Local view: Methadone treatment often the target of irrational criticism

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The News Tribune’s Dec. 6 report on legislative hearings regarding methadone was disappointing, as was this year’s methadone-treatment series. State Rep. Tom Huntley, DFL- There have been multiple similar series in the New York Times, Houston Chronicle and elsewhere. Some were more and others were less attacking and stigmatizing. One would hope the News Tribune staff reviewed these prior publications and outcomes. The newspaper’s series certainly did not enhance public understanding of the therapeutic issues of

substance-use disorders, generally, or opioid dependence, in particular.

Methadone treatment has been the target of irrational criticism because we the people have stigmatized the disease and the patients. Before starting their series, News Tribune reporters would have done well to read an article by Dr. Herb Kleber in the Journal of the American Medical Association on the history and controversy of methadone (“Methadone Maintenance 4 Decades Later, Thousands of Lives Saved But Still Controversial”). Errors reside in the analysis of the problem. Critical is the distinction among the effectiveness of the medication, the treatment system within which methadone is provided, and the effectiveness of treatment provided.

The medication works, indeed, much better than many medications for many diseases.

The treatment “system” is the product of ill-conceived laws that separated this single medication from the entire health-care and medication-delivery system; further, it provides outdated treatment guidelines that have long been countered by evidence.

Also, effectiveness — that is, overall outcome — is variable. However, a clinic with well-trained staff (often not the case) following sound therapeutic guidelines and providing adequate medication doses saves lives and can provide a pathway to a healthy, productive life.

Nationally, there are multiple nonprofit and for-profit clinics distributing methadone. Most make handsome profits since methadone costs about 80 cents a day.

Then there are public-sector programs. Most exist in large Eastern or West Coast cities. On average, they probably provide more effective treatment than the nonprofits or for-profits because of oversight and stated mission. They fill a critical need, which is why an effort to eradicate them in New York City by then-Mayor Rudolph Giuliani failed.

Informed communities recognize the benefit. So: the medication works, many clinics do not.

Segregating “methadone treatment programs” is a failure. This was recognized via the Drug Addiction Treatment Act of 2000 while trying to provide a similar medication, buprenorphine, through an alternative system. The legal origins and constraints, while flawed, were better than the regulations for methadone. Buprenorphine is nearly as effective as methadone for some patients and may have a very slight edge on safety. It is much more expensive. It is available through physicians who undergo brief specialized training. Most of these physicians are unlikely to treat patients who characteristically avail themselves of methadone programs. So, buprenorphine generally is out of reach of most potential patients. A colleague in the Minnesota Department of Health informed me the state has one (count them, one) opioid replacement treatment program. Interestingly, it provides the more expensive medication, buprenorphine.

The solution to the problems? Attack the medication and further stigmatize the treatment population?

No.

Clinics and hospitals providing substandard care for diabetes (not meeting standardized “metrics”) receive bad ratings and, in the extreme, are closed. Patients are shunted to effective clinics providing evidence-based treatment at the hands of skilled health-care providers. But what if no alternative first-rate, or even second-rate, clinic is available?

Going forward, there is a need to simply treat substance-use disorders as the diseases they are. Integrate treatment with other health care. Provide medication with adherence to excellent available guidelines. Provide effective supplemental therapy (including behavior modification and cognitive behavior therapy) when needed. Educate health-care providers and the public about the diseases and the treatments.

Contrary to an individual who testified at the legislative hearings this month substance use disorders are indeed very much like diabetes and hypertension in terms of the need for intervention and the complexity of treatment.

As an aside, that individual also said there is an opioid-treatment approach that has

95 percent effectiveness. There is no such beast anywhere in the country at present. But misinformation abounds. That, too, must be changed.

Bringing it all back home: I have been told that in Duluth there are opioid-dependent patients who travel daily or nearly daily to the Twin Cities because of inadequate care options here. If the News Tribune is to be believed, these patients receive substandard treatment at the methadone clinic that does exist in Duluth. Certainly, the state can work to inform the public and emphasize enhanced treatment guidelines through the Department of Health. However, could not the city government, in collaboration with St. Luke’s and Essentia Health, establish a rational, cost-effective and clinically effective treatment service? It would benefit the community and the patient population. The absence of treatment does not make the disease disappear.

John Grabowski is a clinical scientist and a University of Minnesota Medical School professor. He works in the Department of Bio-behavioral Health at the University of Minnesota Duluth and in the Department of Psychiatry at the university’s Minneapolis campus. He directs the Department of Psychiatry Ambulatory Research Center and over the last four decades has conducted and published multiple studies of substance-use disorders, including opioid dependence and methadone.

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