Unhealthful News 53 – Methadone and the urge to never be positive about harm reduction

It was gratifying to read that first sub-Saharan African methadone-based harm reduction program for injection heroin users had been introduced to Tanzania’s main city, a port of call for shipments from Afghanistan to the West.  (It is a perfect trade arrangement: We send troops to Afghanistan and they send back something that also produces adamant feelings of both love and hate, depending on who you ask.)  Tanzania’s heroin problem is not the biggest harm reduction target in the world, but every little bit of civilized behavior toward drug users makes the world a better place.

Most of the news story was a matter-of-fact presentation of the situation, and a report on the value of providing an alternative to needle sharing, which has led to a very high prevalence of HIV in the target population.  Interesting, there was no mention of the easier and less-invasive response to that problem, needle exchanges.  It is very strange to report a story that focuses on needle sharing and not even note “a needle exchange program is being considered” or “needle exchange is currently politically infeasible in this country”.  But the painful part of the report was this sentence:

Methadone is even more addictive than heroin, though it is given in oral doses meant to be small enough to produce no high.

First, that “no high” observation, presented in the article with a tone of “this is the only/right way to do it”, is often cited as a barrier to harm reduction.  For my readers more familiar with tobacco, it is the equivalent of limiting product substitution for cigarettes to nicotine patches which, unless you use several at once, leave most smokers bereft of the effects they want, even if some of the pain of abstinence is removed.  It is possible to give enough methadone that it produces enough high to attract more product switching, rather that restricting doses to unrewarding levels.  Moreover, methadone patients who are unwilling to forgo the high end up scoring heroin periodically or (if the distribution logistics make it possible) taking multiple days’ doses at once (which likely leaves them wanting heroin on the off day).

But worse is “more addictive”.  Does anyone who writes or takes seriously a claim like that even pause to ask “what would ‘more addictive’ even mean?”  Even without going on to the next logical step, asking “for that matter, what does ‘addictive’ even mean”, it seems like this would evoke some skepticism.  Even to the extent that there is a well-defined phenomenon that is labeled “addiction”, there is no associated quantification, no addicto-meter or even an index of degrees of addiction.  Thus there is no room for comparative statements.

Often the original source of such a statement was someone claiming merely that one behavior is more readily ceased than another.  This often means one takes place for more calendar time than another – e.g., alcohol is “more addictive” than crack cocaine because the typical “addict” continues to consume the drug for more years.  An alternative claim consists of counting up how often someone “tries to quit”, which can be little more than declarations of intent, and using that as a measure.  This tends to be higher for drugs that can be used more casually – e.g., smoking is “more addictive” than heroin use because the average smoker declares “ok, that’s it, I’m quitting” much more often.  Yet another quantification is how often someone starts the behavior again after stopping for long enough to get clean.  By that measure, once again, alcohol use and smoking will be “more addictive” than more ominous behaviors because once someone extricates himself from the culture surrounding use of a highly-life-altering drug it is a huge step to go back. 

I suspect that almost no one thinks any of these is what they are being told when they read “more addictive”.  After all, why would someone use a sweeping term like “more addictive” when what they really mean is something much more specific?  Actually that is pretty easy to answer, but the point is that the phrase misleads people who think they know what they are being told.

So what does today’s news reporter mean by “more addictive”.  I would guess that he has no idea.  What was the basis for the claim that he heard and uncritically repeated?  I am not sure, but either of the first two above is plausible — methadone gets used for a long time, and is not much fun so users probably want to quit all the time (however I do not know, offhand, what the relevant statistics are).  But what seems more clear than what the phrase means is that the counter-intuitive claim about drinking methadone being more addictive than shooting heroin seems to be political rhetoric disguised as a meaningless pseudo-scientific statement:  However positive a report about harm reduction is, someone still sneaks in innuendo about the evils of any intervention that does not just force people to stop.  At least in this case, the politics seem to actually be sympathetic to the poor addicted user, rather than the disturbingly common disdain that demands users suffer until they quit.

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