On Aug. 1, 2018, addiction medicine lost a seminal figure.
Dr. Robert Newman poured his heart and soul into one of New York City’s first methadone programs in the early 1970s. At the time, medication-assisted treatment, or MAT, was a new addiction treatment model with limited evidence to support its efficacy.
At Beth Israel Medical Center, Newman advanced the work of Drs. Vincent Dole and Marie Nyswander, who had piloted the first methadone maintenance therapy. But even after the treatment model was approved in 1972, Newman and others who supported medication-assisted treatment for opioid-dependent patients found themselves at odds with their colleagues in the medical field and thwarted by layers of bureaucracy as they fought to treat their patients effectively and humanely.
Studies have shown that people with opioid use disorders (OUD), as well as those dependent on other substances, achieve recovery with fewer relapses when MAT is part of their treatment program. But despite the documented efficacy of opioid agonist therapy, skepticism and stigma persist among the general public and within the recovery community.
According to researchers from Oregon Health & Science University, “Frequently cited barriers to the use of agonist and antagonist medication include patients and families who request drug-free treatment, persistent expectations of abstinence as the only appropriate treatment outcome, staff resistance to the use of medications, and the cost of the medications; many addiction treatment centers, moreover, do not have prescribers on staff.”
But it’s impossible to ignore the facts. Drug overdoses, which claimed 72,000 lives in 2017, now kill more people than car crashes, gun violence and HIV/AIDS. If we don’t eliminate the stigma of medication-assisted treatment, Americans may continue to witness senseless deaths that our health care system could have prevented.
When asked in 2011 about the prejudice against patients based on their methadone dose, Dr. Newman defended patients’ rights to treatment without discrimination.
“Dosages should be determined like in any other field of medicine, based on what the patient is responding well to,” he said. “There’s no moral judgment as to how much penicillin one uses to treat gonorrhea, and there shouldn’t be any moral judgment as to how much methadone a patient is receiving if the result is satisfactory.”
Throughout the early years of MAT, uninformed policymakers and citizens perpetuated the myth that methadone maintenance programs were simply replacing one addiction with another.
Decades later in New York City, Mayor Rudy Giuliani attempted to shut down methadone maintenance programs in public hospitals and city jails. The mayor insisted that the medication was a crutch for people experiencing addiction.
Even as research showed positive outcomes — including reduced rates of crime and diseases caused by injection drug use — and experts from the National Institutes of Health recommended the expansion of methadone maintenance programs, Giuliani and his cohorts held fast to the conviction that methadone was “a chemical that’s used to enslave people.”
Another 20 years later, in the middle of the nation’s relentless opioid crisis, President Donald Trump’s secretary of Health and Human Services, Tom Price, echoed the familiar refrain at a fire station in Charleston, West Virginia.
Price told first responders in the state with the highest drug overdose death rate in 2016, “If we’re just substituting one opioid for another, we’re not moving the dial much. Folks need to be cured so they can be productive members of society and realize their dreams.”
But not everyone agrees.
On July 22, 2016, former President Obama signed The Comprehensive Addiction Recovery Act (CARA) into law. The act authorized physician assistants and nurse practitioners to prescribe buprenorphine, another medication for opioid use disorders, after they’d completed the required training and registered with the Drug Enforcement Administration and the Substance Abuse and Mental Health Services Administration (SAMHSA).
Then in December 2016, $1 billion was allocated to the opioid epidemic as part of the Obama Administration’s 21st Century Cures Act. The State Opioid Response Grants, funded by the Cures Act, require that “FDA-approved medication-assisted treatment (MAT) be made available to those diagnosed with OUD.”
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Since Trump declared the opioid crisis a public health emergency in October 2017, the Department of Health and Human Services has distributed more than $2 billion in grants to address the problem.
The current secretary of Health and Human Services, Alex Azar, who replaced Price in January 2018, said in a CNBC interview, “This is not a moral issue.”
Explaining that many cases of opioid addiction begin with legal opioids, Azar went on to say, “We have to remove the stigma from [opioids such as methadone and buprenorphine] because there’s evidence-based, scientific-based ways of treating with these that do work.”
“The goal always is reducing or eliminating the use of illicit opioids and other illicit drugs and the problematic use of prescription drugs.”
This statement from Treatment Improvement Protocol (TIP) 43, published by the Substance Abuse and Mental Health Services Administration, challenges the myth of “substitution.” The goal of MAT is harm reduction and the stabilization of patients who would otherwise be unable function without opioids. With supervised MAT programs, these people can be functional members of society, capable of making healthy decisions for their well-being.
The National Institute on Drug Abuse, the Centers for Disease Control and Prevention and the World Health Organization all recognize medication-assisted treatment as the “gold standard” of opioid addiction treatment, and in September 2018, Surgeon General Jerome M. Adams issued a report calling for access to FDA-approved medications — along with behavioral interventions and support groups — as a component of treatment.
The surgeon general’s report acknowledged an undeniable truth.
“Unfortunately, stigma has prevented many sufferers and their families from speaking about their struggles and from seeking help. The way we as a society view and address opioid use disorder must change — individual lives and the health of our nation depend on it,” he wrote in the preface.
In order to dispel the belief that MAT is just the substitution of one addiction for another, experts have explained how these drugs work.
Methadone, buprenorphine and naltrexone can all be used to treat opioid addiction, but they work in different ways.
The FDA has approved two opioid agonist drugs for opioid use disorder and mandates that both —as well as a third option, naltrexone — be made available to patients. The FDA has also advised that treatment with any of these medications continue as long as necessary for a patient’s full recovery.
This withdrawal-free, euphoria-free state allows patients to function normally by tricking the opioid-dependent brain into believing that it has received its expected dose of heroin or prescription opioids.
Classified as a partial opioid agonist, buprenorphine has both agonistic (activating) and antagonistic (blocking) effects. Like methadone, buprenorphine activates opioid receptors but to a lesser degree when it attaches to a person’s opioid receptors. At the same time, it blocks other opioids, such as heroin or morphine, from attaching to the receptor. This limits their euphoria-producing abilities.
Thus, the freedom from withdrawal symptoms and the absence of a high diminish the compulsive drug-seeking behaviors characteristic of addiction.
Additionally, buprenorphine has a ceiling effect, which makes it less likely to cause respiratory depression and other side effects associated with opioid agonists.
Methadone and buprenorphine have the potential for abuse, but when used under medical supervision, the drugs are generally safe and effective in treating opioid addiction. Additionally, SAMHSA mandates that all medication-assisted treatment programs include behavioral therapies and support programs, as well as regular drug testing.
Naloxone and Naltrexone are opioid antagonists, which means they do not activate opioid receptors. They bind to the receptors and block the effects of opioids.
Naloxone can immediately reverse the effects of an opioid overdose.
Doctors sometimes prescribe naloxone with buprenorphine if a patient is at risk of misusing buprenorphine. Suboxone, Zubsolv and Bunavail all contain a combination of buprenorphine and naloxone.
Because the risk of overdose is greater after a period of treatment, when a person’s tolerance is lower, Narcan, a nasal spray formula of naloxone, is an essential component to medication-assisted treatment.
But naloxone has also faced opposition from policymakers and law enforcement who see the drug as an expensive and undeserved indulgence for irresponsible addicts. In Ohio, Sheriff Richard Jones told the Huffington Post that Narcan, the brand name for naloxone, enables people.
“This Narcan, all it does is save people’s lives for another day.”
And in Maine, Gov. Paul LePage, whose controversial comments about traffickers named “D-Money, Smoothie, [and] Shifty” made headlines in 2016, vetoed a bill to increase access to naloxone.
“Creating a situation where an addict has a heroin needle in one hand and a shot of naloxone in the other produces a sense of normalcy and security around heroin use that serves only to perpetuate the cycle of addiction,” LaPage wrote in his veto letter.
Naltrexone, which is also used to treat an alcohol use disorder, may be used to treat opioid dependence. It is nonaddictive and blocks the euphoric effects of opioids and alcohol. Naltrexone, known by the brand name Vivitrol, is not as tightly regulated as buprenorphine and methadone, and any licensed prescriber can write a script for the medication without limitation.
Resistance to new discoveries in medicine, mistaken beliefs that methadone clinics bring crime into communities, and the unquestioning acceptance of current public policy have all contributed to the stigma of medication-assisted treatment.
In 1967, Dr. Vincent Dole, a metabolic scientist and professor at The Rockefeller University, published an article with Dr. Marie Nyswander suggesting that addiction was an alteration of metabolism — a biological disorder, like diabetes, that would respond to medication.
In the years that followed the publication of Dole and Nyswander’s paper, technological and medical advances gave researchers and clinicians new insights into substance use disorders. Brain imaging techniques, such as MRI and PET scans, have allowed researchers to observe the brain’s response to drugs.
A 2007 article in the journal Science & Practice Perspectives defined five types of brain imaging.
“The results to date have firmly established that drug addiction is a disease of the brain, causing important derangements in many areas, including pathways affecting reward and cognition,” the authors stated.
Still, many in the medical profession resist the notion of addiction as a disease. Opponents point to an influential 1970s study of Vietnam veterans, conducted by Dr. Lee Robins of the Washington University School of Medicine.
Dr. Robins had been enlisted by Dr. Jerome Jaffe, the head of the Special Action Office on Drug Abuse Prevention under then-President Nixon, to study heroin addiction in American soldiers who’d become dependent on the opioid in Vietnam.
The study revealed that soldiers who had returned from Vietnam addicted to heroin ceased their drug use without any form of treatment. These findings supported the biopsychosocial model of addiction, which attributes addiction to a combination of biological, psychological, and social factors.
In this case, Robins and her team attributed the behavior change to the soldiers’ environment.
Adherents of the biopsychosocial model claim the addiction-as-disease model is “reductionist” — meaning that doctors and scientists who espouse the disease theory essentially reduce the complex problem of addiction to “nothing but a sum of its parts.”
They say the disease model leans too heavily on relationships between addictive behaviors and biological factors as it tries to identify a single cause for addiction.
But supporters of medication-assisted treatment don’t recommend MAT as an alternative to other treatment models. They understand that medication, like detox and inpatient programming, is only part of a full continuum of care and endorse the use of methadone, buprenorphine and naltrexone as supplementary to other treatment methods.
SAMHSA’s TIP 43 cites Dole and Nyswander in its guidelines, which state that opioid addiction can be treated with medication when treatment “includes comprehensive services, such as psychosocial counseling, treatment for co-occurring disorders, medical services, vocational rehabilitation services, and case management services.”
When asked about his work with the Illinois Drug Abuse Advisory Council in Chicago, Jaffe, who’d defended Dr. Robins’ veteran study despite its surprising results, explained that by stripping preconceived notions about a one-size-fits-all approach to treatment, he and his team changed people’s lives.
Jaffe had committed to the advisory council after realizing the city wasn’t providing decent, ethical drug and alcohol treatment.
“We innovated, we did some unprecedented things, we did not see a sharp distinction between methadone and therapeutic communities and detoxification. And because it was not a major battle in my mind, it was not a major battle in the mind of any of the staff who worked for me,” Jaffe said in a 1999 interview published in the journal Addiction. “And people recycled through who couldn’t make it in one situation, they would try another.”
With the passing of the Harrison Act in 1914, the United States government began its descent into the groundless racialization of drug use.
The Harrison Act, passed amid fear-mongering accusations of black, Mexican and Chinese men committing drug-fueled atrocities under the influence of opiates and cocaine, included a clause allowing doctors to prescribe opiates “in the course of his professional practice only.”
But in 1925, Dr. Charles Linder was arrested for prescribing the drugs to substance-dependent patients. The Supreme Court swiftly overturned his conviction, stating that the federal government did not have the right to control medical practices in the states. The Court said the Harrison Act made no mention of people experiencing addiction and that “they [individuals addicted to drugs] are diseased and proper subjects for such treatment ….”
That didn’t stop the federal government from taking a punitive approach to the problem of drug use and addiction, an approach that targeted the destitute and disenfranchised.
The narrative of drug use as a criminal behavior exclusive to “negro fiends” and “Chinamen” had wormed its way into the American psyche, and discrimination persisted despite the evidence that drug use among black men at the time was lower than among whites.
Naturally, the stigma that surrounded this reviled characterization of addiction was inextricably tied to its treatment.
The current political climate has allowed addiction experts to make inroads with the American people, using decades of research to prove the value of medication-assisted treatment, but they still face many obstacles, including funding, regulatory hurdles and proper education and training.
Prominent social and political figures have expressed their support for MAT and early intervention for at-risk populations, as well as awareness campaigns for prevention and treatment. Chris Christie, Jeb Bush and Carly Fiorina have all shared their personal experiences with addiction in an attempt to chip away at the stigma associated with substance dependence and MAT.
In October 2018, President Trump signed the Support for Patients and Communities Act, which will lift restrictions for prescribers of medications such as methadone and buprenorphine. The passing of this bill is viewed by advocates as progress, but they are calling for more.
A study published in the Journal of Studies on Alcohol and Drugs reviewed crime statistics around commercial businesses and drug treatment centers in Baltimore. The study, led by Debra Furr-Holden, of the Bloomberg School of Public Health’s Department of Mental Health, found that violent crime occurred more often near liquor stores and corner stores than around drug treatment centers.
Some people fear that drug treatment centers will bring more crime to their neighborhoods — a fear that leads to opposition that is referred to as NIMBY, or “not in my backyard.”
The truth, however, is that the ability of MAT to help people control their substance use, remain in treatment and avoid relapse has led to to harm reduction in many of these communities.
When residents in Amherst, New York, learned that an opioid treatment program was opening in their community, their main complaint was the lack of transparency.
Treatment program sponsors realized that the best way to stop the stigma in their community was to communicate openly and honestly with the people of Amherst, to assure them that the program would be tightly regulated and provide them with facts to replace the fear of the unknown.
Erie County Health Commissioner Dr. Gale Burstein told Addiction Treatment Forum, “There are a lot of perceived beliefs about the type of person that seeks care at these sites, but we really need to mythbust, we really need to beat stigma, and these types of restrictions are just fueling the fire for these stigmas and these discriminatory attitudes (toward) people suffering from chronic disease.”
Because the recovery community hasn’t fully embraced MAT patients, people on buprenorphine or methadone maintenance have not had the benefit of the support of their peers.
Research shows medication-assisted treatment significantly decreases relapse rates for opioid-dependent people. A 2016 study in the New England Journal of Medicine found that participants taking extended-release naltrexone (Vivitrol) had a “longer median time to relapse than did those assigned to usual treatment.” Usual treatment, in this case, included brief counseling and community programs.
This is noteworthy because fewer relapses mean fewer overdoses. And fewer overdoses mean fewer deaths. Why, then, is there such stigma among people who may one day owe their recovery and their lives to medication-assisted treatment?
Opioid agonist treatment and other medication-assisted treatments for alcohol and other drug dependencies are still rejected by many in the 12-step community, which believes abstinence is the only true path to recovery.
The Big Book, the official text of Alcoholics Anonymous (AA), references character defects and moral failures that only a higher power can heal, and while the organization has evolved since it was founded in 1935, many AA members still adhere to these beliefs.
This idea of character defect, or moral failing, has contributed to the stigma of addiction and, subsequently, the stigma of medication-assisted treatment as a way to enable a person with a substance use disorder.
Stigma can be a self-fulfilling prophecy as people who face discrimination often develop low self-esteem that hinders their efforts to get and stay sober.
Patients are deterred by the lack of anonymity while standing in dispensary lines, the prison-like atmosphere of methadone clinics, and the feeling that doctors don’t care about them.
“They treat us like crap,” Deana, in treatment for heroin addiction, told a reporter for NPR’s All Things Considered. “We’re not like this because we’re bad people, you know.”
Addressing this internalized stigma is a critical component of helping people reach recovery.
“These clients have so much social vulnerability and not much stability,” Larry LaCross of Catholic Human Services told The Rural Monitor. “But the integrated care helps bridge those issues. In the end, a population who typically ‘no shows’ for appointments shows up. Their treatment is successful, they’re back to work and with their families again.”
The call to end the stigma of addiction has been loud and clear, and MAT has been added to the conversation.
Dr. Newman was a man of great compassion who saw the devastating effects of opioid addiction first-hand. When asked if it was reasonable to equate heroin addiction with diabetes, Dr. Newman invoked the Hippocratic Oath, which urges physicians to treat all patients with sympathy and understanding.
“Do we in the medical community turn away heart attack victims who are obese through overeating? Or cancer victims who smoked? We can certainly disapprove of those behaviors, but we don’t punish people in an advanced society by withholding effective treatment for illnesses they brought on themselves.”
Published on: November 13, 2018
Last updated on: November 19, 2018