Author: David Frank
People on methadone maintenance treatment (MMT) are in a difficult position. I should know since I’ve been on it for close to 20 years. They are caught in the space between a program that helps them in a way that is primarily pragmatic – by providing access to a safe and consistent supply of opioids outside of the difficult and dangerous conditions created by prohibition/criminalization – and our culture’s need to frame everything drug related through the ideological narrative of “addiction” and “recovery.” In short, MMT enables criminalized drug users to decriminalize their opioid use, and yet, like the emperor who wears no clothes, it must publicly masquerade as a “treatment for addiction” so as to not disrupt the War on Drugs ideologies that require firm distinctions between “drug” and “medicine”; “addict” and “non-addict”. It’s no wonder that people end up a little confused.
Methadone: An American Way of Dealing captures these contradictions playing out in real time.
In the film, a documentary that uses a cinema verité approach to exploring the lives of people using MMT in the early 1970’s, we see individuals trying to reconcile their participation, and the stability it brings to their lives, with the belief that the program should be “treating” something or improving people by encouraging their “recovery.” They are unsure if, or for how long they should remain on MMT; whether or not using other drugs while on MMT means that the treatment is unsuccessful; or what it means to have left and then returned to treatment multiple times. Although most are clear about the practical value that MMT provided them, noting that it gives them time to get their habits under control, stabilize their lives, and avoid withdrawal, this is often not enough to withstand the discursive force of narratives that positions MMT strictly as a means to discontinue substance use and treat addiction.
When one patient is finally cornered about the imagined inconsistencies demonstrated by using MMT sporadically and for reasons other than of the pursuit of abstinence, he admits in exasperation that it is simply because he “likes to shoot dope.”
Perhaps instead of trying to force a particular lens onto MMT, we would do best to start with that basic truth: some people like to shoot dope; and when involved in MMT – regardless of whether or not that individual wants to reduce or discontinue their illicit drug use – they are healthier, happier, and more stable then when forced to obtain opioids strictly from the illicit market.
Moreover, if switching from illegal, highly criminalized opioids like heroin to a legalized opioid like methadone can transform people from down-and-out junkies into upstanding citizens, then what do concepts like “abstinence,” “relapse,” and “addiction” even mean?
In my own life as well as in the research I’ve done, most people link their participation in MMT more to the difficulties and dangers of criminalized drug use than to a desire to “recover from addiction.” Like those in the film, they note how MMT allows them to be free from the constant need to hustle up money for drugs from an inconsistent, illegal market; the constant threat of withdrawal and the risks it compels them to take; the fear of arrest; risks of overdose and dependency on a poisoned drug supply; or simply how MMT allows them to maintain a job, go to school, or travel.
Yet the vast majority of programs are not designed with these pragmatic goals in mind. Rather, such patients using MMT for harm reduction inevitably find themselves forced to attend their clinic on a daily basis; arguing with counselors about the legitimacy of their treatment goals; and oftentimes at risk of being discharged or leaving on their own when the treatment becomes too much of a burden.
Thus, while this film is now 50 years old, these tensions still exist in clinics today, and they still create stigma, self-doubt, guilt and shame among a large portion of the patient population. It is partly why programs have consistently low rates of use and retention.
I am hopeful that the dramatically increased rates of overdose and poisoning associated with fentanyl (and other adulterants in the illicit drug supply) will bring increased attention to the plight of people who want to be safer without adopting an abstinence-based ideology. For if MMT isn’t for people that like to shoot dope, then who is it for?
Dr David Frank is an Adjunct Professor at NYU School of Global Public Health. His research focuses primarily on opioid use and medication assisted treatments, and examines the role of structural factors, such as criminalization and the War on Drugs, in the harms that people who use illegal drugs experience.