."

Answer: Studies over the past 30 years have shown that diverted methadone is primarily used for self medication by untreated addicts. A large group of primary methadone street addicts has not emerged (Galea, 1994).

5. "Premature methadone will transform individuals on the margins of addiction career into a permanent addictive dependence."

Answer: The program has set up criteria for admission to prevent persons without demonstrated evidence of physical dependence on opiates from entering. Also, there is evidence that a small number of patients - perhaps 10% -- can live comfortably without relapse after withdrawing from methadone. Ability to live without relapse after an episode of methadone treatment may be related to the duration of heroin addiction.

The type of brainwashing and anti-methadone propaganda that is encouraged by the therapeutic communities reveals a fear of losing the competition for funding and political support. Three patients in this study spent at least one year in different therapeutic communities. Two of the three were graduates. They related that they were consistently brainwashed against methadone. One medical maintenance patient, employed by a state government agency, has been on methadone for about 15 years. He is considered an effective, trusted employee who has worked in ethnographic street research and currently is responsible for overseeing budgets. He is prescribed 100 mg/day of methadone, states that he feels normal and does not experience sedation or mood altering effects from the medication. He related the following about his experiences in a therapeutic community:

"Before entering methadone, I was twice in a therapeutic community, once for two months and the other time I graduated after 18 months of treatment. While in the therapeutic community I was a model resident and soon became a leader and spokesman. We were told that methadone did not work and referred to patients as methadone mummies. When visitors came - politicians, people from Washington, the county - we told them how great our program was. But we always worked methadone into the conversation and told them that methadone did not work. By the time the visit was over they were supporters of our program and against the methadone program. I knew about the relapse rate from the therapeutic community - that it was very high, but we never discussed it. A lot of my friends who were in the therapeutic community are now dead.

I relapsed after leaving and then applied for methadone treatment. At first my parents were against the methadone program. My mother belonged to a parent's group that was affiliated with the therapeutic community. She was told not to let me in the house if I went on methadone. However, she has since seen how the program has helped both me and my wife. Both of my parents are now behind the methadone program. In fact, my father says I should have gotten in sooner. My mother now defends the program and gets upset if anyone says anything against methadone."

Another patient related the following:

" I don't know what therapeutic communities are like today but when I was a resident it was horrible. They took everything away from you, your family could not visit and they put you on the lowest scale. I must have stayed for about a year. Methadone was considered a no-no -- just another drug, the same as shooting dope."

After the patient left the therapeutic community she relapsed to opiate use and entered the methadone program.
Another patient who was a graduate of a famous therapeutic community relapsed within a year of his graduation and then entered methadone treatment. While in the therapeutic community he stated that he was subjected to anti-methadone propaganda.

"We were told methadone doesn't work. That it's a crutch another drug. However, after I graduated and relapsed I got on a methadone program and within two weeks I was working. I returned to the therapeutic community for a reunion and when I told them I was in a methadone program they told me they didn't want me in their buildings. To this day they still have the same attitude. I have a friend that works for them. When I see him he always asks me when am I getting off the stuff."

Methadone is not dignified as a medication but rather referred to as "stuff" which in itself stigmatizes the procedure and the patients. In summation, therapeutic communities in the course of their operations launched a covert attack against methadone maintenance treatment by relaying misinformation about methadone to residents and visitors including politicians. Twelve step programs are also ideologically against methadone treatment. NAMA reports that these groups, and especially NA have consistently discriminated against methadone patients since methadone maintenance is incorrectly perceived as a mood altering procedure. To avoid stigmatization and discrimination directed against them if they should want to participate in a NA or 12 step group, methadone patients have in recent years developed their own self help programs.

Within the past decade programs were developed that combine methadone treatment with drug free residential therapy and counseling. An example is the Short Stay Residence that was developed in 1983 by the Lower East Side Service Center. Methadone patients are referred by their respective programs and remain in the residence for 3 to 6 months. Residents are maintained on methadone and returned to their programs of origin after their problems are resolved.

Stigmatization by the Community
Communities at large have rejected methadone maintenance programs as well as other forms of drug treatment. The NIMBY (not in my backyard) syndrome has successfully prevented the expansion of methadone treatment in the last fifteen years notwithstanding the AIDS and tuberculosis epidemics for which methadone treatment has proven to be a highly effective prevention measure. There are countless examples of community resistance to the establishment of methadone treatment. The Director of Community Relations of OASAS is of the opinion that the bias against methadone treatment is widespread and it is extremely difficult to open programs because of community resistance (McGill, 1995). The following two examples demonstrate the type of resistance that is mounted by communities when faced with the opening of methadone programs. Again, methadone patients are perceived to be no different than heroin addicts. Although most of the patients treated in local community programs are residents of these communities. Communities themselves deny that the problem of addiction exists. There is no relationship in the communities perception that methadone may reduce overall crime in the neighborhood and lessen the transmission of HIV.

Example 1
In 1992, a methadone clinic operated without incident by Beth Israel Medical Center at 113th Street and Broadway for over 20 years moved three blocks to another location within the community. This is the only methadone clinic on the Upper West Side of Manhattan. The local community board mounted a sizeable attack on the move claiming that the methadone clinic was a failure and not needed. They further alleged that the community was being saturated with social service programs (e.g., programs for unmarried mothers, the mentally ill and the homeless). The methadone clinic did not have to obtain new approval for this move since it was an established, approved and licensed program. At the 113th Street location the program was, in fact, so well administered that few in the community were even aware of its existence. At the 110th street location the hospital promised increased security arrangements to placate any fears within the neighborhood. Nevertheless, the community was not satisfied and attempted to stop the move and if possible, close the facility. Demonstrations were organized, meetings were held and a newsletter entitled, United We Win, was printed and distributed within the neighborhood (See Appendix). The headline news story was entitled, "Too Many Methadone Clinics = Genocide?" (Profumo, 1992). The article stressed the need for therapeutic communities in the neighborhood rather than methadone clinics. The article was authored by a white male social worker who claims to have treated dysfunctional methadone patients. The author concludes his article as follows stating that methadone is used "in a way frighteningly similar to the way we used alcohol to repress and control Native People (Native Americans). In fact, methadone reminds me of the small pox infected blankets that European colonists distributed to Native People in 1763. In this context as a member of the Upper West Side Jewish community faced with the prospect of yet another methadone clinic, I feel like saying "Never again!" We must speak up loud and clear against the abusive way in which methadone continues to undermine rather than empower communities of color."

In this excerpt the author summarizes a view of methadone that incorporates mythologies of death and colonization. The overblown analogies offer an insight into a conspiratorial political framework that misleads poor sick untreated addicts and at the same time feeds into reactionary forces within the community that reject social service programs in their neighborhoods. NAMA indicates that methadone patients including members of their organization showed up at community meetings, and one of the patients was booed when he tried to speak. NAMA also indicated that newsletters and articles such as the one distributed by this neighborhood were highly stigmatizing to methadone patients and that members of the community did not disguise their contempt for the program or the patients. According to Bayer (1978), the press has so miseducated the community that opening new clinics has proven to be a herculean task.

The clinic opened, offering the community increased paid security arrangements in the neighborhood. However, the matter became a political issue and the majority of the politicians, with the exception of one brave assemblyman, have backed the community.

Example 2
The second example involves a hospital's attempt in 1995 to open an additional methadone clinic in a white working class community. The clinic would serve 300 addicts from the community. Already two clinics are operating and serve about 770 methadone patients. However, considering the increasing heroin addicted population in this community an additional clinic is needed. Already, heroin addicts applying for methadone treatment have to travel to different boroughs. The existing clinics operated by the hospital appear to be well administered. Nevertheless, the community refused to believe the hospital administration about the effectiveness of methadone or that the existing clinic is well administered (Pagan, 1995). The community mounted a strategy of resistance to the projected clinic by enlisting the support of elected officials and the local newspapers, organizing meetings, committees and demonstrations. In the process the negative reactions to methadone -- the program and the patients -- were expressed by community residents and covered by local newspapers.

One resident, a diabetic took offense to the statement that "methadone treats people addicted to opium just as insulin treats diabetics." Therefore, a patient with a metabolic condition (diabetes) refused to recognize the need for medication in another metabolic condition, merely because of the stigma. The anticipated deviant behavior of the methadone patients defined the origin of their illness not the derangement of metabolic processes such as in diabetes. Also another resident in the community voiced opposition by stating that "... against a methadone clinic anywhere, especially at my expense" (Pagan, 1995).

The newspaper supported the community with the following statements about methadone:

"Methadone treatment is a controversial and still suspect method of treating addiction, although it has been around for a long time. Clients are still addicted to a drug, methadone. ...they tend to congregate outside methadone clinics as people with a common concern and occasion to meet each other daily will.

Those in the drug treatment field, ... , tend to be a little starry-eyed ... about both the efficacy of methadone treatment and the behavior of methadone clients (Editorial, 1995: A16)."

The editorial omits thirty years of worldwide research about the effectiveness of methadone treatment. Instead, it caters to the worst fears of the community such as: loitering and attracting addicts from outside the community to sell and purchase drugs. Methadone advocates are considered "starry eyed" and therefore unrealistic about the impact that the clinic will have on the community. Despite the reassurances of the hospital and the experience of the hospital operating a well administered program, the community board voted unanimously against the establishment of the clinic. The objections of the community could be summarized as follows: perception of increased loitering by patients, although the hospital indicated that this problem would be monitored and patients who were guilty of this infraction would be discharged; the residents also expressed fear of increased crime, harassment of their children and a decrease in property values. None of these problems transpired with the existing clinic operated by the hospital. In these objections the primary and secondary deviance of heroin addiction are invoked against methadone maintenance. Methadone maintenance is not perceived as treatment capable of changing the lives of heroin addicts but as a legal opiate addiction no different than the illegal addiction of heroin.

An elected official suggested that an existing correctional facility in the community would be an appropriate site for a methadone program, since it would remind the methadone patients that continued use of illegal drugs would result in a jail sentence (Pagan, 1995). This suggestion by an official is an example of how the criminal deviance of the heroin addict is transferred to the methadone patient (Miller, 1974). Thus, methadone patients, irrespective of their functioning are perceived to be no different than heroin addicts who commit crimes for drug money.

The director of Methadone Policy and Planning at OASAS indicates that resistance to methadone programs exist in every community. Addiction is not regarded as a disease to be treated medically and methadone is looked upon as just another drug. Because of the stigma against methadone treatment it is difficult to open up the much needed programs.

In the above examples from two communities common themes emerge. Methadone patients are not wanted in the community. They are considered a stigmatized and criminal group. The complexities are such that the community continues the stigmatization and does not understand that addicts have the potential to change when enrolled in methadone treatment.
A well run methadone program improves the quality of life for all in the community. However, the hatred and fear engendered by stigma effectively blocks rational discussion, compromise and equitable resolutions. As Goffman (1963: 5) stated:

"By definition, of course, we believe the person with a stigma is not quite human. On this assumption we exercise varieties of discrimination, through which we effectively, if often unthinkingly, reduce his life chances."

Virulent attacks initiated by the Bureau of Narcotics on the work of Dole and Nyswander began with the initial research at The Rockefeller University in 1964. The attacks continued unabated over the years in scientific publications, popular literature and media. Documentaries produced for nationwide television and movie theaters have miseducated the public about methadone maintenance and heroin addiction. Also, the program has been trivialized by academics and social critics in serious journals and books.

The attacks appear to be especially vitriolic since the critics do not take into account the very serious medical and social problems that addicts present at admission to under funded methadone programs. Methadone clinics are set up to dispense methadone under highly regulated conditions and can not solve the massive social inequities of society including chronic poverty, unemployment and homelessness. There are attempts by clinics to meet these social needs, but in reality methadone clinics can only provide a level of service commensurate with funding (Corradi, 1994). Therefore many of the problems that the patients present must be addressed by social service agencies within the community that unfortunately also discriminate against methadone patients.

The major result of these attacks has been a transfer of stigma from heroin addiction to methadone treatment. Patients who chose methadone treatment are therefore subject to harsh alienation and stigmatization which complicate their lives and can, in the words of Goffman, reduce their life chances.

1. NAMA's executive vice president related the following regarding the use of client. She was talking with a group of patients from California where the use of client is quite common. After relating all the reasons not to use client the patients responded with, "We don't like to be called patient because we aren't treated like patients!"

2. Federal Probation is printed by the Department of Justice with a world wide distribution.

3. The article was published in the June, 1970 edition of Federal Probation entitled, Methadone Patients on Probation and Parole.

4. The following three individuals were contacted in 1975 about this documentary: Dr. Mel Zwissler, Chief, Bureau of Drug Abuse, Dayton Ohio; Mr. Edward Lampton, Director of BUDA Methadone Program; Mr. Fred Stroud, a former patient at BUDA who was in the film, Methadone: An American Way of Dealing. (See Appendix for letters and articles).

5. Dr. Mitchell Rosenthal is the director of Phoenix House, one the largest therapeutic communities in the United States.

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