Angels and Demons Proposed methadone clinic in Washington County revives debate over controversial addiction treatment

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Washington County, where the abuse of heroin and prescription narcotics has hit hard, is angling for a methadone treatment program of its own. With dozens of the area’s residents making the daily drive to clinics in Bangor, Winthrop, South Portland or Westbrook, substance abuse counselors in the Sunrise County say it’s time to bring methadone treatment to the home front.

If the particulars can be worked out, the facility would bring to five the number of programs in Maine that use the controversial drug to treat opiate addiction.

Supporters at the local level say they already provide a broad spectrum of other treatment options, including abstinence support and counseling. Methadone, they say, is an essential, proven tool for treating addictions that can’t be controlled through other interventions.

But others in the community argue that methadone is as dangerous a drug as OxyContin, Percocet, Dilaudid, Vicodin and other addictive narcotics that have hooked so many Down Easters.

A clinic will draw addicts and abusers to the area, increasing crime and worsening the abuse problem, they argue, and methadone’s long-term success in treating hard-core addiction is mixed at best.

Fortunately, players on both sides of the debate in Washington County don’t have far to look to see how a methadone program is likely to affect their community and the people who live there.

Just two hours away in Bangor, methadone maintenance is the treatment of choice for about 300 opiate addicts, and a community that fought long and hard against the idea of a clinic is coming to terms with the reality of its presence.

Two and half years ago, after a heated public battle, Acadia Hospital opened its outpatient methadone clinic in Bangor. Acadia’s is the only nonprofit program in the state. Its mission, supported by the state’s Office of Substance Abuse, is to treat the growing numbers of northern and eastern Maine residents addicted to opiates.

The proposal to bring methadone to Bangor was met with the same strenuous opposition from the community. But after considerable negotiation and debate, the clinic in December 2000 won the qualified approval of a special committee reporting to the Bangor City Council.

Once the clinic’s doors opened the following June, debate seemed to close. There’s been little notice taken of the operations of the clinic or its impact on the greater community.

Hospital administrators say no news is good news, an indicator of good management and clinical success. At the clinic’s one-year mark, Acadia executives released the report of an independent evaluation that backs their claims.

Police records show a general reduction in local crime since the program came on line, and patient surveys suggest many clients have decreased or discontinued their use of illegal and illicit drugs.

About six months ago, a rash of methadone-related deaths in southern Maine resulted in tighter regulations for all methadone programs, even though it was demonstrated that the majority of the drug on the street in the Portland area was in pill form and could not have come from the clinics, which use only liquid methadone.

Even substance abuse treatment providers, once among methadone’s loudest detractors, have changed their tune. Many of these providers are now working closely with the clinic and its clients.

But methadone remains a controversial treatment for addiction. Though broadly accepted for many years by the medical community, it is no silver bullet, and it is poorly understood by the public it serves.

Family members, in particular, remain deeply skeptical as they watch their loved ones struggle to manage their addiction, sometimes succeeding – but tragically and too often, failing.

What is methadone?

Methadone is itself an addictive drug. It is a synthetic opioid, made from chemicals in a lab and not a natural product of the opium plant, although it functions almost identically in the body.

It was developed during World War II as a pain reliever. For years, it was something of a miracle drug, the most effective pain relief available. It also was inexpensive. But as the ever-inventive pharmaceuticals industry developed even more effective medications, methadone fell out of favor.

Then, in the 1960s, in a campaign to bring about “harm reduction” in society, methadone started being used to treat the hardest-core, inner-city heroin users.

Because it mimics the actions of heroin and other narcotics, it answers the biological need for opiates but without the “rush” or “high” associated with other drugs. Give addicts the assurance that they’ll get their life-saving daily fix, the thinking went, and they’ll commit fewer crimes to support their habit.

Methadone treatment in a modern outpatient setting is more focused on restoring the productive life of the addict. Treatment includes counseling and other supports, and clinicians work closely with patients to find just the right dose of methadone – enough to answer the body’s desperate craving for narcotics and to overcome the temptation to use street drugs, but not enough to produce lethargy.

Methadone is unique among the narcotic drugs in that it doesn’t produce much of a “high.” It’s a strong, slow, long-acting substance that proponents say can turn an addict’s life around.

But if a user is still looking to get high, and takes too much or takes other drugs on top of it, methadone can be a killer.

Opiate addiction is a self-inflicted illness, an induced metabolic need that can result in death if not fulfilled. Addicts describe opiate craving as the worst feeling you could ever have, as sick as you could possibly feel. It is acutely painful, it makes you wretchedly sick to your stomach, you sweat and shiver and there is nothing – nothing- you wouldn’t do to make it go away.

Methadone can make it go away. Taken daily in the proper dose, it satisfies the bone-deep craving and keeps the deathly sickness of withdrawal at bay. Taken regularly, and not mixed with other drugs, methadone allows motivated addicts to get on with their lives. They’re still addicted, but without the high; they’re not impaired (except, importantly, by drowsiness).

Addicts in a methadone program are assured of a safe, steady supply of the drug they need to live, without having to spend their days finding a supplier and the money to pay for a fix.

Thus freed, and supported in their efforts to get their lives on track, addicts can drive a car, hold a job, tend to a family, and make progress in personal counseling. They can build a house, go to college, manage a career, serve on the local school board – in short, lead a normal and productive life.

Many clinicians consider methadone dependency a form of abstinence, and liken it to insulin treatment for diabetes – not a cure, but a personalized treatment that may go on for years, or even a lifetime.

But the road to this kind of stability is long and very rough, and addicts entering treatment can expect many setbacks.

They must be prepared to commit to making daily visits to the clinic, undergoing random testing to see if they’re using street drugs, and participating in regular group and individual counseling sessions.

They have to be in it for the long haul, and their motivation must be strong.

No silver bullet

Scott Farnum, administrator of substance abuse services at Acadia Hospital, says two to five years to achieve stability through methadone is typical. Prospective clients must demonstrate both the severity of their addiction and the sincerity of their commitment to overcome it.

“This is not an appropriate treatment for someone who’s been just ‘chipping around’ – just using a little here and there,” Farnum said in a recent interview.

People who have been using for only a short time, or who seem to have a less serious problem, often will be referred to abstinence-based programs, where the goal is to kick their habit completely.

“Methadone may work for you, but if you can do without it, your life will be less complicated,” Farnum said. “Many people don’t realize that methadone treatment is not a short-term commitment. It’s not something you do with somebody and then they’re better in a month, or two months, or even six months.”

Farnum said that of the roughly 300 clients who have enrolled at Acadia, about 85 percent are still in treatment. The others have either dropped out, moved away or tapered their doses down to nothing, he said.

Acknowledging that some of those in treatment at Acadia have died of overdoses or drug interactions, Farnum said it is nearly impossible to tell what role methadone played in their deaths, since in all cases street drugs were involved as well.

At Acadia, and at all the methadone programs in Maine, the methadone is administered in a precisely measured amount in a fruit-flavored liquid. The average maintenance dose is 120 milligrams a day, Farnum said – most clients start out with 40 mg and work up to a higher dose; a very few take as much as 300 mg a day.

Clients report to the clinic daily and swallow their dose under the watchful eye of clinic staff. Some clients, after months or years of treatment, may qualify for take-home privileges. This means they may be entrusted with up to two weeks’ worth of the closely regulated drug, dispensed in individual sealed doses that they must keep under lock and key.

They must return the empty vials to the clinic, and they may be called at any time during the take-home period to bring in their unused doses. These precautions help keep the drug from being diverted for illicit use.

Addicts may stay on daily methadone dosing for years, some for a lifetime. Others may attempt to wean themselves off the drug, a process that must be done incrementally over months or years, under clinical supervision to prevent relapse.

Acadia’s program is too new to have long-term tracking data. But nationally, of the people who stay in treatment for two years, about 60 percent to 70 percent will have stopped using opiates other than methadone.

“That’s a pretty good success rate for a chronic condition like opiate addiction,” Farnum said. Like most clinicians, he doesn’t consider daily methadone dosing a drug habit, but rather therapeutic treatment for a disease.

But what does it take for people to get through those first two years? Farnum said it’s a combination of factors. Sometimes the motivation is external – like the threat of jail time or the loss of child custody – “but most of the time people come here because they’re finally just so sick of how they’re living,” Farnum said.

“By the time people get to this program, the average length of time they’ve been using is five years. In the opiate-using world, that’s a lifetime. Over 80 percent of them have gone to intravenous use. About that many are also hepatitis-C-positive.

“Unless they’re extremely lucky, they’ve had a number of very negative life consequences – maybe they’ve been in some horrible accident, or they’ve been involved in a terrible legal issue. They may be looking at real jail time. They’ve often lost almost all contact with their families, with their children. Their whole life has been absorbed by this disease.

“They spend all their money on it – they’re often spending several hundred dollars a day, they’ve lost their job and they’ve lost all their resources. And it’s so highly illegal that you become an underground person. You associate primarily with other people who are using, and you live in the shadows, because you can’t live any other way. And you are in constant fear of being arrested,” Farnum said. “It just drives your whole life.”

In some cases, methadone will work quickly to make an addict feel better than he has felt in a long time.

“They often get what I call a rush of health,” Farnum said. “They think ‘this is it – this is the cure for my problem.'” Some clients leave the program then, convinced they’ve overcome their addiction.

Farnum said it’s rare for that kind of quick effect to last, “usually because they have so many other problems they have to overcome. It takes that period of years before they can work through [their problems] to the point where they’re not tempted to use again, where they’re out of that life style and not associating with people who are using. Really, it takes that long for them to put their lives back together into any kind of shape.”

Opiate addicts’ most difficult challenge can be in transitioning out of their social circle, where substance abuse and the behavior that accompanies it may be well-established and accepted.

Even well-intentioned family members may prove an impediment to establishing a healthy lifestyle – Farnum said many families cannot accept the long-term nature of methadone treatment and pressure their loved ones to leave the program or reduce their dose before they’re physically or psychologically ready.

Since almost all of the clients at Acadia are over 18, he said, they must be treated as adults even though their judgment may be immature or impaired. Staff members often encourage a family’s participation in counseling or planning, he said, but only with the permission of the client.

Even after many years in treatment, many addicts’ recovery remains tenuous at best, held together by constant attention to healthy behavior, the love and support of their families and communities – if they’re lucky – and a daily dose of methadone.