Methadone maintenance treatment has been the most effective
treatment for addiction to heroin resulting the cessation of
heroin use and criminal behavior. Prior to the development of
methadone maintenance treatment over 28 years ago narcotic
addiction was considered incurable and a behavioral disorder
under the control of law enforcement. Drs. Dole and Nyswander
brought the treatment of heroin use back into the doctor’s
office treating the addict as any other patient with a chronic
disease. However, the original methods employed by Dole and
Nyswander have sometimes been misunderstood often impacting
negatively on a treatment that is virtually life saving for the
addict.
Blind dosing has become a policy that some programs located
outside of the New York City area employ for various reasons.
Several basic characteristics can be found within programs with
blind dosing policies: 1) an adequate dose is not prescribed,
2) dosage has become a problem and 3) the program does not
believe in the disease concept of addiction, 4) the program
views methadone as a substitute drug, 5) the program does not
understand the physiological differences found in addicts, 6)
the program does not follow a medical model, 7) the program does
not appreciate or understand the biological determinants of drug
craving, and 8) the program is basically administered by
behaviorists who treat heroin addiction as a character disorder.
Many programs believe that blind dosing is a therapeutic
strategy to remove the issue of depending on a chemical
substance for support, to make them feel normal and to get them
through the day, so the addict can begin to look to oneself
instead. Unfortunately, it has the opposite effect of being
destructive to the therapeutic relationship between the patient
and counselor and the patient and program. The trust that is
necessary for quality methadone treatment is never developed
because the patient feels betrayed and maligned by the one thing
that is suppose to understand them. And patients who are truly
a very small minority and may have problems such as competition
with other patients for the highest dose never have this problem
dealt with in a therapeutic manner. Blind dosing is the
program’s way of avoiding the problems that these patients may
have. A cop out!
For programs that blind dose, successful patients are rare
because only the motivated patient who is determined is able to
change their life may be able to. This is not to say that blind
dosing is inconsequential to these patients, rather they are
better equipped for rehabilitation and able to overcome their
feelings of anger toward the clinic. For the unmotivated and
ambivalent methadone patient with low self esteem blind dosing
can be disastrous for their response to treatment. These
patients come into treatment with feelings of low self esteem
and hopelessness and need to develop a trusting relationship
with their counselor and the program, which is thwarted. The
majority of these patients could be successful too, but without
their development of trust in the program they can never begin
to acquire the necessary attributes such as responsibility and
Independence to change their lives.
The treatment style of these clinics have been defined as
reformist. According to Rosenbaum (1985) while the reformist
treatment style may work for a short period of time, but
eventually the patient will become angry and feel left out of
treatment decisions. The reformist philosophy is too damaging
to one’s self worth for any extended period of time resulting in
a low retention rate for these programs. Those in need of help
may accept degrading definitions of themselves temporarily,
however the human psyche will attempt to maintain one’s
integrity and dignity, and will not tolerate long-term
degradation, at least not happily. Thus patients become
embittered and resentful toward the clinic eventually realizing
that the program is wrong about many things, including their
treatment. The patient no longer takes their treatment
seriously and becomes frustrated and ambivalent. They can no
longer be engaged in participating in their treatment or it’s
process.
Research has found that patients report that receiving methadone
was both, the best liked and most useful aspect of treatment
(Stark & Campbell, 1991). Studies indicate that patient’s
awareness and influence in dosing decisions are important
treatment practices and related to retention in treatment (
D’Annuno and Vaughn, 1992; Watters, 1986). D’Annuno and Vaughn
(1992) studied 172 methadone programs and found that many have
policies that are not effective, including blind dosing and the
patient’s noninvolvement regarding dosing decisions were noted.
For over a decade HIV has been spreading through the injecting
drug user community thus emphasizing the importance of retaining
patients in treatment. Methadone when given in a adequate dose
will block the craving for heroin resulting in the cessation of
heroin use and criminal activity (GAO, 1990). Therefore, if for
no other reason retention in methadone treatment should be a
priority for programs (Schuster, 1989). From the patient’s
point of view they have a right to know that they are receiving
an adequate dose.
However, their are other aspects of this that many programs may
never think of, perhaps because they know very little about
methadone themselves and which places them in jeopardy. If a
patient is blind dosed and not receiving a blockade dose of
methadone and then overdoses they, or their family should they
die could sue the program. There would be little for the
program to protect itself with in such a legal matter, since the
National Institute on Drug Abuse, the Center for Substance Abuse
Treatment and the American Methadone Treatment Association all
have policy statements which say that blind dosing in
ineffective and wrong. A second problem is the diversion of
methadone by staff which is very tempting in such a situation.
If patients do not know their dose it would be very easy for
program staff to take a few milligrams from every dose. At the
end of the day these few milligrams per patient would become a
nice perk for the employee, especially considering the cost of
illicit methadone in some locals. For the safety of the program
it is common sense that patients should know their dose.
Blind dosing is contrary to the modality developed by Dole and
Nyswander that has been so successful in treating heroin
addiction. Dr. Nyswander believed and taught other
professionals to “…first listen to your patient and you will
never make a mistake” (Dole, 1992). She treated her patients
with dignity and respect, as worthy individuals deserving of
medical care and treatment and as valuable as any other
individual receiving treatment for a chronic condition. And
that was why the Dole – Nyswander program was so successful.
Now I ask you, if you went to a physician who prescribed a
medication that is described as a “powerful narcotic” but would
not tell you the dose, how would you feel? Would any
responsible adult in their right mind take it? Would you go
back to the physician?
Methadone patients like any other health
consumer want to know, and have the right to know their dose.
Program staff that believe in these antiquated policies need to
look within and ask themselves how they would feel if they were
the patient. They need to realize the destructive effects of
blind dosing on the treatment process and have the courage to
reverse the policy. In doing so programs will give the
patient’s the dignity that they deserve thus allowing patients
to go on with the difficult task of changing their lives instead
of being concerned with “What dose am I on?”
References
- D’Annuno, T and T.E. Vaughn. Variations in methadone treatment
practices. Results for a national study. Journal of the
American Medical Association 1992 (January 8) 267(2): 253-258.
- Dole, V.P. Personal communication, 1992.
- General Accounting Office. Methadone Maintenance: Some
Treatment Programs Are Not Effective; Greater Federal Oversight
Needed. Washington, DC: GAO/HRD-90-104, 1990.
- Rosenbaum, M. A matter of style: Variation among methadone
clinics in the control of clients. Contemporary Drug Problems
1985 Fall: 375-399.
- Schuster, C. Methadone maintenance. An adequate dose is vital
in checking the spread of AIDS (Director’s Column). NIDA Notes
1989 Spring/Summer: 3, 33.
- Stark, M.J. and B.K. Campbell. A psychoeducational approach to
methadone maintenance treatment: A survey of client reactions.
Journal of Substance Abuse Treatment 1991 8: 125-131.
- Watters, J.K. Treatment environment and client outcome in
methadone maintenance clinics. Thesis topic: University of
Michigan, 1986.