An Integration of Three Approaches to Addiction and Methadone Maintenance Treatment: The Self-Medication Hypothesis, the Disease Model and Social Criticism
Gelkopf, Marc, Levitt, Shabtai, Bleich, Avi, The Israel Journal of Psychiatry and Related Sciences
Abstract: The two models which have most affected theory and practice of addiction medicine have been the disease model and the self-medication hypothesis. The disease model's fundamental concept is that the addicted individual is sick and suffers from a disease. The self-medication hypothesis proposes that drug and alcohol users are attempting to cope with an underlying psychological or social disorder by means of self-medication. These two viewpoints are presented in the light of a number of specific methadone maintenance treatment and drug abuse related issues such as the question whether drug abuse is an illness of the body, the mind or society; whether the disease model really de-stigmatized drug abuse; what the correct methadone dosing policy should be; the place of psychotherapy in methadone maintenance treatment and drug abuse and how polydrug abuse should be treated. These issues are discussed and an integrated approach is suggested stressing the need for social criticism and a renewed social policy towards drug abuse in general and its treatment in particular.
The use of pharmaceuticals as maintenance for the control or suppression of chronic illness and metabolic deficiencies is not unusual practice in medicine. Methadone maintenance treatment (MMT) for opiate abusers does not attempt to "heal" a symptom or an illness by eradicating its cause, but rather aims at stabilizing the individual to allow him/her to function well in spite of an existing opiate abuse problem. This short overview followed by a discussion does not intend to be an advocate for MMT, neither does it want to enter a diatribe as to the relative advantages, disadvantages or ethical or moral aspects of this and similar treatment modalities. Instead we provide an introduction to MMT, its rationale and how this approach relates to different theoretical viewpoints in relation to a number of drug abuse/dependency issues.
Methadone Maintenance Treatment (MMT)
MMT has been widely documented in 35 years of well-conducted research and has had following the Task Force on Drug Abuse Treatment of the National Institute of Health the best results in the treatment of heroin abuse as observed in the reduction of heroin abuse, crime rate, and the improvement in psychological and physiological well being, vocational status and social status (1). The rationale and history of MMT worldwide as well as in Israel have been widely discussed elsewhere (2-4). Briefly, methadone is a synthetic narcotic analgesic compound whose pharmacological properties lend themselves well to be used for maintenance of opiate addiction (5). When administered in adequate oral doses, a single dose in a stabilized patient lasts between 24 and 36 hours without creating euphoria, sedation or analgesia. Therefore, the patient can function normally and perform any mental or physical tasks without impairment (6), as well as experience normal physical pain and emotions. Most importantly, methadone relieves the persistent narcotic craving or hunger that is believed to be the major reason for relapse (6). In sufficient doses, methadone "blocks" the narcotic effects of normal street doses of short-acting narcotics such as heroin and can lessen the likelihood of overdose should the drugs be self-administered. Because tolerance to methadone remains steady, patients can be maintained indefinitely on the same dose (6). Finally, methadone is a medically safe therapeutic medication with minimal side effects (1). In Israel about 1,700 out of 20,000 assumed heroin abusers receive MMT in 11 clinics and three buses spread over the country.
MMT pharmacotherapy has five major goals (1, 6): to prevent or reduce withdrawal symptoms; to prevent or reduce drug craving; to prevent relapse to use of addictive drugs; to restore or assist in attaining normalcy in any physiological/psychological functions that have been negatively affected by drug abuse; and to prevent or reduce the spread of HIV, hepatitis C and other illnesses caused by the injection of opiates as well as to prevent or reduce illegal behavior related to drug seeking. …