About | Projects | Donations | Contact | Links | Home
Return to Conference Manual Table of Contents
The Dora Weiner Foundation thanks Jocyelyn S. Woods for the use of her html code.
Medical Methadone Maintenance:
The Further Concealment
of a Stigmatized Condition.
Herman Joseph
Posted by permission of the author
In Business, Working as an Employer
Introduction
Sixty-nine former and current methadone patients were interviewed for this study. Without exception they stated that methadone saved their lives, permitted them to establish families and work across the range of employment -- construction work, skilled white collar jobs, professional careers and the owners of successful businesses. Several were able to complete not only college but also graduate and professional education. However, notwithstanding their impressive achievements, without exception they are aware of social stigma that is directed to methadone treatment and patients, both current and former. Collectively they are a closeted group of individuals who cannot reveal their enrollment in a program that has saved their lives. They have witnessed the denigration of methadone treatment not only in the mass media but within their communities, their families, at their work and in the professions including medicine, psychology, sociology and the drug treatment establishment. They are silent voices. In this section oral taped interviews were combined into narratives that not only describe the accomplishments of the patients in medical maintenance but also the fear of discovery and the stigma that is attached to enrollment in the program. The emotion that they expressed was a combination of pride in their accomplishments with the concealed shame, of a dirty secret (Murphy and Irwin, 1992). Return to top
Most of the interviews were held at the time the patients had appointments with their physicians in the morning before going to work. Therefore, the information had to be gathered within less then a half hour. Since this is a highly secretive and hidden group of persons, phone calls to the families were not made because of confidentiality issues. To preserve confidentiality, specific identifiers such as names, places, addresses and cities were omitted from the interviews. Only issues that were pertinent to the individual patients were included although certain issues such as reactions to stigma, a comparison of medical maintenance to the clinic system, and their current adjustments were covered. Return to top
Living With The Dirty Secret
The following interview reveals how the issues of stigma and concealment affect patients. The patient is married, and resides with her husband and children in a small suburban community. She started injecting heroin as a teenager because of curiosity and peer pressure and subsequently became addicted. This particular patient did not use supposed gateway drugs such as marijuana, cigarettes or alcohol before using heroin. Prior to entering methadone treatment, she mainlined heroin for about four and a half years, was arrested on minor charges and was withdrawn from heroin only to relapse. She entered methadone in 1972 and medical maintenance in 1990. About ten years ago she successfully withdrew from methadone. However, after the withdrawal she constantly thought about heroin, eventually relapsed, considered buying methadone on the street but did not want to do that and within six months returned to the program. She has been continuously in treatment after her second admission.
The only ones who know that I am on methadone in my family are my husband and my sister. My mother is deceased but she knew. My older children knew when I was going to a clinic but since I have been in medical maintenance -- I don't know whether they think I am still in the program. We never discuss it. My younger children do not know, they are teenagers. The older ones are in their twenties. My father knew the first time I was in treatment. I never told him about the relapse and that I went back to treatment. When I relapsed and went back to the program, I did not tell my husband for several months because I was ashamed. I finally told him, and he was understanding. He sees that methadone helps me. Nobody at work knows I am on methadone. On my job I work with computers, money and the public. I am considered a square. I don't smoke or drink. If they knew they would fall off their chairs. At work there is negativity about methadone and addicts. They know what they hear from the media -- once an addict always an addict and that methadone is just another drug. I would tell them that even if methadone helps a small number wouldn't that be good. They don't say anything. They just don't know. My old friends who are now in methadone programs know but I do not tell new friends. I have not told another person I am on methadone since I am in medical maintenance.
My family doctor who lives in the same town does not know that I am on methadone. I live in a small town and I am concerned about people finding out. I have arthritis and go to a specialist who does not live in my town. He knows. If methadone prescriptions could be filled in drug stores I would not use a local pharmacy. I would like to be able to fill a prescription but I do like coming to see the doctor for methadone even though I know I am doing well. I like the doctor-patient relationship. Although I have insurance that will cover the costs of medical maintenance, I pay in cash so that there will be no record in my office or the insurance company.
This researcher briefly discussed Doles metabolic theory of addiction and the character disorder theory of addiction with its implications of an emotional problem. She responded as follows:
I consider addiction a physical condition like my arthritic condition. The methadone makes me feel normal and I am able to work. I do not feel anything when I take it. I have never heard of the Dole theory, perhaps it is right. The other theories, I find, are stigmatizing. They do not apply to me. I am like your person next door. I have a family, own a home, and two cars.
This patient is also interested in community and political issues.
I go to meetings in the community and would like to participate more politically. I was asked to consider running for political office, but I am concerned about reporters finding out about my past. I do not want to embarrass my children.
About the comparison between the clinic and medical maintenance she replied as follows:
I could not work at my job if I were in a regular clinic because of the reporting regulations. I could not take the time off every week to pick up methadone. However, when I was in the clinic I did well. When I relapsed and returned I took advantage of the counseling. I am an outgoing person and was a cooperative patient always submitting urines and seeing my counselor -- I never avoided anything in the clinic. There is a big difference between the clinic and medical maintenance. In medical maintenance my whole life has been enhanced.
The major point that this patient is making is the normalcy of her current life - her family, her children, her accepting husband, her job and home. She is the neighbor next door. As Goffman (1963: 7) states:
The stigmatized individual tends to hold the same beliefs about identity that we do; this is a pivotal fact. His deepest feelings about what he is may be his sense of being a normal person, a human being like anybody else a person, therefore, who deserves a fair chance and a fair break.
This patient has followed what Goffman (1963) defines as a definite moral career. The career is of concealment to attain the goals that are important to her, to achieve a credible identity within her family, business and social life. What Goffman labels as a "virtual identity" is this patients outward credible identity -- the normal, working, family-oriented married woman as opposed to a hidden or "actual identity" of the stigmatized methadone patient. In this patient the two are both simultaneously fused and separate. With her trusted husband, sister and physician, the complete identity is known in a logical continuum that is defined within acceptable and understandable social mores. What must be hidden is hidden. The stage therefore is set for the normalcy of what Goffman (1973) refers to as The Presentation of Self in Everyday Life. The patient has her trusted team and is able to present her real self with methadone treatment further concealed in the medical maintenance program. The effect of the further concealment of methadone treatment is noted by the patient since her older children who were aware of her enrollment in the program when she was in the clinic are now not sure whether she is still in treatment.
As Miller (1974) indicated the stigma associated with methadone maintenance is derived from its status as a tertiary deviant state associated with the primary deviance of heroin addiction and the secondary deviance associated with heroin-related criminal activity. The patient has also experienced the deeply held stigma and hatred for heroin addicts and methadone patients from remarks of fellow employees. Their association of methadone with heroin -- the transfer of the stigma of heroin to methadone -- as just another drug and their inability to distinguish heroin addicts from methadone patients has justified the patients decision to remain not only hidden but to be considered the most square person in the office who does not smoke or drink.
To protect her children she must be aware of the limits on participation in social and political activities. Also, the fear of becoming the discredited person extends to her personal physician who was not informed of her enrollment in methadone treatment (Goffman, 1963). The need for concealment extends into the privacy of her home: her younger children and father are not informed about the dirty secret and her older children who are now not sure whether she is still in treatment (Murphy and Irwin, 1992).
While the "virtual identity" of normalcy is the overt stage presentation, it is the hidden, or "actual identity" of the stigmatized methadone patient -- what Goffman (1973) defines as the back stage with its team consisting of her physician and husband -- that continuously shapes her behavior in every day life. The issues of concealment and stigma as analyzed in the above interview can also be identified in the following narratives. Return to top
In Business, Working as an Employer
This narrative illustrates the effects of travel restrictions in traditional methadone programs on patients who are in business and must maintain confidentiality about their enrollment in methadone treatment. The narrator is a patient who after entering medical maintenance was able to establish a successful business.
The Beth Israel methadone program has saved my life. When I was in the clinics I had to travel frequently for business. The program arranged through TRIPS(1) that I pick up methadone in cities where I did business. I traveled with salesmen who did not know. When we arrived in a city I would first have to locate the methadone clinic and fit in the clinic schedule with business appointments. The excuses I made -- I would get up very early in the morning and sneak out. My partners would ask about having breakfast, and I told them that I just wanted to take a walk and would meet them later.
Once a clinic was slow in giving me the medication and I was late in returning to the hotel -- We grabbed a cab since we were late for our appointment and were carrying about $500,000 in diamonds that were set in gold. When we got to the department store, the manager was angry because we were late -- they had another appointment for a $20,000 ad to put in the newspaper, and they were waiting for us. This is what I went through. I cant tell you the pressure, the tension that I was under with TRIPS - the excuses and the places where the clinics were located.
Now I have my own business. I am very successful. I employ six people - three are in my family. I organized this business since I am with the doctor (medical maintenance) and pick up once a month. My wife (also a patient) and I leave at three in the morning - drive in to pick up the methadone. Why do we come into New York City? If it should get out where we live that my wife and I are on methadone our business would be ruined. It is the confidentiality. There are two methadone clinics in the state where we live and if my car should be parked in front or we are seen walking into those clinics people would talk. The business is very successful but if customers and accounts found out that I was a methadone patient they wouldn't understand they would think I was a drug addict.
Its the media. Every time I read something or see a TV show about methadone and see these professionals - psychologist and sociologist types - they call it substituting one addiction for another. This is not true - they don't know what they are talking about. When the public hears substituting they don't understand the difference between heroin and methadone. Here I am a very successful businessman with a wife, son and a beautiful home - methadone for me is medicine. I am on 80 mg. I take it once a day, don't get high and feel normal.
I tried coming down but didn't feel right. My wife detoxed but she had to go back on. We told our teenage son -- he doesn't like it that we are on the program. He feels it is our fault. We have to be careful if it ever gets out, neighbors probably wouldn't allow their children to be friends with him or come to our house - they would think we have drugs. The only people who know we are on methadone are in my family - some work for me but the other employees don't know. I don't know about detoxing. This is a medical condition. My wife detoxed and had to go back on
Here is an example of a successful family. The mother and father are working hard to provide a good home for their teenage son. The stigma is so deeply rooted that the son has rejected any explanation for their enrollment in the program. The son regards their condition (heroin addiction) as volitional -- "he feels it is our fault." He does not see methadone as a medication but regards it as another drug. The son has been brought into the family's "dirty secret" and fears that the stigma will be visited on him. The perception of his parents is painfully lowered.
The next patient is in his mid thirties and lives in small suburban community. He owns a thriving business, has a beautiful home, is married to a nurse and has a child.
When I was addicted to heroin I was wild in the streets. In 1978 I went into a therapeutic community and graduated in 1980. But I relapsed in 1981 and went into the methadone program. The clinic I was in - I was well liked by staff, had lots of friends and within 2 weeks I got a job. What I didn't like about the clinic was the negativity that I was exposed to (e.g., dysfunctional, drug using patients). Although there is a methadone clinic in the community that I live in, I could not attend it since people would eventually see me going there. If I were identified as a methadone patient I would not be allowed in places to do business. However, even in the clinic in Manhattan I had problems, a customer worked for the program and I saw some people in the program that lived in my community. I had to duck. In medical maintenance, I have a one to one relationship with my doctor and more trust than in the clinic. My confidentiality is better preserved by reporting once a month and I have more freedom to work. I do not tell local doctors in my community that I am on methadone.
Last year I had extensive dental work. I did not tell the dentist because I did not want to be looked at as one of those people (e.g., an addict). I was concerned about my confidentiality in the community since the dentist was a local dentist. I do not have a private doctor but I tell my medical maintenance doctor if there are problems.
The only ones who know I am on methadone in my family are my wife and older brother who successfully detoxed from methadone about six years ago. He does not pressure me to detox. My younger sister was on the methadone program, did very well and decided to detox. She moved to a neighborhood where she had friends and support. Everything appeared to be going well. Within a year she was dead from an overdose of heroin and cocaine.
At first my wife pressured me to detox her attitude was -- when are you going to get off, when are you going to get off -- and I decided to try. She thought that methadone was short term and even though she was a nurse she had only stereotypes. She was against maintenance. I went from 80 down to 50 and felt terrible. It was affecting my life. My wife spoke with the medical maintenance doctor and he explained everything. I went back to 80 and now feel normal. I don't get high or have any effects from the methadone and take it everyday like a vitamin. She sees that I am doing better -- in such a short time. We have a beautiful home, a child and I have a thriving business with men working for me. Everything is now normal. She sees that I can function in society. She has no contact with my medication. She now defends methadone when other nurses may say anything about it, but she has to be careful to avoid suspicions about me. She would feel embarrassed if somebody found out through the grapevine. She also tells me what they think about methadone patients if one should be in the hospital. They are put on the back burner, they are not respected.
I saw the 60 Minutes program from Texas and felt angry and frustrated. I wanted to come forward and speak but it challenged my confidentiality. I have two other friends on methadone who are doing well. I've seen it work. Methadone is not substituting one addiction for another. It does not get me high, I can work. I also believe this is a physical problem.
Question: If you saw the title of a book called Methadone Maintenance: A Technological Fix (Nelkin, 1973), what would your reaction be?
Answer: I don't like it. It is still marking me a junkie.
Question: If you saw the title of an article, It takes your Heart (Hunt, Lipton, Goldsmith, Strug and Spunt, 1985-1986) or the statement, Methadone causes a film over the emotions, what would your reaction be?
Answer: I can still cry, I can still feel. -- Who is writing this? They don't know what they are talking about.
With this interview several issues emerge. The patient comes from a white working class family where the three children - his brother and sister - were involved with heroin. The outcomes are dramatically different. The older brother who is employed withdrew six years ago and has remained abstinent. However, the sister attempted abstinence and within one year had relapsed and died from an overdose of heroin and cocaine. This patient attempted to withdraw after being pressured by his wife and was unable to.
The wife is a nurse and originally incorporated all the bias and stereotypes against methadone treatment. Initially she was not a member of what Goffman (1973) describes as "the team." The medical maintenance physician explained in professional terms the theory of addiction and the use of methadone as replacement chemotherapy. Once she understood her husbands condition, she accepted it and he was restabilized. She is cognizant of the stigma against methadone patients within the medical profession and now defends methadone but in a circumspect manner to avoid suspicions about her husband.
The third issue concerns the titles of sociology studies and papers that create, augment and reinforce stigma directed towards methadone patients, irrespective of the contents.
The following patient is a business woman. She has been a patient for about 15 years.
Methadone has allowed me to be a mother, a wife and a business woman. Before I came into methadone treatment I was addicted for about five years and tried to detox by going into a therapeutic community. I stayed there over a year, I believe. It was terrible. I don't know what they do now, but they pulled you apart, broke everything down, would not let you call your family. They were against methadone treatment but when I got out I relapsed and entered the methadone program. Since getting into the program I have always worked, and I been a model patient. At first, I was in sales and had to travel. The clinic staff was understanding but the regulations caused problems.
On business trips I was placed on TRIPS and was sent to clinics in different cities to pick up methadone. I had to be very organized. One day I would pick up in New Orleans, another day in Dallas. Plans had to be worked out about a week in advance. On one trip I was in Texas and had to fly on a Friday to Dallas to pick up my methadone about 80 miles from my business meeting. A dust storm prevented the plane from taking off. I was in such a panic that I told a fellow passenger about my situation. I actually revealed that I was on methadone. He also had to go to Dallas and was very supportive of my situation. We hired a car. I called the clinic and told them I was driving. We drove through the storm to the Dallas clinic but arrived after 2:00 PM, after the clinic finished dispensing methadone for the weekend. I explained the situation but they insisted that they had rules and that I would not be medicated. They made no exceptions and indicated that I knew I had to be there by 2:00. I cannot tell you the panic I felt. It was Friday and I was in Texas with no methadone for the weekend. I called my brother in New York and I told him what happened. My clinic in New York City was also closed.
I then boarded a plane back to New York City -- again I cant tell you the panic and anxiety I felt. My brother bought street methadone. This was the only time I was forced to do something wrong in all of my years on methadone. The TRIPS program is just not good enough if your job involves a lot of travel. At that time I was making between $80,000 and $90,000 a year on this job and they would not trust you to handle extra medication.
The medical maintenance program gave me the freedom to travel for work. At present, I have my own business which I developed on medical maintenance and work about 10 hours a day. I report once a month and attend to my business and my family. My husband is in sales. I am happily married with two beautiful daughters. The babies were born within the last seven years. I was maintained on methadone during my pregnancies. I took off time from work after the births of my daughters. The girls are doing well, there were no problems with withdrawal or other effects.
Who knows that I am on methadone -- my mother, brother and husband. My father does not know because he would not understand. Nobody in the town where I live knows that I am on the program. The press is negative and people wouldn't understand. In my mind methadone is not substituting one addiction for another, it is a medicine, and it has not only saved my life but has allowed me to have a family, a home and business. I live an idyllic life. No I don't see myself as being weak willed or having a character disorder. Methadone: A Technological Fix (Nelkin, 1973), Methadone - It Takes Your Heart (Hunt, Lipton, Goldsmith, Strug and Spunt, 1985-1986). Who writes this stuff? Some Ph.D.s wrote this -- doesn't impress me! It is not true. Of course it is stigmatizing. This gets me very angry. I am currently on 20 mg/day. I feel comfortable at that dose, no withdrawal or sleeping problems. I have no intention of getting off methadone -- I have lived a wonderful life and I see no reason to get off.
The impression of a drug addict is one who has a character disorder, weak will and is disorganized. This patient belies this image: she is organized, intelligent and building a successful business. In addition, she is a responsible mother. Her two children were born while she was a patient and neither child was born dependent on methadone. Her reaction to the titles of sociological publications was anger and disbelief.
The following patient became addicted to heroin while serving in Vietnam. After returning to the United States, he continued his addiction for about six years, withdrawing several times before entering a methadone program.
When I first entered methadone I got a lot of odd jobs working around carnivals. However, my counselor advised me to go to college and I got a BS in electronics. Then I started to get jobs in the electronics field. I didn't use other drugs, was considered a good patient and was placed on once a week reporting. I never had problems in the clinic. When I started medical maintenance, I began to build my own business, and now I am very successful with nine people working for me. I could not build a business in the regular clinic because of the reporting regulations. I have my own home, but nobody in the town where I live knows I am a patient. My family knows but they do not accept it even though I am very successful -- more successful than my brothers who have technician jobs. They only want to know when I am getting off. They have never told me that I am doing great. I am on 90 mg, feel fine, don't get high and am able to do all types of work without any effect from the methadone. My employees do not know that I am a patient. People, if they know you are a methadone patient will think you are an addict and look at you differently. Medical maintenance is much better then the clinics, I report once a month, it is faster, the doctor will change his schedule if I can not make it. Most of all, nobody knows you are in the program. The confidentiality is better.
This patient brings up an important point. His family does not accept methadone treatment and has never encouraged him even though he is more successful than his brothers.
The next patient became addicted to narcotics while in the army in the 1960s. After returning home he continued to use heroin and after several years of addiction and attempts at withdrawing.
When I first came on methadone, I worked at several jobs. I also attended college, got a degree and got married. However, the problem with the clinic was the reporting regulations. I never had problems with the staff, they cooperated but the hours I put in at work and the travel really made the clinic program inconvenient. When I was transferred into medical maintenance, I was able to work and expand the business without worrying about the clinic schedule. Now I am the owner of a very successful business.
Who knows that I am on methadone? My wife is the only one. I am the most successful person in my family and belong to social clubs in my community. All of this can be destroyed if they knew I was on methadone. I have two teenage children -- they do not know. Medical maintenance helps me hide the fact that I am a patient. There are no daily bottles of methadone to hide -- just a months supply of tablets that fit into a small medicine bottle. I am on 50 mg/day and feel no side effects. I feel normal. I associate with many people in my business, family and social life. Nobody can tell I am on methadone. If they did it would destroy everything because people rely on me.
It is the publicity. One night I was watching a TV show about Rikers Island. They showed the prisoners taking methadone. My teenage son also saw the show and indicated that all they have at Rikers are heroin addicts. I did not say anything.
This patient demonstrates the fear of social ostracism which is so great that he can only confide in his wife. He rightfully fears that the knowledge of his current treatment can destroy his business and social status -- unraveling everything he has worked hard for, including the respect of his own children. Return to top
Working As An Employee
Methadone patients work at a variety of jobs. They perform jobs that demand skill, intelligence, good coordination, and in some cases physical risks such as working on scaffolds. The following patient is a highly skilled construction worker and electrician with a 20 year safety record.
I've been on methadone since 1972. Before I was on methadone I used heroin for about seven years, must have had about 11 convictions and spent a few years in jail. I learned electrical work in jail but was never able to hold down a job until I got on methadone. I've been working on the same job for about 20 years. None of the bosses know because I would be fired. IM on 100 mg/day and I feel fine - normal - no side effects. I work on scaffolds, and extension ladders up to 30 feet, walk over rooftops and install electrical wiring. In 20 years I have never had an accident on the job! At night I teach twice a week at the union school. My hobbies -- I race boats and have lots of trophies. If they knew I was on methadone they would not let me race -- they look at it as a drug! You cant even drink beer before the race, that's how strict they are. They do not let liquor near the boats, so they would not let methadone.
Everybody in my family knows I am on methadone. My family has only seen the good that methadone has done. They remember the stealing when I was addicted to heroin. They cant understand the negative publicity. Every time I read an article - like the Village Voice - they only present the negative never the patient like myself who is working.
I never had too many problems in the methadone clinics. Sometimes the nurses had an attitude. I was on once a week for years because I always worked and never had a dirty urine. Medical maintenance makes things easier for me. I can work overtime, teach at night -- no problems. However, there is stigma. Once I accidentally cut myself and had to go to a hospital clinic. Everything was fine until I told the nurse that I was a methadone patient. Her attitude changed immediately - you could see it in her face. No, I don't consider methadone substituting one drug for another. I don't get high and I can work, I don't get arrested.
Everyone in this patient's family knows about his enrollment in the program, is supportive of him and accepts the medication. They do not understand the negative publicity because of his dramatic improvement while on the program. Yet, he is cognizant of the stigma in his work and social life.
This particular patient has worked for a federal agency and received several promotions. He is now in an important position supervising over one hundred people.
The only one who knows I am on methadone is my wife. My parents, brothers and sisters do not know and I am not going to tell them. Its been about 17 years that I've been in treatment and have not used heroin. They will not understand I still need methadone. They think that I stopped using drugs. None of my friends know. The publicity is so negative. I saw the 60 Minutes show from Texas - it was all one-sided. While on methadone I got a job and received about five promotions. Today I supervise over 100 people. I have also gone to college and got a straight A average. IM on 60 mg/day. I feel normal at this dose. Medical maintenance does not interfere with my job. I pick up once a month and nobody knows.
However, I hated the clinic - if you were the president of General Electric you would still be treated like a junkie in the clinic. Once you walked in the door and had to stand on line with patients who were still using drugs - I used to get an anxiety attack being exposed to all of this. Also the hours were not good in the clinic -- from 6:00 AM to 2 PM. The clinic and my job were in opposite directions from my house. Sometimes I would have to sneak out of my job leaving my station and supervisory duties to get the methadone. This is something you don't do if you want a promotion. Here (medical maintenance) I am treated like a patient. The once a month reporting does not interfere with my job and if a problem comes up at work I can call the doctor and make other arrangements to pick up.
This patient cannot reveal his enrollment in methadone treatment to his family. The narrative also demonstrates the need of medical maintenance for a group of patients who find the clinic system degrading and bereft of dignity. (2) For this patient the methadone clinic did not enhance his functioning, but impeded it. The medical maintenance program restored his dignity and assured this patient that his job concerns will be respected and further progress in life will not be restricted.
The next patient is a highly skilled health care worker. She was addicted to heroin for about eight years before entering methadone maintenance.
I was what you might call a controlled addict. I started to use as teenager among friends. But I was careful with needles and from whom I bought drugs. I never had to sell myself in the streets, I've had a lot of close calls but I always managed to get drugs since I was always working - I was one of the lucky ones, I only used about two bags a day to keep me straight. My family thinks that I stopped using drugs. They are strictly middle class and do not approve of methadone, and that includes my two sisters. My father is an engineer and my mother a school aide. My sisters have good jobs -- one in a bank and the other is a medical professional. Still the stigma against methadone is so great that I cannot tell them.
On methadone I was able to complete college and take professional courses. I now have a wonderful job which demands a lot of responsibility, education and skill. My boyfriend is also a patient and an engineer. I have friends who are on the program. Many of them went through therapeutic communities and 12 step programs only to relapse. I was in two clinics before being transferred to medical maintenance. One clinic was horrible, the staff had attitudes about the patients. I transferred out and the second clinic was much better. The staff was interested. However, as I began to work, the reporting regulations interfered with my job. Medical maintenance is perfect. I like my doctor. If I cannot make my monthly appointment because of a job conflict I can call and make other arrangements. Right now I work about 70 hours a week and am on 90 mg/day. I have received small increases in my dose. I did not feel comfortable on lower doses. At 90 I am able to function, don't feel high or have any effects from the methadone. However, I do feel some withdrawal before the 24 hours -- I will discuss this with the doctor, if the 90 level is sufficient. Methadone has allowed me to live without compromising my ethics or values, which may not have been possible if I continued to use heroin. This is very important to me.
Unfortunately, there is a lot of stigma against patients and ignorance about methadone in the health professions. I am considered very competent and skilled. Physicians trust me since in my specialized field I know practically as much as they do. This has given me a great deal of satisfaction. I work with highly skilled professionals -- If they knew I was a methadone patient I would either loose my job or be restricted in my duties.
I have lost one job because a nurse in my former clinic left, and obtained a job in the agency where I was working and obviously informed the management since they laid me off within a few weeks after she got the job. I reported this to the Legal Action Center. They said I had a case but I did not pursue it because it would have meant divulging my status as a methadone patient to a number of agencies.
This patient comes from an upper middle class family with a strong work ethic and value system. Methadone has helped to maintain these values which would have been destroyed had she continued using heroin. She has become a skilled professional and is cognizant of the biases within the medical profession that are directed towards methadone treatment and patients. Also, in this narrative is an example of the bias within the methadone treatment system. She was enrolled in one clinic where staff attitudes towards patients were punitive.
A patient who works for a major corporation as an electrician advised that he was employed by the corporation about 20 years ago and that personnel knew he was a methadone patient when they hired him. However, he relates the following:
I have an excellent safety and attendance record. I also have received good evaluations. For the past 20 years I have had to take urine tests about every two months (120 tests). Theater all clean. I've never used drugs since I've been in the methadone program and the urine tests in the methadone program are all clean. Drug users at work are placed in special programs. If the other workers find out they don't associate with you. So nobody I work with knows that I am in the program. I never got a promotion and I think it was because of the methadone. They have no complaints about my work. After 20 years they are still taking urine tests. Who knows I am on methadone - people in the personnel office and my wife -- she knows that I am a good man. My children do not know. Medical maintenance lets me work overtime. The clinic hours were very hard if you had a steady job.
This is an example of the deep rooted bias. This patient has a good work record, yet he is not trusted. After twenty years on the job he is still subjected to random urine tests and has never received a promotion.
Another patient is employed as a window cleaner on skyscrapers. He has been employed in this work for over 15 years since he was on methadone.
I never had any problems in the clinic. I always worked as a window cleaner on skyscrapers. Nobody at the job knows. I've never had an accident and work on scaffolds and even attachments to the buildings. The reason nobody knows is that I work with two other men on scaffolds and any worker can refuse to go up on the scaffold if he feels it is not safe. I cannot tell my boss or the other men that I am a patient because they would not work with me. I am considered a good worker and the men trust me. With medical maintenance I can work overtime. My wife is the only one who knows I am in the program. I am on 50 mg/day. The methadone has no effect - at work I am very steady and work on buildings over 50 stories high.
This narrative demonstrates that patients are capable of performing dangerous work However, because of the misconceptions and the image of methadone patients he cannot divulge his enrollment in the program.
The next patient is a retired counselor. He is also diabetic and is treated by his medical maintenance physician for both conditions. He has been admitted to the diabetic practice where he is treated for diabetes and receives his monthly supply of methadone. He related the following:
Compared to medical maintenance, the clinics were impersonal and dehumanizing. You stood on line and waited for your turn. However, I did well in the methadone programs - never had any problems - it saved my life. In medical maintenance it is more personal. The doctor talks to you and is interested. Practically everybody I know knows I am a diabetic, but not too many people know I am a methadone patient. I am a little ashamed of this dependency. I tell people I am taking insulin what's wrong with me taking methadone to stop killing myself.
This patient demonstrates the power of stigma and bias directed towards methadone. Even though the patient worked in methadone treatment, he is open about his diabetes but circumspect in admitting he is a methadone patient. This patient has two metabolic diseases: diabetes which is treated with insulin and is socially acceptable, while the other, opiate dependency treated with methadone, is not.
One patient has a career that involves international travel and refused to be tape recorded because of confidentiality. He believes that his career would be placed in jeopardy if it were known that he has been a methadone patient for over 25 years. Several years ago he withdrew from methadone but had to be restabilized. Currently, he is on 50 mg/day and indicated that he feels normal and is not impaired from the medication. He advised that he would not have been able to develop an international career if he were treated in the clinic system with the rigid reporting regulations. Return to top
The Stigma of a Yawn
Goffman (1973) stresses the performances that persons create in everyday life. Performances are essential for patients to conceal the discreditable state of being on methadone. These performances include the control of calculated behaviorisms to emphasize normalcy or simulate behavior that adds to the performance - that of the creditable productive person. The small gesture may reveal the invisible stigma. As Goffman (1973: 52) asserts:
... a performer may accidentally convey incapacity ... by momentarily losing muscular control. He may trip, stumble, fall; he may ... yawn, .... scratch his body, ..
Of all the incapacities the yawn is the most innocent, yet for the methadone patient, the yawn is the most dangerous -- it may convey the impression of a narcotized state. As Goffman (1973: 66) states:
Whether an honest performer wishes to convey the truth or whether a dishonest performer wishes to convey a falsehood, both must take care to enliven their performances with appropriate expressions, exclude from their performances expressions that might discredit the impression being fostered, and take care lest the audience impute unintended meanings.
As one medical maintenance patient who is in the field of merchandising and design indicated:
I have a demanding job. I travel, buy and select merchandise. Medical maintenance has enabled me to work long hours and to travel extensively on foreign and local business trips. My job involves international and exotic design. I could not do this job if I were in the clinics. I am seen as a hard worker and eventually I would like to have my own business. Suppose everybody knew I was on methadone. Its not that I would be blamed if a pocket book were missing in the office - I wouldn't since this rarely happens and IM out a lot. But if I yawned in the office and felt a little tired, they would think I was stoned on methadone.
The methadone patient, therefore, must guard against the most harmless and ubiquitous act, to maintain as Goffman (1973: 51) states, expressive control. What happens when the patient reveals to friends that she or he is a methadone patient. One medical maintenance patient relayed the following:
I work in management and put in very long hours. I am also registered in graduate school for my masters. Recently I told two close friends that I was on methadone. I tried to explain it but they now insist that I try to get off. Before they knew I was a patient, they accepted that I was tired after a day at the office and school. If I yawned or went to sleep early -- this was normal. Now if they see me yawning or going to sleep early it is not accepted as normal but that the methadone is causing me to yawn and be tired. Before I was napping, now I am nodding.
This is getting me quite angry ...I feel no effect from methadone. The only reason I told these two friends is that nobody knows I am a methadone patient and I wanted someone to know. I told my two closest friends and now I am almost sorry that I did.
The patient in her personal life became involved in a double bind situation - to tell or not to tell the truth to her close friends. The result at best could be considered ambiguous - it has distorted the friends perceptions of the patients behavior. This is an example that the majority of all methadone patients face, they cannot divulge their accomplishments while on methadone or the perception of their normal behavior will be distorted.
The expressive control of small inconsequential acts becomes a major conscious scenario for patients who have revealed themselves. Methadone patients who are out of the closet must convince their audience that methadone does not impair functioning or alter their conscious state. They are normal people pursuing a career within conventional society. The following patient revealed her status as a methadone patient and sought to resolve issues related to mythologies about possible impairment from the medication:
I attended NYU Law School while maintained on 90 mg of methadone a day. The methadone has no effect. This is my dose and I feel normal. After graduation I passed both the New Jersey and New York Bar examinations. However, I decided to reveal my status as a methadone patient since they asked about drug abuse and criminal histories. I wanted to be honest and reveal my enrollment in the program rather then not tell the truth. I wanted to avoid problems if anybody should find out about my enrollment in a methadone program in the future. The New Jersey Bar refused to admit me to the bar unless I went through a hearing about my character and methadone treatment. The New York Bar indicated that they would accept the decision of the New Jersey Bar. The New Jersey Bar put me through a cross examination for hours. The most intimate questions were asked about my relationships. At one point I wanted to close my eyes and pray silently that I get through this ordeal. But I realized that if I closed my eyes or had an itch -- if I scratched -- this might be misinterpreted by the legal committee as an effect of the methadone. I had to watch everything I did -- my mannerisms, my movements -- I was very conscious of the smallest movement. Finally, they agreed to let me practice but only under the close scrutiny of an approved lawyer. I was never so humiliated in my life. I was an exemplary patient for over ten years, never had a dirty urine and they were going to treat me like a delinquent attorney who needs supervision. I was so angry that I hired a lawyer and took the case to the New Jersey Supreme Court and won a reversal of the decision. I am now able to practice in both states without being supervised. However, they did not make this a written precedent making decision. Methadone patients in good standing who follow me will have to go through the same procedure. Return to top
Favorable Discharges
Seven of 11 patients who were discharged in good standing were contacted. Six of the seven still regarded the stigma of methadone as very powerful even though they were successfully withdrawn and have not relapsed to heroin use. All preferred medical maintenance over the clinic system because of the restricting rules and regulations. The following are summaries of contacts with the former patients.
Although methadone has saved their lives and they were able to build successful business while on medical maintenance, five of the six are unable to reveal their former status as methadone patients to business associates and friends. Return to top
The Stigma of Pain Medication
Methadone patients are not the only ones who are stigmatized by the use of methadone. Patients with serious chronic conditions involving malignant and nonmalignant pain are now being maintained on opioids, including methadone for relief of pain. The procedures vary but the regimens are successful in relieving pain and allowing pain patients to resume functional lives.
However, these patients are experiencing the social stigma reported by methadone patients. In an article by Elizabeth Rosenthal (1993) for the New York Times, it was reported that probably the pain treatments worst side effect is social stigma. One pain patients husband, a physician, tried to sabotage her treatment by telling pharmacies not to fill her methadone prescriptions since she was an addict. The article concluded with a comment by a pain patient who indicated that:
IM not doing anything wrong or illegal, but I feel like I am every time I go to the pharmacy. Each time you confront your fears of being discovered and their bias. In a sense it would be easier to have cancer. Return to top
Discussion
Medical maintenance treatment is an exemplary program to expand the patients life opportunities and at the same time to better conceal the stigma of methadone treatment. This holds for the patients currently enrolled in the program and those who were withdrawn. Unfortunately, the stigmatized status has also been transferred to pain patients treated with opiate medications that may include methadone.
The problem of stigma will be difficult to resolve. American society perceives addiction as a behavioral disorder -- a blemish of individual character (Goffman, 1963). Acceptable solutions to addiction have targeted the blemish with legislation, imprisonment and therapeutic approaches that attempted to rid the blemish. Theories that conceptualize addiction to include biological factors as the primary cause have not been accepted as legitimate since the perceived character blemish has not been extirpated.
The first step in the reversing of stigma rests with the medical profession claiming addiction as a metabolic disease. This is beginning to occur with the emergence of neuroscience. Also, the American Society of Addiction Medicine is beginning to adopt and support positions concerning the legitimacy of methadone maintenance as a procedure that can be placed within the mainstream of medical practice. The report issued by the Institute of Medicine (1995) recognizing the effectiveness of methadone maintenance treatment can facilitate its acceptance within the medical profession.
Secondly, successful patients are the creditable proof that methadone treatment can work. Few successful patients can now come out of the closet. However, with NAMA helping to organize local advocacy groups, methadone patients have begun to demand the respect and dignity that they rightfully deserve. Return to top
About | Projects | Donations | Contact | Links | Home
The DWF site is a historical archive. With the exception of this message no content has been altered or changed in any manner. Many links will no longer work, most email addresses and phone numbers are outdated (unless you have access to a time machine that connects with the 2000s). For a present-day organization based upon similar concepts (circa 2015) you may want to try visiting GITA.
| Rebooted by MindVox Corporation | Thanks to Clear Sky Recovery |