Thursday, December 27, 2007


Two specific words that have been criticized are "blockade" and "substitution." Here are some thoughts - and comments are welcomed as always.

Over the years many have made the same observation that "blockade" is an unfortunate term (so is "antinarcotic agent" which dole and nyswander also used in a paper presented in London in 1967 and reprinted in Br J Adict, 1968, vol. 63, pp55-57. Blockade is not an action of methadone; it is an unscientific (and probably misleading) term that simply refers to tolerance, a phenomenon that any 1st or 2nd year med student understands and virtually all physicians have experienced to their frustration and their patients' pain.

As for "substitution" - D and N criticize in the paper cited the term in a very specific sense: " needs to be well understood that methadone can be used as an antinarcotic agent, blocking the euphorigenic action of narcotic drugs rather than substituting for them." So certainly, they condemned the notion that methadone treatment provided a substitute high I doubt, though, that D or N would have cared in the least (they almost certainly would have applauded) advocates who shouted from the rooftops that methadone maintenance substituted a legal medication that enhances and prolongs life for an illegal substance that is associated with horrendous costs of suffering, sickness and death (as well as terrible consequences for the community).

I know it's presumptuous of me, but based on my long-standing and close relationship with D and N I am convinced they would focus on practical issues: they'd be thrilled that in Germany and Switzerland, for example, care is available to all who need it, from community-based generalists as well as "programs," with relatively modest constraints - even though in those countries the term "substitution" is almost universally used. By the same token, i'm convinced their horror over the therapeutic tyranny practiced in so very many USA "programs," and the severe limitations on access to humane and respectful community-based treatment, would not have been mitigated in the slightest by virtue of the strong and indignant campaign to get rid of the term "substitution."

Sure, in the best of all worlds where we had no major concerns except semantics, we could all push for the most correct and precise terminology. But in USA, with virtually no one seemingly giving much of a damn about the fate of the estimated 80% of heroin dependent folks having no access to care, I feel a semantic preoccupation is a diversion. And the other 20% who do receive methadone treatment have far far more serious problems - problems associated with the exercise of power by "program" staff who all too often demand they accept "contracts," make medication a function of meeting "contingencies," videotape their urination and terminate patients whose urines are "dirty" - etc. Don't mean to generalize - but God knows these are not issues to trivialize either. And I do respectfully suggest they should be far, far higher on the list of priorities to criticize than semantics.


At 3:51 PM, Blogger Rokki-NAMA said...

One of the first things I learned when coming into Methadone Advocacy is every Advocate has their own flavor in how they do things. Each patient Advocate may find various stigma's to take on,as there is so many. One Advocate may fight to change language as they see it as a hindrence to ones Recovery. Another Advocate may take up a fight that providers not re-use take homes bottles for years,which is so gross and has no place in Any medical Care. My point being there is enough Stigma to go around and in the process we are making medical care better for future patients and patients who have lived their lives in Fear of not knowing what to expect when they get to the program to get their medication. Which is pretty much the standard these days.
So I will continue to educate about language as it's important to me and others,just I continue to fight many forms of Stigma. Pick One.

Roxanne B

At 10:35 PM, Anonymous Anonymous said...

Dole understood tolerance better than any scientist, physician or student of the 20th century and understood that tolerance was the basis of what he observed and accurately described clinically as a blockade effect. He thought very deeply about this phenomenon and it led to a paper entitled the Biochemistry of Addiction which in turn led to the discovery of the opiate receptors --- one of the great seminal papers.In summation he regarded addiction as a deficiency in the functioning of the endogenous opioid system and methadone as a medical corrective treatment for this condition.


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