Bangor’s question

Just in time for Bangor’s nonbinding vote on a proposed methadone treatment facility, an editorial in the New England Journal of Medicine last week took up the subject of methadone and the new opiate-dependence fighter, buprenorphine. Though it did not consider the dispute in Bangor directly, its conclusion was unmistakable.

The Bangor vote of 6,000 in support of the clinic and 7,500 for its indefinite delay was not surprising. It is a difficult question, as a local committee concluding its work now has found, and one that should not be decided by popular vote. Bangor’s vote was intended to give guidance as well as vent frustration, but the actual future of the facility rests with the state, making the ballot question awkwardly worded and vague. Complicating the question further for voters is a new method of treatment, buprenorphine, which opponents of the methadone clinic point to as proof that the clinic is not needed.

Someday, they may be right, but not during the next several years. In contrast to the local referendum, the NEJM says plainly when discussing methadone, buprenorphine and a third type of treatment, levomethadyl acetate, that, “Future research should include an evaluation of which medication might be most appropriate for specific groups of patients or in specific clinical situations.” That is, each has a place in the range of treatment regimes; no one is the best choice for all patients.

The editorial, written by Patrick G. O’Connor of the Yale University School of Medicine, indicates that Bangor has less to fear from a methadone clinic than opponents have suggested. Dr. O’Connor concludes, “Methadone maintenance can decrease the use of illicit drugs and crime and help patients function better, gain employment, and contribute to society. It can also prevent health problems such as HIV infection and is thus a cost-effective public health intervention. Research during the past decade has provided important information about how to optimize the effectiveness of methadone maintenance.”

Bangor has largely focused on the first part of this message – methadone’s effects on illicit drug use, crime, public health. Now, it should focus on the second – “how to optimize the effectiveness of methadone maintenance.” Concerns about the effect of a clinic are legitimate; denying opiate-addicted residents a widely recognized and widely approved form of treatment is not. Bangor should be focusing now on the methods Acadia Hospital, which would operate the clinic, plans to use in operating a clinic and examples of where these methods have proven effective.

Acadia, for its part, cannot help but note that if buprenorphine is approved for use from doctors’ offices, it will not be long before there is a similar office-based demand for methadone. The hospital needs to show that if a shift in treatment from a central clinic to private offices is appropriate, it will support the idea. Indeed, in years to come it may prove that buprenorphine or another medication should actually replace methadone. The hospital should be prepared to support that, as well.

Though an outsider wouldn’t know it from the angry comments in Bangor over the last eight months, methadone maintenance is not the end of this city. It is one treatment program among the dozens of health-care programs available here. It is directed at heroin users, who anecdotal evidence suggests are one the rise, and abusers of painkillers, who are more prevalent than anyone knew just a couple of years ago. Bangor residents have every right to see that a methadone maintenance program is run effectively, but the time is ending for arguments over whether such treatment is needed at all.