On February 12, Terry Gross interviewed neuroscientist Judith Grisel for NPR about her forthcoming book, Never Enough: The Neuroscience and Experience of Addiction (Doubleday, 2019). Grisel, a professor of Psychology at Bucknell University who has been sober for 30 years after struggling with alcohol, marijuana and cocaine, seemed to embrace a harm reduction perspective about drug use when she said:
I also think, though, that it’s important to ask, individually, I guess, ‘Is this drug use enhancing my life, or is it diminishing it?’ So for coffee I can say, happily, it’s enhancing my life and the costs of a little tolerance and dependence are not so bad, because I can just drink three cups. But I think that is something that we have to go into our own hearts to know the answer to.
At one point, though, Grisel shared some concerning thoughts about medication-assisted treatment:
Methadone is a pure substitute addiction so it takes the place of other opiates… It’s easier for society because it’s very long-lasting, so people aren’t going through this really intense period of withdrawal. … It’s cheap and it lasts a long time, and it makes the user not withdraw. So for the rest of us, it’s kind of a nice thing, because these people who are opiate-dependent are kind of out of the way; they’re not so hard to deal with. But for those users—especially if they’re young—it’s even harder to get off of methadone than it is to get off of say, heroin, because it lasts such a long time.”
This seriously undersells the value of methadone, which is not only a “nice thing” for society, but is also—having been shown to cut the death rate from opioid addiction by half or more when used long term—critically important for many people who use it.
It’s also unclear exactly what Grisel means about methadone being a “pure substitute addiction” for other opioids, like heroin. Taking prescribed methadone removes, for example, the many negatives associated with using a drug that is illegal: adulteration with drugs like fentanyl that occurs in an unregulated market; cost (as opposed to methadone covered by insurance); potential for interactions with the criminal justice system or the violence associated with illicit markets; and the dangers associated with having to inject quickly, covertly and often without access to sterile syringes.
Many point out that methadone causes dependence, though not necessarily addiction (addiction can best be thought of as physical dependence and/or compulsive behavior or drug use despite serious negative consequences). In this way, it is similar to some anti-depressants, for example.
It is certainly true that there are real-world negative consequences to methadone use, but these are overwhelmingly caused by societal attitudes and bad regulation, not inherent to the drug. (While methadone-involved overdose is possible, it occurs overwhelmingly when it’s prescribed for pain, used not as prescribed, or combined with other drugs.)
Heroin, of course, can also be used safely in clinical settings. But since the US doesn’t permit heroin-assisted treatment, emphasizing the ability of methadone to keep people safer right now must be paramount.
Grisel had not responded to Filter’s request for comment at time of publication. But her words risk actively encouraging the existing stigma against medication-assisted therapy—stigma that inhibits access to lifesaving services, whether in jails and prisons or in the outside world.
For years, scientists and advocates have fought against the idea that methadone and buprenorphine are “just” “replacing one addiction with another.” In the meantime, many people have died and will continue to die while the US fails to catch up with the World Health Organization and other countries on MAT access.
Photo: @USAIDVietnam via flickr