The Methadone Manifesto is a brilliant, badass, long-overdue gut punch to the antiquated US methadone clinic system. Written by members of the Urban Survivors Union’s methadone advocacy and reform team, composed of current and former methadone patients and allies, it centers the voices of methadone users. For anyone unfamiliar with what happens inside clinics, this document will be eye-opening and enraging.
In many ways, The Methadone Manifesto, published last month, builds on and expands a seminal 2001 article written by Peter Vanderkloot: Methadone: Medicine, Harm Reduction or Social Control. Vanderkloot, himself a methadone patient, railed against “Methadone the institution—the system of chemical parole that endeavors to keep tens of thousands of the most vulnerable under the thumb of a perverse and avaricious bureaucracy.” He concluded: “The methadone clinic system must go … All that is needed is parity with other medications.” Sadly, not much has changed in the 20 years since the article was published.
The Methadone Manifesto, then, is a new salvo in the struggle to liberate people from the clinic system. It is unapologetic in its criticisms. COVID-19 was clearly a catalyst that has given people the confidence to fight back. As a result of the pandemic, the DEA and SAMSHA eased restrictive take-home doses policies. Suddenly, everyone was eligible for 14- or 28-day take-home bottles. It served as a massive wake-up call, illustrating how unnecessary the status quo had been. Changing an onerous regulation that forced people to organize their lives around the clinic really was possible!
The Methadone Manifesto breaks new ground in scrutinizing the clinic system from the perspective of people with lived experience. It is written in painstaking detail and jargon-free language, backed up by 245 citations. Chapters variously examine barriers to treatment, the use of punishment and discharge, cost, patients’ use of other drugs (especially benzodiazepines) and access to methadone as a human right. The Manifesto further outlines how the system disproportionately harms people of color, pregnant people, and those impacted by disabilities and homelessness.
The Methadone Manifesto is an historic exposure of the sick culture of cruelty inherent to the clinic system. It is a fierce declaration that the fight is on to replace the system with something person-centered and compassionate.
Filter is publishing two excerpts from the Manifesto below, with permission. I would urge you to read the whole thing here.
Call to Action
While methadone is the most effective treatment legally available for those diagnosed with opioid use disorder (OUD) it is the most stigmatized and the most heavily regulated. Methadone significantly reduces the risk of overdose, HIV and HCV infection, and is the only safe supply available to people who use drugs (PWUD) in the United States. Over 1.6 million people meet the criteria for OUD in the US and less than a quarter receive methadone treatment. Even during an adulterant and overdose crisis combined with a COVID-19 pandemic, we continue to experience barriers which keep PWUD from accessing treatment. We are traumatized as we try and access treatment because many people believe we are simply substituting one drug for another. This results in shame and stigma in practices and in the recovery community. We are watching our loved ones die and our community decimated. Our trauma demands this collaborative living document detail the culture of cruelty that continues to shame, stigmatize and kill.
Our goal requires the elimination of the clinic system.
While the rest of the world responds to this crisis with safe supply options and evidence-based treatment, here in the US we have doubled down on drug war policy and coercive, abstinence-based treatment options, many of which increase our risk of death. We are the only national drug users union in the United States and we present this manifesto as our vision for change.
Our goal requires the elimination of the clinic system. Methadone dispensing should not be limited to tertiary healthcare sites, and ample evidence from Canada, Europe, and Australia demonstrates the efficacy of pharmacy and primary care dispensing models.
Throughout this document, we go over the failings of the current system and outline specific steps clinics can take to improve without major policy changes. Our next project will be the design of a model methadone clinic in this regulatory context because we know we need immediate and drastic reform.
The manifesto highlights human rights violations such as punitive responses to urine drug screenings; useless, time-consuming, mandated counseling; high barriers to take-home dose provision; stringent admission criteria and arduous intake processes; dose capping; onerous and rising clinic costs and exploitative charging practices; transportation difficulties; lockbox requirements; limited dosing hours; accelerated tapering schedules or administrative discharge; and lack of patient autonomy in determining treatment plans.
COVID-19 hit and the world economy closed. Businesses scrambled to develop safer policies allowing them to remain open and provide essential health services. Unsurprisingly, methadone clinics behaved as if nothing had changed. Our group shared stories from around the country confirming that we were forced to choose between withdrawal and COVID-19 infection risk. We were being forced to fill waiting rooms and wait unmasked for our doses. Many PWUD were already confused about the reality of COVID-19, and clinics were reinforcing their confusion. The clinics acted in line with their corporate model that reduced our treatment to a profit motive—we are nothing but a commodity to them.
People on methadone must become active decision makers in their treatment environment.
Urban Survivors led the charge for the implantation of relaxed federal methadone guidelines required to keep us safe during COVID-19. We knew that the bottom would not fall out if methadone was treated like any other medication. The fear that these relaxed guidelines would lead to uncontrollable diversion and overdose came to nothing. Urban Survivors Union championed the relaxed take-home guidelines suggested by the Substance Abuse and Mental Health Administration (SAMHSA). Our open letter in support of these guidelines and further reforms, which was signed on to by organizations at the highest levels of drug policy and the recovery community and covered by multiple media outlets, secured our place at the table.
We demand that clinics eliminate the deadly culture of cruelty and implement only the bare minimum of federal and state regulations. People on methadone must become active decision makers in their treatment environment and our treatment goals must be respected. Abstinence is not the only indicator of success. Successful treatment must always be measured by our behavior, not the chemical content of our urine.
Barriers to Treatment
Research shows that clinics regularly withhold access to methadone as a form of punishment,<1> putting people at risk for a multitude of negative outcomes.<2,3> There are no other systems in society in which people with a medical condition are at constant risk of being pulled off their medication and forced into withdrawal. This is a violation of human rights and the Hippocratic oath. Methadone clinics create a culture of cruelty, suspicion, and antagonism in which patients are guilty until proven innocent.
Patient health must always be prioritized above the profit motive or punitive moralism.
The methadone treatment system currently stands detached from true patient success, which should be defined as the reduction of harm in each patient’s life in a self-defined way. We need to push back against the idea that patients must earn their right to opioid agonist treatment by following one prescribed path. This clinic ideology proves that opioid dependence is still being treated with moral censure.<4>
Moreover, cutting someone off methadone precipitously is a form of torture, as the drug is long-acting and leads to painful withdrawal that can last for months.<5,6> We need stronger protection for patients to prevent them from being discharged and tapered off too quickly for not being abstinent from illicit or licit drugs, breaking bureaucratic clinic rules, or simply for not being able to pay fees. Clinics should only discharge patients for violence against others, and even then the process of tapering them off should be long and humane. Patient health must always be prioritized above the profit motive or punitive moralism.
<1> Bourgois P. Disciplining addictions: the bio-politics of methadone and heroin in the United States. Cult Med Psychiatry. 2000;24(2):165-195. doi:10.1023/a:1005574918294.
<2> Frank D. ‘We’re gonna be addressing your Pepsi use’: how recovery limits methadone maintenance treatment’s ability to help people in the era of overdose. Journal of Extreme Anthropology. 2019;3(2):1-20. doi:10.5617/jea.6737.
<3> Langendam M, Brussel H, Coutinho R, et al. The impact of harm-reduction-based methadone treatment on mortality among heroin users. Am J Public Health. 2001;91(5):774-780. doi:10.2105/ajph.91.5.774.
<4> Pollack H, D’Aunno. Dosage patterns in methadone treatment: results from a national survey, 1988-2005. Health Serv Res. 2008;43(6):2143-2163. doi:10.1111/ j.1475-6773.2008.00870.x.
<5> Fu J, Zaller N, Yokell M, et al. Forced withdrawal from methadone maintenance therapy in criminal justice settings: a critical treatment barriers in the United States. J Subst Abuse Treat. 2013;44(5):502-505. doi:10.1016/j.jsat.2012.10.005.
<6> Langendam M, Brussel H, Coutinho R, et al. The impact of harm-reduction-based methadone treatment on mortality among heroin users. Am J Public Health. 2001;91(5):774-780. doi:10.2105/ajph.91.5.774.
Photograph of lock box containing methadone bottles by Helen Redmond