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Categorising methadone: Addiction and analgesia

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Abstract

While methadone was first developed as an analgesic, and used for this purpose before it was adopted as a therapy for drug dependence, it is this latter use which has saturated its identity. Most of the literature and commentary on methadone discusses it in the context of methadone maintenance therapy (MMT). But one of the effects of the liberalization of opiate prescription for chronic pain which took place in the 1990s was the re-emergence of methadone as a painkiller. This article examines the relationship between methadone the painkiller and methadone the addiction treatment as it is constituted in recent medical research literature and treatment guidelines. It highlights the way medical discourse separates methadone into two substances with different effects depending on the problem that is being treated. Central to this separation is the classification of patients into addicts and non-addicts; and pain sufferers and non-pain sufferers. The article argues that despite this work of making and maintaining distinctions, the similarities in the way methadone is used and acts in these different medical contexts complicates these categories. The difficulties of keeping the ‘two methadones’ separate becomes most apparent in cases of MMT patients also being treated for chronic pain.

Introduction

On its drug education website targeted at teenagers, the US National Institute on Drug Abuse divides opiates into two contrasting categories:

‘[Opiates are] powerful painkillers, they are sometimes prescribed to control severe diarrhea and they can also be found in cough medicine. Maybe you’ve heard of drugs called Vicodin, morphine or codeine…When used properly for medical purposes, they can be very helpful. Opiates used without a doctor's prescription or in ways other than how they are prescribed, can be dangerous and addictive. Heroin is another example of an opiate, but it isn’t used as a medicine—it's used to get high.’ (National Institute on Drug Abuse, 2009)

This statement reflects the long history of medical discourse and practice on opiates which works hard to establish and maintain the differences between the beneficial and therapeutic use of these substances, and the dangers of their illicit abuse. The boundaries between the medical and illicit are reinforced through several overlapping distinctions which frequently appear in both expert and popular accounts of opiates, but are also materialized in regulatory systems and institutional structures. Firstly, as the NIDA passage demonstrates, a distinction is made between types of drugs: morphine, codeine and Vicodin are helpful medicines, whereas heroin is not a medicine and is therefore dangerous and addictive. Secondly, the context of use is distinguished: proper use requires medical prescription, while the absence of medical authority produces addiction and harm. Thirdly, the types of drug and the context of use are linked to different effects. Prescribed opiates like morphine produce analgesia (also digestive relief and cough suppression) while illicit opiates produce euphoria and addiction. Finally, (although this step is not taken in the NIDA passage), the distinctions between drugs, contexts and effects are incorporated into identity categories in which the status of ‘patient’ and ‘addict’ describes not only the circumstances and forms of drug use but designates a type of person (Bell & Salmon, 2009).

However, the relationship between medical and illicit opiate use has always been more complicated than the NIDA website suggests (Acker, 2004). Because of its status as a substitute opiate for heroin, methadone blurs the distinction between good medication and addictive drug in a particularly intriguing and irresolvable way (and its absence from the NIDA passage is therefore not surprising). Its use as a substitution treatment for drug dependency places it in a unique position in relation to addiction. As Fraser and valentine state, methadone in the context of maintenance therapy is produced as a paradoxical substance with a double identity, it is both ‘not heroin and like heroin’; and it is both addictive and a treatment for addiction (2008, p. 55, original emphasis). As a substance that replaces heroin and is consumed by heroin addicts, methadone is stigmatised and constructed in public discourse as dangerous and disorderly (Fraser & Valentine, 2008). On the other hand, methadone is recognized in medicine and national drug policies as an effective treatment which produces stability and normality in its users (World Health Organization, 2009).

The substantial increase in the use of methadone as a prescription analgesic over the past decade and a half has added another dimension to the categorization of methadone and its status as a problematic but useful drug (Trescot et al., 2008). In this context methadone has been described as ‘a new old drug’, as it was originally developed as an analgesic in the 1930s before it was adopted as a therapy for drug dependence (Trafton & Ramani, 2009). Its renaissance as a painkiller was one of the effects of the liberalization of opiate prescription for chronic pain which took place in the 1990s (Fishman et al., 2002, Fredheim et al., 2008). The US Centers for Disease Control and Prevention reported that 4 million methadone prescriptions for pain were written in 2012. Retail sales of methadone increased by more than 1000% from 1997 to 2006 (Trescot et al., 2008, p. S13).

This article examines the relationship between methadone the painkiller and methadone the addiction treatment, within the contemporary landscape of liberalized opiate prescription. The article highlights the way medical discourse separates methadone into two substances with different effects depending on the problem that is being treated. Central to this separation is the classification of patients into addicts and non-addicts; and pain sufferers and non-pain sufferers. The article argues that despite this work of making and maintaining distinctions, the similarities in the way methadone is used and acts in these different medical contexts complicates these categories.

The separation of methadone into two substances which act either on addiction or pain is further undermined by the phenomenon of prescription painkiller abuse which has become a highly visible drug problem, particularly in the United States (Fischer & Rehm, 2007). Over the past decade and a half, in the wake of increased prescription rates, opiate medications, including those mentioned in the NIDA passage quoted earlier, have been linked with increasing rates of dependence and overdose (Compton and Volkow, 2006, Quintero, 2012). Concerns about painkiller abuse have prompted a return to a discourse of addiction which identifies addictiveness as an inherent property of all opiates, whatever their context of use.

Section snippets

Approach

My discussion is based primarily on the critical analysis of recent medical literature about (1) opiate treatment of chronic pain and (2) methadone prescription. It is in this literature that the challenge of managing methadone's different identities and effects is addressed in a detailed and systematic way. I adopt an interpretive approach informed by Foucauldian discourse analysis in which discourses are understood as regulated and systematic ways of thinking, talking and writing about a

The special properties of methadone

In the 1980s, pain specialists and patient advocates began to argue for the more liberal use of opiates as a humane and rational response to the widespread suffering produced by poorly treated chronic pain (Keane and Hamill, 2010, Meldrum, 2003). By 2000, bodies such as the American Pain Society and the American Academy of Pain Medicine had published consensus statements supporting the use of opioid therapy in chronic pain patients (Portenoy, 2000). Pharmaceutical companies also played an

Medical opiates and patient classification

Contemporary drug control policy places methadone and other opiates under strict legislative control. For example, in the United States methadone is a schedule II controlled substance, that is, a substance that has a ‘high potential for abuse’, and whose abuse can lead to ‘severe psychological or physical dependence’ (US Department of Justice, n.d.). Thus it is the addictive potential of methadone and other medically utilised opiates which classifies them as individually and socially dangerous

One patient, two methadones

As I have outlined above, some pain medicine literature suggests that pain and addiction should not be seen as a dichotomy because pain patients sometimes have concurrent addictive disorders and self-medication for pain has been identified as a possible contributing factor in illicit drug use (Gourlay et al., 2005, Savage et al., 2008). The limited research that has been done on pain among MMT patients has found that chronic pain, including severe pain, is common in this population (Blinderman

Conclusion

Medical discourse and practice has emphasized the differences between the beneficial medical use of opiates and their illicit and addictive use. As is seen in the NIDA website discussed at the start of this article, this distinction between good medicine and addictive drug is often mapped onto an opposition between analgesic effects and euphoric/rewarding effects, the latter being linked with the development of compulsive use. However, methadone, as a drug which is used in substitution therapy

Conflict of interest

None declared.

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