I have often thought -- over the 25 + years I've spent on Methadone Maintenance treatment (MMT) -- that perhaps the superlative proof of just how wonderfully effective MMT is, lies in the fact that so many patients do so well with it, despite the fact that the clinic system (Methadone Maintenance Treatment Programs -- MMTPs) is "designed for failure" -- i.e., the very founding assumptions of MMT clinics, to say nothing of how they actually operate, undermine patients' well being and dignity in countless ways.

MMTPs were integrated under the various states' pre-existing "drug abuse" treatment agencies. Almost without exception, these agencies (still!) operate under the "mental health" model of drug dependency, married to the AA/NA 12-step "philosophy." The result of this shotgun wedding of two modalities which are of dubious validity for opiate dependency to begin with, was the creation of an approach to MMT that combined the worst aspects of psycho-babble social-workerese, parole agencies, and the revival tent ambience of a 12-step meeting.

Methadone, as a drug for opiate maintenance, was isolated from all other drugs in the pharmacopeia and thus demonized as if it were some sort of supremely dangerous substance, requiring the kind of endlessly detailed protocols which bring to mind radioactive isotopes. Layered atop the federal and individual states' rigid rules and regulations for clinic operation have been the completely arbitrary set of policies of the clinics themselves, which were and are subject to the particular agendas of program directors -- who have what amounts to the power possessed by tin-horn dictators over patients' lives.

Clinics were -- and many still are -- staffed by clueless "counselors" -- "90-day wonders" -- whose first introduction to the concept of MMT often occurs at their employment interviews, and by "Medical Directors" who all too often are hopeless drunks, incompetents, or merely the kind of scape-the-bottom-of-the-barrel physicians typical of those who work at prisons or who restrict their practices to giving insurance company and employment physicals.

No one else in American society -- not paroled killers, not even child molesters -- is subjected to what amounts to parole without end, with (at best, and only after years) a weekly reporting schedule and submission to degrading "monitored urines" on demand -- for life. Until recently, this was the rule at most MMTPs. Although the recent changes in federal regulations are a breath of common sense, decency and fairness, they are linked to and depend upon withholding accreditation for "persuading" the clinics to come into compliance: there is no direct legal compulsion for them to do so, and many are resisting every inch of the way -- because they see these changes as a threat to their lucrative monopoly over MMT.

The new regs make possible, for the first time in about a century, the re-integration of the treatment of opiate dependency into regular medical care. Although at present this is available only to patients with a relatively long treatment history and with exemplary records, the clinics see the handwriting on the wall -- and they do not like it!

For over thirty-five years, the clinics have surrounded Methadone and MMT with mystification. They have gotten away with this largely because their creation spawned an entire class feeding off of Meathdone patients -- so-called "counselors," administrators, nursing staff, "medical directors," etc. They have learned the one lesson rudimentary for all bureaucrats -- how to create an endless series of "look-busy-and-important" non-essential (or totally useless) tasks, and how to take several paragraphs to convey information which could have been contained in one sentence. The MMTP "scam" relies upon putting the idea over on the funding public that the clinics are providing some sort of highly individualized, highly intensive "treatment" by "addiction experts," and that "counseling" (presumably of a "psychological" nature) is something absolutely critical for patient "recovery."

The truth of the matter should outrage us all: what the clinics are providing is a relatively cheap medicine its "clients" need in order to function -- and surrounding the administration of that medicine with a enormous collection of hocus-pocus pseudo- expertise and rigamarole, which not only wastes millions of tax-payer dollars, but (in many clinics) bleeds paying "clients" like a loan shark, while treating them like untouchables.

In New York State, for example, Medicaid "reimburses" the clinics at a rate of about $100 per week for each "client." Just what justifies this compensation for doling out a medicine that costs a small fraction of that, at weekly or even twice-a-month clinic visits, with a mandatory "counseling" session each month, which most patients neither want nor need?? Tax-payers have begun to wake up to the inordinate fees charged to the public purse -- for providing a service which could be performed better and more cheaply at a physician's office -- and that awareness naturally has resulted in the public balking at funding MMTPs.

Yet as bad as the bilking of the public is, the fees charged to working patients are disgraceful in many, many clinics. Patients pay $150 a week and more at many clinics -- and for someone making a near minimum wage salary, there is no way on earth that food, clothing and shelter expenses can be met while paying the clinic what it demands.

The re-integration of opiate maintenance treatment into mainstream medical practices can and must be done -- but it must be done right. Beginning with a group of well-established MMT patients, with proven track records for stability, makes sense. The critical question is the case management of those new to MMT, or of patients with less stability. I suggest making use of the experience of those of us who have done well under MMT over many years; many of us are now in our 40s, 50s and older and would welcome the chance to contribute to establishing private practice or mainstream medical clinical practice OBOT protocols for case management. We could work as mentors, and as liaison between patients and practice. We know MMT -- what works, what doesn't. As patients, it is most emphatically in our interest to see that OBOT works: we know that OBOT practices -- and their patients -- will be held to a standard demanded of no others. If a patient prescribed sleeping pills or tranquilizers overdoses, or sells his/her medicine, the newspapers, the public and government agencies do not demand that all patients receiving sleeping pills or tranquilizers begin attending a clinic daily and take their medicine in front of "staff" -- but any untoward publicity due to the actions of a few "rotten apples" could easily result in exactly that for all MMT patients again. That would not be in the interests of the great majority of MMT patients, of their OBOT physicians, of the tax-paying public (which includes most MMT patients!), nor of anyone but the clinic system "providers."