It’s a good a time to scrap the methadone clinic system
The rapid onset of the coronavirus and subsequent shutdowns have got those of us on methadone feeling pretty scared right now. Although the government (and my clinic doctor) insist that clinics will remain open—and the Substance Abuse and Mental Health Services Administration has instituted relaxed guidelines for distributing take-home doses—lots of us are still checking to see if we still have that old dealer’s number, wondering if the local dope spot is still around, and starting to ask ourselves tough questions about whether, and for how long, we would be willing to hold out without our daily dose of methadone. I know because that’s what I’m doing.
Like most people on methadone maintenance treatment (MMT), there’s almost nothing that scares me as much as not having easy access to my methadone. I’ve booked multiple overlapping flights, canceled important events, woken up at ungodly hours and much, much more—all to ensure that I get to my clinic in time to put another 24 hours between me and the creeping horror of withdrawal. And thus, this event has been stressful, not only from a healthcare perspective, but also in that it reminds us of our stigmatized status within the world of healthcare consumers. We know that if the methadone clinics do close, aside from a few doctors and advocates, most people aren’t going to care that much.
The main reason for my cynicism when it comes to the official messaging is that the clinic system doesn’t work very well during the best of times. Like any highly regulated government program, it is characterized by bureaucracy, inefficiency and wide variation in treatment quality and practices between programs in one location versus another. Relatively minor issues can thus cause major problems with service; catastrophic events, like the one we’re currently experiencing, almost always do.
During Hurricane Sandy, for example, large numbers of New York and New Jersey area patients had to go without service as their clinics closed—in many cases with no advance notification to patients and no backup plan to help them find alternative ways of obtaining their medication. Moreover, because of stigma against people on MMT and people who use drugs in general, many of those seeking help from hospitals and other medical providers were met with stony indifference—sometimes even accused of diverting necessary resources away from the “real” patients.
As social scientists Ellen Benoit and Harlan Matusow, who studied the effects of Hurricane Sandy on methadone patients, described, many were forced to choose between suffering through withdrawal, or, if they were able, buying heroin (ironically participants reported that illegal opioids were easier to get than their prescription methadone). All of this while also trying to protect themselves and their loved ones from a hurricane.
Clinics’ insistence on daily attendance for the majority of patients is not only highly unfair, but is simply not a sustainable model of long-term treatment—that they have to abandon it so quickly in a crisis of itself suggests the system’s unworkability, and there are already reports of chaos at some New York City clinics as they try to implement the new rules during the pandemic.
As I’ve previously written, any program that requires large numbers of people to show up somewhere on an everyday basis, indefinitely, is not going to work very well, particularly when many of the patients are already living with multiple difficulties. I’ve known countless patients who had to quit because showing up every morning was impossible to maintain along with their job, or because their clinic wouldn’t provide them with medicine for travel to a family member’s funeral.
The failure of the clinic system is easy to observe in its consistently low rates of patient retention. According to the United States Treatment Episode Data Set, in 2014, more than half of those receiving methadone (or buprenorphine) either left treatment on their own (41 percent) or were discharged by their clinic (11 percent).
It is therefore my hope that in addition to demonstrating and possibly exacerbating the huge problems with the clinic system, this emergency will also serve as a catalyst for scrapping it—in favor of office-based, physician-managed care, like we do with every other prescription medication.
As numerous people who study substance use treatment have argued, there are many reasons for transitioning from clinic-based to office-based methadone maintenance treatment (MMT). In addition to the problems endemic to a giant bureaucracy, methadone clinics have also been criticized for their rigid, punitive and abstinence-only approach to treatment—an approach at odds with the goals of many patients, who use MMT as a pragmatic way of reducing the dangers and instability of illegal drug use such as overdose, withdrawal and law enforcement.
By enabling patients to work directly with their doctors—as opposed to counselors, who often have very little training on substance use issues and yet are the primary point of contact for patients in the clinic system—treatment could become more individualized and better able to assist people with a range of treatment goals.
Simply visiting doctors and pharmacies—rather than large, centralized treatment facilities at a siloed physical location—would also be far less stigmatizing for patients. It should even make local businesses and communities, who are usually opposed to having a methadone clinic located within their midst, happy.
Envisaging a system like this doesn’t require much imagination. This is already how buprenorphine maintenance treatment, a substitution-based treatment similar to MMT, is typically administered, and while there are still problems, they pale in comparison to those generated by MMT.
Proponents of the clinic model sometimes argue that many patients actually benefit from, and prefer, the structure and stability that daily attendance at clinics provides. Although I sometimes find this argument disingenuous—in that I think this sentiment comes more from a desire to exert control over the lives of people who use drugs than from a genuine concern with their treatment preferences—I have no doubt that for many reasons, some people would opt for clinics, particularly early on in their treatment.
I don’t therefore advocate for the summary closure of all clinics, but for the abolition of a system that makes them compulsory. Clinics could remain open for those who want them, but everyone should also have access to regular office-based care. Given the choice, I believe most patients would eventually vote with their feet.
Transitioning from a clinic-based system to a primarily office-based model is the only way that people on methadone will feel confident that their treatment is being administered through a reasonably reliable doctor-patient relationship—one stable enough to provide quality, individualized service both during emergencies and on a day-to-day basis. This is by far the best way of reducing many of the problems that make MMT a huge pain-in-the-ass during the best of times, and threaten to collapse it entirely during the worst.