Doctors, Not Dealers

Photo by Alexandros Chatzidimos via Pexels.

To access methadone in America, you might have to set your daily alarm to 4:00 a.m. — maybe earlier, if you live in a rural part of the country, like South Dakota, which only has one methadone clinic. You will take your car or a bus — or two, or three — to get to the clinic. You might have to cross state lines. You will join a line of people that snakes around an unmarked façade with police presence outside. Security cameras are fastened to the walls. A sign saying “no firearms or weapons allowed” hangs on an off-white wall in need of spackling. If the methadone clinic happens to be in a building with other doctors’ offices, no other patients are there because the sun is not yet up. You’re bundled in a coat because it is below freezing outside.

“Dosing” may start as early as 5:00 a.m. A clinician hands you your methadone through the small opening of a plexiglass window and watches you swallow, confirming by asking you to stick out your tongue. Someone may watch while you give a urine sample. If you’re due for a counseling session, you will wait longer. Once you’ve gotten your dose, you head back home so you can get ready for work. But, because you’re on methadone, you might not have a job, since the treatment regime is so disruptive to one’s life.

The cycle repeats daily. There is little forgiveness or room for the unexpected realities, the needed pivots, that come with being alive. If your daily dosing is disrupted — by a family emergency, by your own trip to urgent care — your clinic might penalize you. Punishment, not care, characterizes this form of addiction treatment. I hesitate to even label it “treatment,” because nothing else I’ve seen as a doctor in my first year of residency remotely resembles it. No other medication exists for which patients are required to show up daily to receive their dose; meanwhile, patients prescribed methadone for chronic pain can pick it up at any pharmacy. Only people with addiction are forced to travel to special clinics, to wait in long lines, to submit their bodies to daily surveillance.

And yet, methadone is one of the best medications we have to treat opioid addiction. Countless studies over the decades have shown that daily doses of methadone reduce cravings for opioids; decrease the risk of overdose by over 80 percent; and lower mortality rates among users who overdose by 50 percent or more. Methadone decreases rates of infectious diseases like HIV and hepatitis C, and improves the quality of life and the physical and mental health of patients. Methadone is far more effective than abstinence-only approaches to treatment, which in many states continue to be standard of care. Methadone carries risks: low testosterone levels, constipation, arrhythmia, and like any other opioid, overdose. But OxyContin, which carries similar risks, is available for pickup at a pharmacy.

During medical school, my first introduction to caring for people with addiction was in a primary care office two flights up from a methadone clinic in New Haven, Connecticut. I heard countless stories from patients on methadone: people losing their jobs after starting treatment, having to hide the fact that they were on meds from their friends and employers, not being able to get take-home doses for years despite “good behavior,” wanting to get off methadone so they could feel free again.

“I feel shackled on methadone. I don’t want to be tied to anything, any system,” one patient told me.

Many of the clinicians who took care of these patients were not just healers, but activists. They advocated for their patients in ways I didn’t think possible, circumventing a treatment system designed to penalize and reprimand rather than care and support. They worked with lawyers and testified in front of city councils. They rode around in vans distributing wound-care supplies and sterile syringes to people who injected drugs. They protested in the streets alongside their patients and neighbors. They were part of a larger political movement, one with roots I was just beginning to uncover.

* * *

Across the US, heroin use escalated in the 1960s. Methadone emerged as an attractive treatment option, but not because it was a novel drug. US intelligence officials discovered methadone at the end of World War II while reviewing a German pharmaceutical company’s records. By 1947, US physicians were using methadone for a variety of ailments, including pain relief, cough suppression, and opioid withdrawal. In 1966, researchers at The Rockefeller University in New York City determined that fixed daily doses of the medication could curb cravings for opioids and stymie addiction to heroin. The data showed that patients who took methadone on a daily basis could remain employed, take care of their families, and return to school. (The Bureau of Narcotics and Dangerous Drugs, a predecessor agency of today’s Drug Enforcement Agency, accused the scientists of making up the data.)

Research on the medication proliferated after the Rockefeller trials. Crime fell as methadone became more widely used, and researchers and doctors posited, with little evidence of causality, that reductions in city crime rates could be attributed to methadone programs. Many of the initial methadone studies involved young Black men. Some trials were conducted on people incarcerated in jails or prisons. In these studies, graph after table after graph highlighted methadone’s presumed effect on crime reduction. Rather than focusing on individuals’ health, researchers looked at whether crime rates and drug charges were dropping, or the street price of heroin was rising, to measure the effectiveness of methadone programs.

On June 17, 1971, President Richard Nixon famously declared America’s first War on Drugs — and, less famously, embraced a newfound commitment to addiction treatment. By 1974, two-thirds of America’s $750 million drug budget was allocated to drug treatment and research, a radical departure from decades prior when most of the budget had been directed towards supply reduction. In 1968, fewer than 400 patients across America were enrolled in methadone programs. By 1976, this number shot up to 80,000.

But Nixon’s interest was in reducing crime, not necessarily treating addiction. It was the crime-reduction aspect of methadone treatment that caught his eye. His support of the medication solidified the perceived relationship among opioid addiction, race, and criminal behavior, and built assumptions about criminality into the federal approach to treatment. The Bureau of Narcotics considered addiction to be a manifestation of criminal behavior that should be dealt with by law enforcement, not doctors. In the late 1960s, federal agents surveilled clinics and the physicians who ran them, communicating with neighborhood groups and political actors who wanted these clinics gone and “addicts” off their streets.

By 1972, the FDA required that methadone be dispensed in a “closed system of clinics” — known as opioid treatment or methadone programs — segregated from the rest of the healthcare system. Physicians could no longer prescribe the medication out of their offices and patients could no longer pick it up at pharmacies. These regulations have not changed in the past fifty years.

* * *

Against this backdrop, Dr. James T. Nix helped pioneer methadone treatment. Beginning in the late 1960s, Nix started dispensing methadone in New Orleans, where he was born and raised.

His approach to methadone was unique: he was one of the only doctors in New Orleans who provided methadone from his own office. Most patients had to get their methadone from hospitals or government centers. Located on a quiet, tree-lined street, Nix’s clinic was unusually homey. His methadone patients lined up early in the morning, even on the weekends. Soon there would be hundreds. One local resident wrote to the Times-Picayune demanding Nix hire a “uniformed guard” to “keep these people within the confines of the clinic.”

These people.

Nix was no ordinary doctor. He had trained as a general surgeon, but he often worked from his house. He rarely donned a white coat. He wore sandals, a white button-down shirt, and dress pants rolled up above his ankles. He wanted to look like the patients he treated. He accepted barter from his patients — a freshly slaughtered cow leg, for example — in exchange for medical care. In the 1950s, he worked with Black physicians in New Orleans to desegregate two of the city’s Catholic hospitals.

Nix first learned about methadone from perusing medical journals. By 1970, his city was facing an epidemic of addiction: between 2,000 and 2,500 people were addicted to heroin, according to a study published by the National Institute of Mental Health — nearly three times more than the year before. And people were dying of overdose.

Nix was aware of national debates about methadone — some people in the medical community felt treating patients with the medication was substituting one drug for another. One prominent New York psychiatrist called methadone “not the solution, but the very epitome of the problem.” Black Power groups felt it was a mechanism of social control. But Nix felt differently: he believed that if it were prescribed humanely, in a way that upheld patients’ autonomy and dignity, it could restore life. In that case, how could he not prescribe it? And if he didn’t, who else in New Orleans would?

Nix’s first methadone patients were a married couple, referred to him by the priest of his church. The couple used heroin together, and it was ruining their lives. Nix’s son Jay — the owner of a successful po’boy shop in New Orleans — worked in his father’s clinic as a teenager and told me how Nix would listen intently when the couple described the highs of heroin euphoria and the lows of its withdrawal. In 1968, it was illegal for private doctors to dispense methadone on a daily basis. This didn’t deter Nix: the couple’s heroin addiction was a medical problem, and methadone was a drug that could treat it.

But local and federal government officials wanted methadone dispensed in dedicated institutional settings. In the late 1960s, New Orleans politicians called for the establishment of a 50-bed hospital that would dispense methadone. They wanted this hospital up and running as soon as possible. But Nix was not convinced that a hospital was the best place to treat patients with methadone. He felt he did not need legal permission to prescribe a medication — already available in pharmacies for the treatment of pain — that might help his patients.

By 1970, hundreds of patients flocked to Nix’s clinic to get methadone daily. This made his practice unusual, according to a Louisiana newspaper, which reported that most methadone programs required six weeks of expensive inpatient treatment with methadone and frequent mandatory counseling sessions at a government- or university-run clinic. Nix saw no need for this; indeed, he felt that patients struggling with addiction — who had already been denied their humanity — needed the freedom to decide where and from whom they sought treatment.

Nix did not offer counseling as part of his methadone program. He controversially declared that “ex-addicts on methadone need jobs, not group therapy and expensive nonproductive psychiatric consultation,” which he felt limited methadone access and benefited psychiatrists more than patients. According to the federal regulations, at least one counseling session per month is still required for patients on methadone today. Some methadone clinics require more frequent sessions.

For all this, Nix was surveilled — not by the feds just yet, but by his peers. Just one month after he started dispensing methadone, the Orleans Parish Medical Society — hesitant to embrace the idea that addiction was a medical condition that could be treated by doctors — advised that closing his clinic down “would be wise, particularly from an ethical standpoint.” They ordered that he disband his clinic within ten days.

Nix considered his medical society colleagues to be the unethical ones. In a fiery reply, he argued that his private methadone clinic could restore the rights of “the narcotic addict,” who, while “unable to pay for medical care…is still an American citizen.” His clinic remained open. He even opened a second location across the city.

By 1970, Nix’s name had leapt out of the pages of the Times-Picayune and into prestigious medical journals. His uncompromising views on methadone turned heads. He was no longer just a respected surgeon but a renegade methadone doctor who challenged prevailing medical ethics in service of patients. In a 1970 Dallas Morning News article, a reporter stated that Nix “had to defend himself because he operated (and still does) a clinic ‘maintaining’ several hundred addicts on methadone.” The reporter continued, “no one knows how many doctors quickly gave up methadone with the first breath of disapproval from other doctors, but their number is doubtlessly sizable.”

Members of the medical society brought their concerns about Nix to the most powerful medical and legal constituencies in America: the American Medical Association (AMA) and the Bureau of Narcotics and Dangerous Drugs. To the Bureau, Nix was beginning to look more like a dealer than a doctor. Henry L. Giordano, the director of the Bureau, told Nix’s medical society that his clinic was “not…bona fide medical practice…under the Federal laws and regulations.”

On a hot summer day in July 1971, agents with search warrants showed up at Nix’s methadone clinics. The agents also raided his home and the local drug store that prepared his clinics’ methadone. They alleged record-keeping violations and street sale of methadone and revoked his license to operate his clinics. Jay told me that after the raid, his father became “a criminal…overnight…he went from, wearing a white hat to wearing a black hat.”

Just two years after the raid, Nix, at the age of 55, retired from the practice of medicine. But the raid did not muzzle him. In 1971, he gave a speech at a conference held on the campus of Xavier University in New Orleans. He recounted the backlash he encountered at the hands of the narcotics agents and his medical society. He praised other methadone doctors who “exposed themselves to criminal federal indictment” simply “for being knowledgeable and following the Hippocratic Oath.” He wanted to be sure other physicians who believed in methadone were recognized as doctors who stood up for their patients — not criminals or dealers.

* * *

When I walk by a methadone clinic, I think of Nixon and his advisors plotting how methadone could further a tough-on-crime agenda. I think of the early methadone studies and their metrics: how few focused on health and most dwelled on crime, how stigma and assumptions were baked into the “evidence” that fueled the regulation of methadone. I see punishment reflected in the physical space of these clinics, and I think of Nix, and the many other providers and patients, who fought for autonomy and dignity.

Today, there are many Nixes, and their resistance is building. They gather on Zoom, in hospital hallways, in drop-in centers, and in methadone clinics themselves. More young doctors are choosing to pursue careers in addiction. They are committed to undoing the stigma of this treatment and to overcoming the history that stigma is rooted in.

They do all this because they know lives depend on it: since the 1970s, the number of overdose deaths has increased almost every year. From 1999 to 2017, there were nearly 400,000 overdose deaths involving opioids in the US. In 2020, as the COVID-19 pandemic devastated communities, so too did overdose deaths, reaching 93,000, the highest number of overdose deaths on record. Overdose deaths among Black people increased by 44 percent during the pandemic, about twice the rate of increase in deaths among white people. Most overdose deaths involved synthetic opioids like fentanyl.

Yet until the pandemic, little had changed about methadone regulation since Nix retired. Federal law requires methadone patients to show up daily, swallow their methadone dose under supervision, receive counseling, and undergo urine drug screens. To prevent patients from sharing or selling their methadone, security guards make daily “rounds,” and video cameras record clinic activity during dosing hours.

The pandemic brought a historic shift in methadone policy, when a federal waiver dramatically increased the availability of take-home methadone for patients. The policy change didn’t result in an increase in overdoses or street sales of methadone, and yet many states went back to requiring daily in-person dosing as soon as calls for social distancing ceased.

In early 2022, I joined a Zoom call with doctors, drug user union members, and addiction researchers to discuss the Opioid Treatment Access Act of 2022, a bipartisan bill that purported to increase access but stopped short of allowing primary care doctors or advanced practice providers to prescribe methadone in their offices. The anger of the participants on that Zoom call was palpable. One physician unmuted himself and let out an impassioned yell. Another physician, calling from a methadone clinic and whispering for fear of being overheard, said “I feel like I work in a prison.”

Dr. Rachel Simon, an assistant professor of medicine and psychiatry at NYU’s Grossman School of Medicine, told me, “I didn’t realize how emotional it would be to work in a methadone clinic. I take care of people every day who are impacted by these regulations. The regulations negatively affect patients’ ability to work, take care of their families, the list goes on and on.” Abby Coulter, a member of a major users’ union and an advocate for patients on methadone, has called the clinic system a “culture of cruelty” she must endure daily.

The field of addiction is one of the few disciplines in medicine where effective and relatively safe treatments are overly scrutinized rather than embraced. Even in the face of our current overdose epidemic, the regulations surrounding these treatments are governed by laws rooted in the mistrust of patients and criminalization of addiction. Meanwhile, racial inequities in access persist: providers who prescribe buprenorphine, an opioid addiction treatment administered in an office, tend to be located in white communities, while methadone clinics are disproportionately located in Black and brown neighborhoods.

To design a methadone treatment system that is less punitive, people who have been directly impacted must be a part of the change. Many people on methadone wish to see the clinic system abolished, as it has been in Australia, Canada, and the UK, where methadone can be prescribed during primary care visits and picked up at a pharmacy. Some patients, however, feel they benefit from the structure of daily dosing. Rather than being forced to abide by regulations, patients should have the option to choose what works best for them, as they do for many other medical conditions. The same forces that plagued Nix — the ones that shunned him from his medical society and shut down his clinics — are still present, if more insidious. To save lives, citing statistics will not be enough. Our coalitions must grow larger and louder. Only then might we topple the dehumanizing status quo of addiction treatment in America.

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