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Volume III, No. 2 (February 1998)
An Interview With Dr. Vincent Dole (Part I) - Odus Green
Americans With Disabilities Act (ADA) - by Beth Francisco
LETTER and POLICY STATEMENT to your Legislators
NIH Policy Statement
Briefly Speaking - Short items about drugs in history
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An Interview With Dr. Vincent Dole - (Part
by Odus Green
I would like to preface this article with some words of thanks for those who made
it possible. First and foremost, many thanks go to Ms. Beth Francisco, Editor of
Methadone Today, without whom this whole exercise would not have happened;
to Ms. MaryAnn Hayes, Dr. Dole's secretary, who was gracious and kind to me; to all
those fine folks on the "Methadone List" for the questions which
they sent me; to Edward Breecher, who wrote the Consumers Union Report on Licit
and Illicit Drugs, which provided a plethora of information while researching
this article; and to Dr. Dole himself, who is one of the most humble men I have ever
had the pleasure to know. Finally, to my lovely wife, Cindy, who puts up with my
many hours locked away in my office, doing all types of advocacy work, as well as
writing articles. - Odus Green
Dr. Vincent Dole--the name brings to mind a picture of a man in a white lab coat, glasses worn way down on the end of his nose, asking questions of one of the early volunteers in his experimental methadone program--a caring man who, along with Dr. Marie Nyswander, "invented" the concept of Methadone Maintenance (MM). He is a man who is very shy about taking any credit for his hard work and dedication.
There weren't many scientists in the 60's willing to work with opiate addicts. Even among those in the field of drug rehabilitation, opiates are looked upon as the most insidious of all drugs.
Dr. Dole was working on a study of obesity when he saw that some people craved food much as drug addicts craved drugs. This prompted him to read a book named The Drug Addict as a Patient by a psychiatrist, Dr. Marie Nyswander. Both were commissioned as officers in the Navy during WWII, both worked on diseases which were perceived as "a weakness of will" rather than a metabolic disorder. To this day, that particular perception still exists among most of the population of America! Despite this perception, they continued to work with addicts throughout the rest of their careers. They were also partners in another venture that seems to have worked out very well. In 1965 they were married.
During the early part of their research, they were working with two patients in order to study the metabolic effects of opiates. These two patients were allowed to take as much IV morphine as they wanted. Accordingly, these patients were being "perfect patients" in every way. They were not at all shy, and were very cooperative with the researchers. Morphine became their whole lives; they sat passively in front of television awaiting their next shot. Although they were offered other activities, they declined them.
After the researchers were through with these studies, they were required by law to detoxify these two patients before discharging them out into the world. The approved method of detoxification then was to transfer a patient from his opiate of choice--in this case, morphine to methadone. The daily dose of methadone was then decreased slowly over a period of time until a zero dose is reached. So, as per the law, Drs. Dole and Nyswander placed their patients on methadone. However, instead of reducing the methadone right away, they decided to keep the patients on it for a length of time sufficient to run the same metabolic tests which had previously been run while the patients were on morphine.
After the patients were switched to methadone, a peculiar thing began to happen. Instead of laying around in their pajamas all day watching TV, the patients started asking for access to activities which required actual physical exertion on their part! This was very far removed from their behavior while on morphine. The eldest patient (34) asked for, and received, permission to paint which had been a hobby of his years ago. The younger patient (21) began to ask for permission to attend a night class, so he could earn his high-school equivalency diploma. He was allowed to attend classes, while still residing at the hospital and participating in the tests. Eventually, they were both attending classes off the hospital grounds, while still living there. They were both still taking their methadone daily. As far as the doctors could tell, they were both "cured" of their addictions! It is from this auspicious beginning that the current state of methadone maintenance has evolved.
Unfortunately, politics was forced upon the equation, and methadone maintenance still hasn't reached its full potential because of that fact. Drs. Dole and Nyswander went on to study further the effects of MM on tens of thousands of patients. It is as the "father of methadone maintenance" that I think of Dr. Dole.
So, with the background described, what follows is an interview I conducted with Dr. Dole over a two day period in January of this year. I simply hope I am able to convey one-tenth of the sincerity and intelligence this man possesses. His humility and genuine caring are what I feel make him a great man. If I never meet another historical figure in my life, I am very glad that Dr. Dole was my "brush with greatness!"
Odus: Dr. Dole, how would you go about improving today's methadone programs?
Dr. Dole: First and foremost, I must address the whole issue of urinalysis. The nature of the whole interaction points up to me one of the most glaring and disturbing faults with the treatment of addicts. That is, namely, that the urinalysis is used to find fraud or deception by a patient instead of a means of documenting what has been accomplished by them. If you have such an adversarial relationship between a clinic and its patients, it is a bad clinic. Many clinics tend to act as some sort of police agency, thinking they can stand over the patient and somehow or another cure a patient by holding a big stick over his head. That isn't a very therapeutic approach. The whole image just isn't something I would have ever dreamed about, and that is sad, but it is not uncommon.
A lot of this is because untrained and fundamentally cynical people are often recruited into being counselors. How can someone with this disposition counsel anybody? They come into it with the attitude, "O.K., you aren't going to fool me. I'm on top of every little trick you can pull." That attitude is the most anti-therapeutic attitude one could have! This is then re-enforced by government policies, which task the clinics with being policemen! When you've lost the "WE" in a patient/clinic relationship, you've lost the heart of the program.
Odus: What do you think of the government's role in methadone treatment?
Dr. Dole: The nature of government intervention is very heavy handed in a political way. It has suppressed the normal medical responsibility. The restrictions, which are so politically loaded, are meant to restrict and contain methadone treatment, which is politically unpopular. That type of repressive, negative attitude tends to drive out the most responsible and caring doctors. It leaves, therefore, only "jobs to be filled," as in warm bodies to fill positions as opposed to caring professionals. I think government tries to separate the addiction field from what it considers the "legitimate medical field." Therefore, it became a much more administrative type job than a medical job. I notice that today the majority of clinics are owned by nonmedical people. I would like to see it brought back into the medical field, as opposed to the administrative field it is now in.
The result of government has been to alienate the medical profession from methadone treatment. This results in what would be otherwise caring individuals (doctors) having an indifference or even hostility toward methadone. Even backing up and changing legislation wouldn't stop that attitude overnight.
Odus: Should counselors start a patient's treatment with the goal of eventually being totally drug free, including free of methadone?
Dr. Dole: I think that has been a very serious misunderstanding from the beginning. The goal is NOT abstinence, the goal is to become functional. The data collected over the years has shown that abstinence is an unlikely goal. It is a terrible mistake to put someone in the position of either eventually becoming abstinent or becoming a failure. I am very sorry to hear that many clinics continue to do just that. Unfortunately, that is a philosophy at many clinics. They are willing to "put up with" maintenance in the short term, but they feel that a patient isn't really "cured" unless they are abstinent.
Odus: Do you see any similarities between your model and the clinics that exist today?
Dr. Dole: Well, of course I see similarities, but the main difference is the philosophy, which has been drummed into them by those who are anti-maintenance, that the patient isn't "cured" unless they are "drug-free", no matter what else. The patient can be employed gainfully, taking care of his family, and in all respects a fine citizen, still they feel that unless he is free of methadone, he isn't "cured". That is totally opposite from what I believed then and still believe today.
Odus: What do you think of the policy, by which most clinics seem to abide, of forcing a patient to detox due to illicit drug use?
Dr. Dole: I think it totally misses the point, from a medical standpoint. I feel that each and every patient should be examined by the doctor individually and treated like an individual. I like very much the concept of dealing with one thing at a time. If the patient has shown some sign of a problem, the physician should talk with him. He should ask him, "How are you doing? What is the problem, and how can we help to eliminate the problem."
Odus: What percentage of your patients were eventually able to live completely free of all drugs, including methadone?
Dr. Dole: You see, even you are prejudiced to a degree, you want to know how many people get off methadone altogether when the question should have been, " How many patients were able to achieve a normal life consistent with their own abilities, strengths and so forth." The answer to that question is, "quite a large percentage were able to go on with their lives with some people reaching very high social and employment positions."
Odus: I understand you were working on obesity before you became involved in drug addiction. Did you find that the two addictions (food and drugs) were similar or were they totally dissimilar?
Dr. Dole: Actually, they are similar in some respects and not similar in others. The biochemical control mechanisms that govern the release of fat are not the same as the control mechanisms that deal with pain; there is a world of difference.
On the other hand, I can tell you that in a social sense and even in a medical sense, they are both dealt with by prejudice rather than by intelligent analysis. I can tell you that I have worked with obese people who could only maintain a socially acceptable weight by living on a starvation diet. Many obese people have no control over how their body deals with calories, much as many people cannot control the craving for heroin. Still, the biochemical reasons are different.
This ends part one of the interview. I certainly hope y'all enjoyed reading it half as much as I enjoyed writing it. I spent the better part of the morning talking to Dr. Dole, and could have stayed and talked all day long. He is a very interesting and articulate man, and I am proud to have met him.
Once we realized we were both in the Navy, we swapped sea stories for a couple of hours. It was difficult to stick with the work at hand; he was so filled with knowledge, I kept getting sidetracked.
To illustrate just how humble the man is, I will tell a story: We were sharing our Navy adventures when he told me he was working for them at Rockefeller during the war, "doing some research." He didn't elucidate; I had to drag it out of him. What type of research, you ask? Well, he was among the ones who pioneered the administration of plasma to wounded soldiers in the field! This undoubtedly saved tens of thousands of lives in the war years alone, not to mention the years since with methadone. This, to him, is just a day's work.
We can be proud to say he actually thinks it is US who deserve accolades. I feel as though I was blessed to talk with him. I hope this article conveys even a bit of his gracious and humble manner.
I will appreciate any comments or constructive criticism. - Odus Green
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Americans With Disabilities Act (ADA)
by Beth Francisco
I have mentioned the ADA in the newsletter, telling you that it is illegal for
employers to discriminate against methadone patients. If you are taking methadone
as prescribed by a doctor, you are covered under this act. Since this information
was published, I have had several calls from patients who have applied for jobs and
have been turned down because they are on methadone maintenance. This is illegal!
The following applied to employers with 25 or more employees, effective July 26, 1992; employers with 15-24 employees had until July 26, 1994 to comply.
Employers may not discriminate against an individual with a disability in hiring or promotion if the person is otherwise qualified for the job.
Employers can ask about one's ability to perform a job but cannot inquire if someone has a disability or subject a person to tests that tend to screen out people with disabilities.
For more information about the ADA, contact:
U.S. Department of Justice
Civil Rights Division
Coordination and Review Section
P.O. Box 66118
Washington, D.C. 20035-6118
(202) 514-0301 (Voice)
(202) 514-0381 (TDD)
(202) 514-0383 (TDD)
Also, I have acquired the name of an attorney in the Detroit area who is willing to take this type of case on contingency (i.e., if you win, he gets paid; if not, he doesn't). This means that after he reviews your case, and if he decides to take it, he thinks you have a good chance of winning. If you would like further information, please call me (Beth) at Methadone Today, (810) 658-9064, and I will put you in touch with him.
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THIS IS VERY IMPORTANT--PLEASE DO YOUR PART - IF NOT YOU, WHO?
IT DOESN'T MATTER WHAT OTHERS DO--IT'S WHAT YOU DO THAT COUNTS!
Please do it. Distribute it. HAVE YOUR FRIENDS & FAMILY SEND A LETTER TOO!
Together, we can make a difference.
Make enough copies of the letter and Policy Statement (next page) to send to your federal and state senators and representatives. Then send a copy of the letter only to each of the people in the cc: section on the back of the letter (i.e. Joycelyn Woods (NAMA), Beth Francisco (DONT), and Alan Leshner (NIDA). Copies of the letter to Ms. Woods and Ms. Francisco are for the purpose of keeping track of how many letters have been sent.
The two Michigan Senators are Spencer Abraham and Carl Levin; also, everyone has a representative in their respective districts.
If you do not live in Michigan but know your senators' names, all federal U.S. Senators receive their mail at: U.S. Senate, Washington, D.C. 20510; U.S. Representatives mail should be sent to: House of Representatives, Washington, D.C. 20515.
You will have to find out who to write to in the State Legislature, but it is equally (probably more) important to send the letter to your state representatives.
The time is right to flood policy makers with letters. The Institue of Medicine; The American Medical Association; Drug Czar, Barry McCaffrey; and the National Institute of Health have all said that regulations on methadone should be relaxed. That's all well and good, but we have to let the policy makers know that. What could be easier than making a few copies and addressing a few envelopes.
Well, what are you waiting for?
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Letter to Legislators
On November 17-19, 1997 the National Institutes of Health and National Institutes on Drug Abuse sponsored a consensus development conference on the "Effective Medical Treatment of Heroin Addiction." Of significance here is that the NIH consensus statements are prepared by a non-advocate, non-Federal panel of experts and therefore provide an objective view of the issues.
As my representative I ask that you read the statement prepared by the consensus panel and then to make every effort to support the recommendations. Of particular importance are the following recommendations that the panel made.
1. Expand the availability of opiate agonist treatment (methadone and LAAM maintenance) in those states where this treatment option is currently unavailable.
2. Reduce the unnecessary regulation of methadone maintenance treatment and opiate addiction in all long-acting agonist treatment programs. And specifically allow physicians to once again prescribe methadone for addiction.
3. Improve the training of physicians and other health care professionals in diagnosis and treatment of heroin addiction. For example, NIDA and other agencies would provide funds to improve training for diagnosis and treatment of opiate addiction in medical schools.
4. Increase funding for methadone maintenance treatment and require that public and private insurance benefits for methadone maintenance treatment be brought into parity of coverage for all medical and mental disorders.
5. The panel called attention to the need for opiate addicted persons under legal supervision to have access to methadone maintenance treatment. Very often courts and probation/parole agencies consider methadone maintenance treatment as a violation and the individual is violated and placed back in prison for their seeking help. In addition, methadone patients who are arrested are denied their medication or even a medically supervised withdrawal often with serious medical consequences. These practices must stop.
6. Opiate dependent women should be targeted for methadone maintenance treatment. They should receive full benefits both prior and post partum so that they can maintain a stable home for their newborn.
7. Methadone maintenance must be culturally sensitive to enhance a favorable outcome for participating African American and Hispanic persons.
8. Misrepresented minorities, patients and consumers should be included in bodies charged with policy development guiding heroin addiction.
9. Vigorous and effective leadership is needed to inform the public that addiction is a medical disorder that can be effectively treated with significant benefits for the patient and society.
Another issue which deserves your attention is Medical Maintenance or the physician prescribing of methadone in an office setting. Long-term, socially productive patients are forced by regulations to adhere to rules which were intended for the newly admitted. This negatively impacts otherwise "normal" lives and shackles the medically maintained patient to the clinic. Today's clinical paradigm doesn't allow for these stabilized individuals who might need medication for the remainder of their lives. The clinic model is patterned for the 'sick' patient coming off the street. This would free up valuable treatment slots and relieve the unnecessary regulation of long term patients if doctors were licensed to treat the stabilized patient with methadone. This is desperately needed if we are to maximize the efficacy of this life saving treatment.
Finally, we are approaching a very serious heroin epidemic. A law enforcement approach has done nothing to reduce illicit drug use in the past eighty years, nor did the increased funding have any impact on the cocaine epidemic except to create a crack epidemic. The lives of our children are at stake and we do not need to create another generation of heroin addicts because our government refuses to admit that our policies have failed.
I ask you as my representative to undertake the final recommendation, that you provide leadership in Congress to educate the public that addiction is a medical disorder that can be effectively treated with methadone maintenance treatment. I ask that you use your influence to reduce the unnecessary regulations, allow physicians to prescribe and to expand methadone maintenance treatment to all American citizens who need and rightly deserve this life-saving treatment.
cc. Beth Francisco, Editor
P.O. Box 164
Davison, MI 48423-1020
National Alliance of Methadone Advocates
435 Second Avenue
New York, NY 10024
Dr. Alan Leshner, Director
National Institute on Drug Abuse
5600 Fisher's Lane
Rockville, MD 20857
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NIH Policy Statement
The National Alliance of Methadone Advocates supports the Consensus Statement
on Effective Treatment of Heroin Addiction that was facilitated by the National Institute
on Drug Abuse and the National Institute of Health.
The Consensus Committee recommended that a strong leadership is necessary in educating the public that addiction is not self inflicted but is a medical disorder that includes a spectrum of brain and medical conditions that can be effectively treated. They emphasized the rigorous scientific studies that methadone maintenance had undergone over the past 30 years that demonstrate its effectiveness in significantly lowering illicit opiate drug use, reducing illness and death from illicit opiate drug use, reducing crime, and by enhancing social productivity.
The committee recommended that the current Federal and State regulations that have limited the ability of physicians and other health care professionals to provide methadone maintenance services for their patients should be eliminated. Rather, they recommended alternatives such as physician accreditation and certification and to improve education of physicians and other health professionals. By reducing the unnecessary regulation treatment and providing increased funding methadone maintenance treatment can be expanded in all states including those that do not currently provide it. The committee emphasized that funding should be sufficient to provide access to treatment for all who require it and strongly recommended that legislators and regulators recognize the cost effectiveness of methadone maintenance treatment and that benefits for treatment be part of public and private insurance programs.
The committee stressed that methadone treatment must be culturally sensitive and that risk groups, such as pregnant women should be targeted. Misrepresented minorities, patients and consumers the committee urged should be included in bodies charged with policy. The committee concluded that we as a society must make a commitment to offer effective treatment for heroin addiction for all who need it.
1. Effective Medical Treatment of Heroin Addiction. NIH Consensus Statement 1997 November 17-19; 15 (6): in press.
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1955 - The Prasidium des Deutschen Artztetages declares: "Treatment
of the drug addict should be effected in the closed sector of a psychiatric institution.
Ambulatory treatment is useless and in conflict, moreover, with principles of medical
ethics." The view is quoted approvingly, as representative of the opinion of
"most of the authors recommending commitment to an institution," by the
World Health Organization in 1962. World Health Organization, "The Treatment
of Drug Addicts," p. 5.
1963 - Tobacco sales total $8.08 billion, of which $3.3 billion go to federal, state, and local taxes. A news release from the tobacco industry proudly states: "Tobacco products pass across sales counters more frequently than anything else--except money" (Tobacco: After publicity surge Surgeon General's Report seems to have little enduring effect. (1964, Sept. 4). Science, 145: 1021-1022, p. 1021).
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