Course Readings

Lesson 1: Brief History of Methadone Maintenance Treatment A short introduction about how methadone started. The original team consisted of four and included Drs. Dole and Nyswander who were the investigators, Dr. Herman Joseph who did the statistics and Dr. Mary Jeanne Kreek who was a medical student at the time. Lesson 2: Methadone Maintenance Treatment and Clinical Issues by Herman Joseph An excellent document to help anyone understand methadone and why it works beginning with the initial study up to issues that impact methadone treatment today. Lesson 3: The Discovery of Endorphins by Joycelyn Woods A brief history of the discovery of opiate receptors and endorphins. It is interesting to note that the first research was undertaken in Dr. Dole's laboratory at Rockefeller. However at the time it was abandoned because the technology was not yet available and Dr. Dole was to busy with setting up methadone programs. Lesson 4: Methadone As Normal Medicine by Marc Reisinger Dr. Reisinger describes the issues and benefits of normalizing methadone treatment and integrating it into medicine. Recommended Reading Bibliography



What is Methadone Maintenance Treatment? The most effective treatment for heroin and other opioid dependence?





A means of reducing the transmission of the AIDS virus?





The most progressive and misunderstood form of substance abuse treatment?





All of the above?



The answer is: D) All of the above

Brief History of Methadone Maintenance Treatment

Methadone maintenance treatment came into being in an unexpected way. By 1963, on the cusp of the social revolution of the sixties, doctors and public health workers had concluded what objective observers and users alike had known for decades: that there was no treatment known which could cure more than a small fraction of long term opiate (heroin, morphine, etc) addicts. In fact, there wasn't even any treatment which could honestly claim to be more successful than no treatment at all! Every imaginable option had been tried, from lobotomies and insulin shock to psychoanalysis and the threat of lifetime incarceration. But in every case the result was the same: between 70 and 90 percent of these chronic addicts would return to opiates within a short time. In light of such statistics a number of prestigious panels examined the problem and by 1963 had come to the same conclusion: it was time to re-examine nearly fifty years of prohibition and consider allowing doctors to prescribe addicts the opiates they needed.

At Rockefeller University in New York City, Dr. Vincent Dole, an expert in metabolic disorders, and Dr. Marie Nyswander, a psychiatrist who'd worked at the U.S. Public Health Hospital/Prison for addicts in Lexington, Kentucky, began experiments with several chronic heroin addicts. In attempting to determine if addicts could be maintained on stable doses of pharmaceutical opiates, the volunteers were given access to the spectrum of opiates available to medical practitioners. The researchers tried everything from morphine to dilaudid, but found that it was extremely difficult to stabilize the subjects. The addicts were either oversedated or in mild withdrawal most of the time, and spent their days either "on the nod", waiting for their next shot, or comparing the relative merits of the drugs used. Reluctantly, Drs Dole and Nyswander concluded that the experiment had been a failure, and decided to "detox" the addicts and release them from the hospital. To accomplish the withdrawal, they turned to a synthetic narcotic called methadone. Methadone had first been synthesized by German chemists before World War Two, and after the war it was used to withdraw addicts at Lexington. It had the advantage of being cheap, significantly orally active, and longer lasting than opiates like morphine. For the researchers at Rockefeller, it seemed merely a convenient and humane means of ending the experiment with maintenance. As the addict volunteers had been built up to large doses of narcotics by street standards, they were given relatively large doses of methadone to stabilize their "habits" before beginning the reduction.

And then something completely unexpected happened. A few days after the subjects had been switched to methadone, and before the "detox" had begun, they began to exhibit very different behavior. Whereas for weeks they had spent their days either feeling the effects of the narcotics or complaining of their need for more narcotics, suddenly the focus of their days turned away from drugs. One subject asked the researchers for supplies so that he might resume his long neglected hobby of painting. Another inquired after the possibility of continuing his interrupted education. In short, the addicts- who when admitted to the hospital had looked and behaved very much alike -now began to differentiate. They began to manifest the potential that each had obscured during years of chasing street narcotics.

Recommended Reading Bibliography

Chapters on Methadone Licit and Illicit Drugs- The Consumers Union Report by Edward M. Brecher and the Editors of Consumer Reports Magazine, 1972.

In the Course of Professional Medical Practice (pdf format) by Vincent P. Dole M.D.. NYS Journal of Medicine 1966 55(7): 927-930.

Note: This was the first paper publishede on methadone and it is an editorial spoofing the Harrison Narcotic Act. Dr. Dole was preparing to challenge the Bureau of Narcotics (now the DEA).

Narcotic Blockade (pdf format) byDole, V.P.; Nyswander, M.E.; and Kreek, M.J. Arch Intern Med 118:304, 1966.

Rehabilitation of the Street Addict (pdf format) by Vincent, Dole, P., et al, Archives of Internal Medicine. 14(1967): pp. 477-480.

Implications of Methadone Maintenance for Theories of Narcotic Addiction (pdf format) by Vincent P. Dole M.D.. JAMA 1988 260: 3025-3029. (Written for the event of the Lasker Medical Award)

What Have We Learned from Three Decades of Methadone Maintenance Treatment? (pdf format) by Dole, Vincent P. Drug and Alcohol Review. 1994(13): 3-4.

Confidentiality - The Case of People vs Newman (pdf format) by Newman, Robert G. Methadone Treatment in Narcotic Addiction: Program Management, Findings, and Prospects for the Future (Chapter 6). New York: Academic Press; 1977.

Brainstorms (1-8) (pdf format) by Stewart B. Leavitt. Addiction Treatment Forum, 1999-2001.

Insulin as An Analogy to Methadone Maintenance (pdf format) by J. T. Payte, M.D. Jour Psychoactive Drugs 1991 23(2): 109-110. Reprinted in Journal of Maintenance in the Addictions 2003 2(3).

The Functional Potential of the Methadone Maintained Person (pdf format) by Norman B. Gordon, Ph.D.. In: Methadone Treatment Works, NYS OASAS, New York.