The politics of addiction

In medical literature and position statements by drug-treatment organizations and advocacy groups, methadone is referred to as the “gold standard” for treating opiate addiction, with studies pointing not only to its medical benefits, but social benefits as well. For instance, a study released last April by the National Institute on Drug Addiction found that heroin addicts who were wait-listed for treatment were more likely to actually enroll in treatment—and less likely to be involved in criminal activity—if they’re put on methadone in the interim.

But, out in the real world, methadone’s been plagued by problems of misuse and lingering stereotypes.

“When you start talking about methadone, everybody gets the same visceral gut reaction,” said John Peloquin, vice president of operations for CRC’s Southwest Division, “that it’s a seedy-looking little facility that you go to the back door and knock on the door three times and you get your fix of methadone.”

Though it’s not available without a prescription, there’s a high incidence of methadone street-sales to addicts looking for something to hold them over until their next fix. And, during the past decade, the drug has become a popular pain medication—used more widely for pain management than addiction treatment, in fact—because of its low cost compared with other prescription painkillers. But, after a significant increase in fatalities from methadone overdose—up 390 percent since 1998—on Jan. 1 of this year, the Drug Enforcement Administration put a moratorium on doctors prescribing 40-milligram methadone tablets in non-treatment settings; pharmacies can no longer stock 40-milligram tablets, either (5- and 10-milligram tablets and the liquid form are still available, however).

Like the drugs it’s designed to combat, methadone creates physical dependence—users must wean off the drug under a doctor’s supervision—though the withdrawal symptoms aren’t as severe as heroin withdrawal. Methadone’s not a quick-fix for addiction, either. In one mid-’80s study involving 671 addicts, 92 percent of participants who stuck to a methadone-treatment program for four-and-a-half years stayed clean. But of the 105 patients who stopped methadone after one year, 82 percent went back to using drugs. In terms of publicly funded drug-treatment programs, having to make a long-term commitment to an addict might not sit well with taxpayers.

No one wants to be tied to a prescription drug for the rest of their life, Peloquin said—the goal is to stabilize a person and then start them on the process of weaning off methadone. But, “if a patient has 20, 30 years of hardcore drug abuse, the patient’s brain chemistry has altered so much that they may never find themselves off of methadone,” he said.

San Diego is the largest county in California that neither provides medically assisted drug treatment nor contracts with any providers that do. Drug-treatment providers that get funding from the county operate under a drug-free model, also known as social-model treatment, meaning anyone enrolled in their programs must abstain from any substance that could result in dependence, even if that substance is helping them kick their habit. A person who enters a county drug-treatment program on methadone might as well have entered the program on heroin.

The drug-free treatment model carries over to the criminal justice system, too. San Diego County’s Drug Court, a diversion program that offers nonviolent offenders the option to enter treatment rather than jail, forbids medically assisted treatment. And of the $9 million San Diego County receives annually to pay for Prop. 36—the statewide drug-treatment initiative that’s based on the drug-court model but with more lenient probation rules—none of that money funds medically assisted treatment.

Of the state’s 21 largest counties, San Diego is one of only five that doesn’t allocate any money for narcotic-replacement therapy (NRT), even though state officials have consistently recommended that it be included as a treatment option because of its proven success rate. In a final report on Prop. 36’s first five years, published last April, researchers from UCLA found that only between 10 and 15 percent of Prop. 36-eligible heroin addicts  were referred to NRT, but of that group, 71 percent successfully completed treatment. Meanwhile, 52 percent of heroin addicts who entered a drug-free treatment program successfully completed it.

“Heroin users’ performance in treatment may improve significantly if NRT is made more available,” the UCLA report concluded.

Susan Bower, head of San Diego County’s department of alcohol and drug services, explained that the county doesn’t fund medically assisted drug treatment because clients who opt to go that route can pay out-of-pocket or apply for state assistance. A 1994 legal settlement ordered the state to fund methadone treatment for anyone who qualifies for what’s called Drug Medi-Cal, which has basically the same eligibility requirements as regular Medi-Cal.

“It doesn’t mean there’s any more or any less services because of that,” Bower said. (Whether Prop. 36 clients know that self-funded or state-funded methadone treatment is an option isn’t clear; a spokesperson for the county said that drug-treatment providers who contract with the county can refer patients to methadone programs if the provider thinks that’s the patient’s best option, but two law-enforcement officials who work with Prop. 36 clients were unaware of any sort of referral system, and a spokesperson for the California Department of Drug and Alcohol Programs said their records show that no San Diego County Prop. 36 participants have been referred to narcotic-replacement therapy between the program’s start in 2001 and 2006, the most recent year for which numbers are available.

The decision not to fund methadone is also a matter of limited resources, Bower said. “[If] we chose to take money from current treatment programs and shifted that over to fund methadone, that means waiting lists in other treatment programs.”

Then there’s the fact that heroin addiction isn’t the epidemic it once was. As Richard McCue, a deputy district attorney who oversees three of the county’s drug courts, said, “I don’t want to sound cavalier about it, but within the context of the people we are working with, heroin addiction is rare. What we’re seeing is methamphetamine, methamphetamine and more methamphetamine.”

Methamphetamine may have surpassed heroin in numbers of new addicts, but prescription opiate abuse—OxyContin, hyrodcodone, Vicodin—is on a slow creep. In January, the Community Epidemiology Working Group (CWEG), a panel of researchers who track drug-use statistics from 16 metropolitan areas, reported that in San Diego County, opiate addiction (separate from heroin addiction) was the only category of addictive drugs for which treatment admissions had increased during the past five years. And the Drug Abuse Warning Network, a  drug-monitoring group that tracks drug-related emergency-room visits, reported that in San Diego County, opiate abuse landed more people in the ER (460) in 2006 than heroin (371) cocaine (342) and marijuana (432).