State of Mind

How the Crackdown on Methadone Set Back Treatment for Addiction

Two white pills.
Photo illustration by Slate. Photo by Whitney Hayward/Portland Portland Press Herald via Getty Images.

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From The Urge: Our History of Addiction by Carl Erik Fisher, published by Penguin Press, an imprint of Penguin Publishing Group, a division of Penguin Random House, LLC. Copyright © 2022 by Carl Erik Fisher.

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On June 17, 1971, in the midst of another heroin epidemic, Nixon formally declared his “war on drugs.” That year, Americans listed heroin addiction as the nation’s third‑most‑pressing problem, behind only the seemingly endless war in Vietnam and the stagnating economy. (By comparison, in 2019, even during the widely publicized opioid overdose crisis, drugs and drug addiction were rated the 12th most important problem facing the nation.) Worsening the panic further, heroin was widespread in the Vietnam War, too—more than one-third of all U.S. enlisted personnel had tried heroin. Street peddlers stuffed vials of 95‑percent‑pure heroin in the pockets of GIs as they strolled around downtown Saigon, and even a congressional commission with a uniformed Army escort was approached several times by dealers. (It’s important to note that heroin was widely available because the CIA had reportedly protected and participated in the opium cultivation businesses of its strategic allies in the “Golden Triangle” of Southeast Asia.) In 1971, two congressmen gave several high‑profile press conferences reporting that as many as 10 to 15 percent of servicemen were addicted. In keeping with the ominous mood, in the television broadcast announcing the drug war, Nixon predicted that drugs would destroy the country, and he claimed, falsely, that heroin users were responsible for $2 billion in property crime every year.

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However, the amazing thing about Nixon’s war, from today’s perspective, is how much it was oriented toward a therapeutic response to addiction: When Nixon made his declaration, it was the only time in the history of the war on drugs that the majority of funding went toward treatment rather than law enforcement. Nixon also presented a relatively young psychiatrist named Jerome Jaffe (yet another alumnus of Narco, the massive prison-hospital that was essentially the only home of addiction medicine in midcentury) to the country as the first drug czar, and the administration subsequently took control of the entire federal response to drug addiction treatment, pouring massive funding into those efforts. One of Nixon’s advisers called it the “Camelot period of drug policy,” and one scholar has even called Nixon “the first therapeutic president.”

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Yet within the federal government, there remained serious opposition to therapeutic approaches to addiction, especially treatment in the form of methadone. From its Harry Anslinger days, when the nation was singularly focused on prohibitionist crackdowns, the Federal Bureau of Narcotics (FBN) had opposed maintenance, to the point of flexing its might internationally to prevent it: In the early 1940s, the Mexican government tried to establish legal opioid maintenance, but Anslinger imposed a total embargo on morphine, thus quashing the Mexican experiment within six months. Federal prosecutors had long enforced their own ban against maintenance treatment—never mind that they had created the ban out of sheer force and it had no real basis in law. So when the FBN heard of the experiments of Vincent Dole and Marie Nyswander on methadone, they were not pleased.

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Dole and Nyswander had conducted crucial research on methadone for people with opioid addiction, and they found that the medication could abolish drug cravings, “block” the euphoric effects of opioids like heroin, and help their patients return to functional, meaningful lives. Soon after Dole and Nyswander started this work, the FBN sent an agent to harass Dole, who found the agent arrogant and a little comical as he pounded the table and insisted, “You’re breaking the law.” Dole knew that was a lie. A savvy, seasoned academic leader, Dole had already secured New York Gov. Nelson Rockefeller’s support. In the process, their attorneys had learned, to their total surprise, that there was never any definitive law or court case prohibiting maintenance treatment. Dole was placid. As he later recalled, he looked back at the incensed agent and calmly suggested, “You ought to take me to court so we can have a determination on this point.” The agent’s face abruptly changed; Dole had called his bluff.

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In the ensuing years, methadone seemed to have won a secure place in the halls of medicine. Though the FBN continued its opposition—including starting a rumor campaign implying that Dole and Nyswander had fabricated their data—money poured into methadone programs. But the money was both a blessing and a curse. Programs expanded so rapidly that they far outstripped what their actual competence allowed. In New York, even the most ardent methadone advocates urged the health department to slow down. There were unscrupulous physicians who ran “pill mills,” but more commonly, “gas station” programs did little more than dispense medications, providing none of the wrap‑ around rehabilitative services that Dole and Nyswander included in their original version, such as job training and other social supports. A New York Times reporter twice walked into a clinic and, without any evidence of addiction (or even any identification), bought 280 milligrams of methadone for a $30 fee (the usual starting dose is 20 to 30 milligrams). Nonmedical use of methadone, including some overdose deaths, increased. Dole and Nyswander, who had worked so hard to establish warm, holistic, rehabilitative programs, looked on in dismay: Dole bemoaned “the stupidity of thinking that just giving methadone will solve a complicated social problem.”

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Prohibitionists in the federal government used these problems to fuel their opposition to methadone. In addition to their harassment of Dole and Nyswander, they sounded the alarm about black markets for methadone, played on methadone’s symbolic association with Black and Brown inner‑city drug use, and counterattacked with a flurry of amendments and regulations meant to limit its use. They couldn’t kill methadone, but they could hamstring it and turn it into a system of control. In just a matter of years, methadone treatment was transformed into something more like an arm of law enforcement than medicine: Private physicians could no longer offer office‑based treatment, and only special federally approved and licensed programs could prescribe methadone for addiction treatment (and only under the looming threat of constant scrutiny from federal drug enforcement). In 1981, the former Communist Marie Nyswander wryly noted that she was “sounding like a Republican” in criticizing the extraordinary federal controls on methadone’s use. Today, methadone treatment has significant problems, but many of them stem from overzealous regulation with roots in this period: rigid, arbitrary dosing policies, inflexible schedules, exorbitant fees, and inadequate psychotherapy and other recovery services.

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Methadone also remains one of the strongest examples we have of the stark racial disparities in the understanding and treatment of addiction. Black and Brown communities have long had to fight for treatment—for example, in the 1970s, Black and Puerto Rican community groups staged numerous sit‑ins and protests to force hospitals to open drug treatment facilities. One demonstration had to occupy the community psychiatry division of St. Luke’s Hospital in Harlem for four days to obtain drug treatment for teens. Addiction in communities of color, perennially a major problem, is too often explained in a stigmatized way that justifies prohibitionist approaches: portrayed as self‑chosen and irresponsible. On a structural level, addiction is explained away as the intractable effect of poverty or other root causes, treated as inevitable and expected, and thus left to the criminal legal system. Meanwhile, other explanations of addiction fuel entirely separate tiers of addiction treatment.

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The medication buprenorphine was first proposed as an addiction treatment by Narco researchers in 1975, but it was long sidelined by anti‑medication stigma, especially the regulatory restrictions that were built around methadone. As the scholars Samuel Roberts and Helena Hansen have documented, it was only when the opioid epidemic emerged as a supposedly white problem that buprenorphine was made available. In the late 1990s, treatment advocates warned Congress that “narcotic addiction is spreading from urban to suburban areas,” and the “current system” of methadone treatment was “a poor fit for the suburban spread of narcotic addiction.” Congress accordingly passed legislation that carved out a special regulatory category for buprenorphine as an office‑based treatment—a pharmaceutical and clinical intervention rather than a punitive one—but only through specially waivered physicians who were more likely to take only self‑pay and private insurance. Sure enough, three years after buprenorphine’s approval, roughly 90 percent of U.S. patients taking it were white. (In fact, some of the only opposition to the buprenorphine legislation came from members of Congress who correctly identified that buprenorphine would be available only to those with financial resources, and lower‑income people with addiction would be left in the lurch.) Today, white people are still far more likely to receive buprenorphine, and the medication largely functions as one piece of the entirely separate system for responding to white and upper‑class drug use, relegating the majority of socially marginalized patients to the system of control enacted in the 1970s.

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Anti‑medication stigma has also, ironically, permeated some of the 12‑step communities so central to addiction recovery today, creating an unnecessary tension between therapeutic and mutual‑help approaches that need not be in opposition to each other. Early Narcotics Anonymous leaders spoke favorably about methadone, such as Father Daniel Egan, featured widely in the news in the early 1960s as the “junkie priest” for his work ministering to people with addiction in New York City. But the crackdown on methadone drove anti‑medication attitudes in 12‑step communities to an unhealthy extreme, and in time, methadone patients in NA weren’t allowed to hold a service commitment or even speak at meetings. Soon, people on methadone began avoiding NA groups or keeping their methadone treatment a secret. As recently as 1996, NA’s board of trustees strongly suggested that people using methadone should not be allowed to be speakers or chair meetings, and to this day, official communications from NA have consistently specified that patients receiving medications for addiction treatment are not “clean.”

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That same anti‑medication stigma bled outward to all psychoactive medications. In part, mutual‑help groups and people in recovery were having a reasonable response to the overprescription of drugs like amphetamines, barbiturates, and benzodiazepines—as early as the 1940s, AA publications recognized sedative addiction as “chewing your booze.” Also, it’s important to note that the culture of 12‑step communities is dynamic and heterogeneous, and these attitudes vary by group and continue to evolve today. Still, and especially in treatment settings strongly influenced by 12‑step fundamentalism, people are sometimes pressured to stop psychiatric medications in search of the ever‑elusive ideal of being “drug‑free.” I’ve heard of abstinence‑based programs that have refused to accept people on heart medication.

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Medications for addiction—especially for opioid addiction—save lives. Study after study, from carefully controlled clinical trials to massive investigations of everyday practice, have shown that buprenorphine and methadone cut the rate of death among opioid‑addicted patients by half or more. A recent, massive study of more than 40,000 patients has found that among all treatments—medications and therapy alike, including intensive outpatient and residential rehabs—buprenorphine and methadone are the only ones that reduce opioid overdoses. (Another, newer medication for opioid use disorder, extended‑release naltrexone, is also useful, and it suffers from comparatively less anti‑medication stigma.) There are signs of some softening among previously unreceptive communities to allow for medication treatments, but it is slow in coming, and often incomplete. In 2012, Hazelden, the first residential addiction recovery program in the 12-step-based “Minnesota Model,” announced that it would provide buprenorphine. But, like many other treatment centers, it does not allow its clients to use methadone.

State of Mind is a partnership of Slate and Arizona State University that offers a practical look at our mental health system—and how to make it better.

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