Methadone Madness

Delta Drive, off Larrabbee Road in Westbrook, is a complex of anonymous industrial buildings with textured concrete walls and metal roofs and signs for lawn-care companies, garage-door specialists, insurance companies, and the CAP Quality Care clinic. The clinic's lunch-hour rush is on, and a steady stream of people flows in and out. Most appear to be young, more women than men, in their twenties and thirties and wearing jeans or office clothes and raincoats against a daylong downpour. They chat and make jokes about the weather and their jobs.

All of them are drug addicts. CAP Quality Care is a methadone clinic, one of five in Maine - the others are located in South Portland, Waterville, Bangor, and Calais - that treat opiate-addicted Mainers with daily doses of another addictive drug, methadone. Most people involved with drug addiction treatment in Maine say five clinics aren't enough. But folks from Portland to Rockland to Dexter are saying - often shouting - even one more is too many.

"We've never met the demand for treatment in this state," says Kimberly Johnson, director of Maine's Office of Substance Abuse in Augusta, who estimates the number of addicts receiving methadone statewide at about 2,000. Johnson believes Maine needs at least two or three additional methadone clinics.

By law, a Maine methadone clinic can have no more than 500 clients. By late April CAP Quality Care had 573 and was taking in more under a special state waiver that allows it to have up to 610.

"There aren't enough clinic openings to take care of the need in the state of Maine," explains clinic director Susan L. Sullivan, a former Portland high-school teacher and substance-abuse counselor. "We opened up for new intakes in November, screening no more than three people a day, and almost immediately we were booked one-and-a-half to two months in advance. We used to allow people to come by at 7 a.m. each morning in case one of the scheduled three didn't show up, but we had to stop that because too many people lined up at the door."

Maine's newest methadone clinic opened in April in Calais, quietly and with little public opposition following a carefully planned educational campaign among the residents of the Washington County community. Almost simultaneously - and in dramatic contrast - promoters of a methadone clinic in Rockland filed a lawsuit against the city after their effort to open an office on Route 1 sparked widespread controversy and public acrimony. Meanwhile Bangor's city council passed a moratorium on future methadone clinics following heated public debate over a proposed second clinic in the Queen City.

In January in Dexter, a tiny rural community thirty miles northwest of Bangor, the town council, after exhaustive debate, voted to impose a moratorium on methadone clinics even though no one had ever mentioned opening one anywhere near Dexter.

it's amazing - and disheartening - to realize that only ten years ago the number of addicts in the entire state of Maine wasn't large enough to support even two clinics. "A clinic needs about 200 patients to be profitable," explains Johnson, of the Office of Substance Abuse. "When Discovery House [a national methadone clinic company] first opened in South Portland in 1995 there was already a methadone clinic, Habit Management, in operation down there. Habit Management ended up closing because there wasn't enough business for both operations."

Back in the 1990s Johnson worked for six years at Crossroads for Women, an addiction treatment center in Windham, and saw only three or four opiate addicts in that entire time. "Prescription narcotic abuse opened up the market in Maine, and then the Columbian cocaine dealers got into the heroin business," Johnson explains. "They flooded the state with cheap heroin."

Today Johnson estimates that a "relatively low " 3 percent of Mainers, or about 39,000 people, are addicted to illegal drugs, such as heroin, painkillers diverted from legal uses, cocaine, and methamphetamines. (The addiction rate rises to 7 to 8 percent when alcoholism is added.) The number is increasing, although not as quickly as during the OxyContin epidemic of 2000 to 2003, when the much-abused painkiller was blamed for a skyrocketing addiction problem.

"That's how I started, with OxyContin," says a wind-burned Rockland fisherman who has been a regular patient at the Westbrook clinic since March 17, 2003 - "my freedom day," he calls it. Now forty years old, he admits he did some recreational drug use in his twenties, but he had been drug-free for years before 2000, when spinal stenosis - a degeneration of the nerve pathways in the spine - and a lack of health insurance sent him onto the streets to self-medicate his crippling back pain.

Within months the Rockland resident, who requested that his name not be used, was an addict spending $500 to $1,000 a day and driving as far as New Bedford, Massachusetts, in search of drugs. (He also confirms longstanding reports that heroin first became popular along the Maine coast among fishermen who brought it back from southern New England ports such as New Bedford.) OxyContin at $100 for an eighty-milligram tablet became too expensive, so he shifted to heroin, which was both more available and cheaper.

"I was spending all my time chasing down drugs," the fisherman recalls. Finally, friends convinced him he had a problem, and he convinced himself that "I was sick and tired of being sick and tired."

He enrolled in the Westbrook program and for ten months made the two-hour drive from Rockland to Westbrook every day. By keeping a clean record and passing repeated urine tests that showed he was staying free of other drugs, he was able to enter a new program that allowed him to carry his methadone doses out of the clinic, first for weekends and then for a week at a time.

Most addicts still come every day to gulp down the cherry-flavored liquid - at a flat rate of $85 a week - under the watchful eyes of the nurses who distribute the drug. Some patients prefer a thin wafer soaked in Tang or Kool-Aid. (By itself, methadone has a bitter, chalky taste.) Clinics routinely open early, 5:30 a.m. or so, to accommodate clients on their way to work, and reopen at noon for late risers and lunch-hour clients.

The Rockland fisherman is older than the average methadone client in Maine, according to clinic director Sullivan. "Addiction is a young disease in Maine," she explains. "Many of our patients started when they were fifteen or sixteen years old, usually with OxyContin."

methadone doesn't cure addiction. "Nothing cures addiction," Kimberley Johnson points out. "Whether it's alcoholism or gambling or drugs, a person lives with the addiction every day." Once a maintenance dose is established, methadone works by blocking the craving for opiates without providing the euphoria.

"When people are using an opiate, it changes the brain chemistry that affects clear thinking and emotions," explains Sullivan. "Methadone allows them to have a more normal brain function. It diminishes the drug-seeking behavior and allows a better quality of life that lets addicts hold a job and have a family life."

Advocates for the treatment argue that methadone also greatly reduces the public health risk posed by needle-swapping heroin addicts, as well as the crime associated with financing a $1,000-a-day drug habit and the cost to society of repeatedly dealing with addicts who cannot control their own lives.

A sedative with a legitimate use as a painkiller, methadone is much slower acting than heroin and doesn't produce heroin's quick high, facts that contributed to a widely publicized spate of twenty-six overdose deaths in Portland alone and fifty-seven in Maine in 2002. Methadone abuse continues today, although the death toll has gone down. "People take methadone expecting an instant buzz like heroin or OxyContin," Kimberley Johnson explains. "When they don't get it, they take more, and then even more. A few hours later, the methadone kicks in, and they fall asleep and die of an overdose."

The abuse problem is further complicated by the fact that an addict's maintenance dose of methadone may exceed the lethal dose for someone who is not a regular user and hasn't built up a tolerance to the drug. As a result, Sullivan says, Maine methadone clinics have tightened up their procedures considerably in recent years, both on their own and as a result of changes in the regulations they must follow from the four different state and federal licensing agencies that oversee them. "Nothing is 100 percent," she allows, "but I think it's telling that most of the methadone on the street today is in tablets, diverted prescription medication, rather than the liquid and wafers clinics use."

Even so, methadone's potential for misuse still generates most of the opposition to clinics among law enforcement. Portland has never had a methadone clinic, for example, because police chief Michael Chitwood has a longstanding and well-publicized policy of fighting any facility proposed for his city.

Chitwood's opposition dates to his early days as a policeman in Philadelphia. "In 1966 methadone was introduced in Philadelphia as the drug that was going to cure the heroin situation," he recalls. "All it did was exacerbate the situation. The clinics became meeting places for criminal activity." He accepts methadone only as part of a treatment that leads to total drug abstinence.

as most of the rest of the nation learned before Maine, opiate addiction has an abysmal rehabilitation rate. "There are people who can quit and live without drugs for the rest of their lives," Sullivan notes, "but the relapse rate for those who attempt drug abstinence is 70 to 90 percent and up."

In the national substance abuse treatment community, many social workers and counselors still believe abstinence is the better answer. Both Sullivan and Johnson say that view is gradually shifting in Maine to allow the idea that, for some addicts, methadone is an acceptable alternative. "Drug addiction is like heart disease or asthma or diabetes," Johnson asserts. "It's something you treat, and the symptoms react to some treatments better than others."

And that means that most opiate addicts can anticipate taking methadone every day for the rest of their lives. Johnson carefully refers to methadone in its therapeutic role as a "medication" and compares it to the daily insulin shots that diabetics must take. But she acknowledges "there are a lot of misperceptions about methadone clinics among the public. Many people see [prescribing methadone to addicts] as importing another drug problem rather than a treatment for an existing one."

Johnson also says Maine needs additional methadone clinics to meet the existing need in the midcoast region and in both northern and southern Maine. The Rockland methadone patient is but one of many midcoast addicts who make the trek to Westbrook for methadone treatment. "The people who say Rockland doesn't have an addict problem are walking around with their eyes closed," the fisherman adds emphatically. "There's a drastic need for a clinic in this area."

"When I think about this, and I think about it a lot," Johnson says, "the fear in communities surrounding the issue of methadone clinics and addiction is the real story. We have this phenomenon in Maine - drug addiction - that is new and frightening to us, and the reaction is not so much denial as it is a transference of anxiety from the problem to the solution.

"The challenge is to work with communities to help them address the problem," she continues, "because if you don't address it you wind up with everyone behind closed doors. And that's a dangerous neighborhood to live in."