The Other Side of the Tracks

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The evolving view of addiction as a disease of the brain rather than as a moral failure has had important implications for both addicts and doctors. Only a decade ago, addiction was generally considered outside the scope of a non-addiction psychiatrist or a primary care physician; now buprenorphine is sparking more and more opiate addicts to get treatment independent of the traditional recovery routes, particularly methadone clinics. "We have the mainstreaming of addiction treatment into [general] medicine with Suboxone," Duncan says. "In primary care a patient tends to have a partnership with their doctor. No one has to know."

For people who depend on traditional recovery at methadone clinics it is a very different matter—they face the traditional stigma that attaches to addiction. The best example? The speed and frequency with which "Not in My Backyard" protests spring up at the very mention that a methadone clinic might be located in the neighborhood. This stigma may be taken for granted, and the problems it causes are predictable. 

Irish researchers studying methadone treatment at OTPs this year found that "linkages between social control and institutional stigma that serve to reinforce 'addict' identities, expose undeserving customers to the public gaze, and encourage clients to be passive recipients of treatment." A federally funded study of methadone policy found that "frequent clinic visits hinder patients' full reintegration into society by restricting their ability to travel and imposing continued contact with less stable patients. Such restrictions may also deter out-of-treatment patients, who see an unending, inconvenient and stigmatized regimen." In this way, the necessity of daily visits to a methadone clinic can prevent people who are in recovery from recovering their place as functional and respected members of society: once an addict, always an addict. As a result, some opt out of methadone treatment; others opt out of society to go on treatment. 

People who depend on traditional recovery at methadone clinics face traditional addiction stigma. 

Another important difference between methadone and buprenorphine is their dosing requirements. People on methadone must make frequent visits to the clinic—usually daily for the first 30 to 90 days—to receive their doses in order to prevent “diversion,” the act of misusing or selling the drug. Those prescribed Suboxone, however, may get anywhere from a week’s to a month’s supply. In most states, methadone maintenance patients are allowed a month’s worth only after showing two years of compliance—clean drug tests and, often, mandatory counseling or meetings. (In Florida, it is five years.) When traveling, methadone-takers must put in a vacation request at their clinic to qualify for extra medication, or “take homes”; if they do not qualify, they have to set up courtesy dosing at a clinic near their destination. Bupe-takers merely pack the right number of pills.

The emerging approach to treatment—non-specialist physician prescriptions for opiod dependence—has its own drawbacks. Many people in recovery benefit from a combination of medication and self-help or counseling in order to address the many issues related to addition. But in a recent SAMHSA study, 41% of bupe patients had attended no substance abuse or mental health counseling sessions in their first month of treatment. On this score, methadone clinics that require such attendance may have an advantage.

The disease model of addiction is widely perceived as resulting in a decrease in stigma. (It could be argued that popular culture's obsession with celebrity—and their high rates of substance abuse—has done more.) Yet the stigma persists, especially for people who live on the margins because of the color of their skin or the size of their income—those who stand in line at the nation's methadone clinics. While no less an "addict," a person who is on Suboxone can, if desired, entirely skirt the stigma by keeping their disease private, even a secret, including no public acknowledgement at a clinic or a 12-step meeting. As Tom points out, bupe is white-collar maintenance; methadone is for everybody else.

There’s nothing new in how society confers social stigma on those who live on have nots. If we truly believe addiction is a medical disease, then it seems cruel to restrict the economically disadvantaged to the treatment that is more burdensome in terms of risk, adherence and disrespect. Making Suboxone available at methadone clinics will not magically make stigma disappear, but it is likely to improve the odds of a successful recovery for people who have nowhere else to go.

Kelly Bourdet is a journalist focusing on the culture of science, technology and medicine. Her work has appeared in Vice, Motherboard, Buzzfeed's FWD, Nerve, Black Book and other publications. She tweets at www.twitter.com/kellybourdet.