The promises and failures of methadone and LAAM
I’ve watched Methadone: An American Way of Dealing five times now. Each time, I’m taken aback by how skillfully directors Julia Reichert and James Klein present this moment—a period of peak tension in the addiction treatment community. By 1974, when the film was released, the early promises of methadone were butting up, often painfully, against the era’s difficult realities. Through interviews with patients at the Dayton, Ohio, Bureau of Drug Abuse clinic (BUDA) at the center of the film, Reichert and Klein make it clear that methadone, once hailed as the solution to the decade’s twin problems of addiction and crime, couldn’t overcome the era’s other issues: deindustrialization, Vietnam, and America’s trends toward atomization and its concomitant political right turn.
As Nancy Campbell points out in her post, “normalization” was the goal of methadone treatment: once maintained on a sufficient dose, patients were supposed to become normal, to stop acting like “junkies,” and transform into productive, law-abiding citizens. This was, in fact, the entire point of the Nixon administration’s interest in methadone, as evidenced by a memo domestic policy advisor Jeffrey Donfeld sent to Egil Krogh in June 1970. In response to rising rates of drug use and crime, Krogh was tasked with envisioning a national treatment system that would bring down both–but with crime being the greater priority. Donfeld recommended Dr. Jerome Jaffe’s clinics in Chicago as a model. “Jaffe has three goals,” Donfeld wrote, “A.) prevent crime; B.) develop productive, tax-paying people, and C.) stop the use of illicit drugs.”
Jaffe’s clinics didn’t rely solely on methadone, but opioid substitution therapy–making a legal synthetic opioid available to help patients stay away from illicit heroin–was, Donfeld believed, the fastest and easiest way to reduce drug-related crime. A year later, in June 1971, Jaffe was put in charge of the newly-formed Special Action Office for Drug Abuse Prevention (SAODAP), which helped open hundreds of methadone clinics nationwide. Jaffe clearly understood his mission. At a press conference after his new position was announced, Jaffe said that SAODAP was going to make clinical rehabilitation “so available that no one could say he committed a crime because he couldn’t get treatment.“
Methadone shows how that vision–the promise of a daily drink of methadone to curtail crime and transform addicts into productive taxpayers—failed as it transitioned between theory and practice. This was not because of an innate problem with methadone or substitution therapy (a treatment still widely used today), but rather because, as the documentary shows, by the early 1970s clinics had become problems of their own. Rather than a solution to addiction and crime, clinics became places to participate in both.
In theory, patients on methadone had more time to work. When their days were no longer spent “ripping and running” (trying to afford, locate, and use illicit drugs), “you’ve got a lot of time on your hands,” one patient said over footage of clients sleeping on clinic benches.
But to be “productive” in Dayton generally meant working in one of the factories that dominated the city’s economic core—work that many of Klein and Reichert’s interviewees said was degrading and dull. Methadone could promise “productive, tax-paying” patients, but, in practice, it couldn’t force them to work. Many patients didn’t want the stultifying, dead-end positions that were, in hindsight, only going to be available for a few years longer, before deindustrialization brought a new set of problems to Ohio. To many, a life of crime—pimping, selling watches, dealing heroin—brought far greater and more rapid rewards.
The practice of attending a methadone clinic also raised its own set of issues. Methadone was released in 1974, shortly after new FDA regulations reigned in some of the excesses of clinics that served as “filling stations” rather than legitimate rehabilitation centers. In order to receive federal support, clinics now had to offer minimum program services, including counseling, rehabilitation, and social assistance to help the patient “become a well functioning member of society.” But the sessions at BUDA didn’t seem to be working terribly well. Patients told Reichert and Klein that they received little (or useless) counseling, while footage from a group therapy session showed patients nodding out.
In order to decrease the threat of diversion (selling clinical methadone on the street), the new regulations also required patients to report every day for their dose, take it under observation, and submit to frequent urinalysis. Dr. Peter Bourne, assistant director at SAODAP, argued that this could be seen as a positive aspect of treatment, noting how daily visits allowed clinic operators to “develop a degree of rapport” with their patients.
For patients, however, the clinic’s requirements were a disturbing form of social control. Methadone was the only free and legal means of avoiding withdrawal available, but accessing it meant entering into a strange transactional relationship with the federal government—many felt clinics were reducing crime by tranquilizing disruptive communities with a dependence-causing drug. Methadone “wasn’t intended to help me,” one patient observed. “It was intended to make me stop stealing.”
But the biggest irony of the clinic, Klein and Reichert point out, was how quickly a place like that became a center for trafficking and illicit drug use. Footage of a counselor openly dealing in the parking lot (and then attending a staff meeting, where he nodded while being told to “watch out” for illegal deals) was intercut with patients discussing how they used methadone to take breaks from, but not stop, heroin use. In 1970, clinics like the run by BUDA were envisioned as a way to reduce drug use and crime–but by 1974, Methadone showed they were abetting it.
Methadone makes clear that the problems with the clinic system were evident from the start, culminating, just a few years after SAODAP spread the modality nationwide, in the mounting issues at BUDA. But what Methadone doesn’t mention, at least in this version, is that the methadone maintenance system was never intended to be the final means by which America treated heroin addiction. Shortly after the BUDA clinic opened, another treatment drug promised to solve all the problems methadone caused—and Klein and Reichert covered that, too.
According to Klein, several years after making Methadone, he and Reichert were asked by PBS to record a follow-up. They went back to Washington to talk to officials about what was being done to solve the problems methadone clinics had created.
In a short clip available on YouTube, Dr. Robert DuPont, a SAODAP official who became the first director of the National Institute on Drug Abuse in 1975, admitted that the “difficulties” of methadone treatment were much greater than he anticipated. Communities didn’t like methadone, and neither did many patients. As much as he wanted to get on his soapbox and proclaim that methadone was “just another medication,” DuPont said, “from the point of view of an awful lot of people out there, it’s dope and they don’t want it.”
But that didn’t mean medication wasn’t useful. At the five minute mark, Reichert mentions a different drug that might be used in substitution therapy: levo-alpha-acetyl-methadol, better known as LAAM. LAAM “is basically the same as methadone, with similar side effects,” Reichert says. “The difference is that LAAM lasts for about three days, rather than 24 hours.” That meant LAAM patients only had to come to the clinic three times a week for their medication, rather than every day like for methadone.
For DuPont, it was a perfect compromise. LAAM was an opioid agonist developed in Germany in 1948 as a synthetic congener of methadone, and, like methadone, it could quell withdrawal symptoms when taken orally. But LAAM’s longer acting delivery meant that, for people concerned about the problems plaguing clinics, LAAM was socially and politically superior to methadone. If patients only had to come to the clinic three times a week, DuPont speculated, issues like diversion, illegal dealing, and loitering would disappear. The problem wasn’t with substitution therapy—it was with substitution therapy that required daily attendance. With LAAM, the problems of methadone could be treated, too.
By the mid-1970s, DuPont believed that LAAM was poised to transform addiction treatment for the better, simultaneously replacing methadone and improving clinic operations. “I envision the methadone clinic as we now know it disappearing over the next few years,” DuPont declared, “and in its place will be the LAAM clinic, which I think is better for the community, better for the patients, and better for the country.”
But as we mark almost fifty years since Methadone’s release, it’s clear that DuPont’s predictions didn’t come true. Despite the drug’s potential, LAAM clinics didn’t cover the country. In fact, the drug barely got off the ground. After decades of stops and starts, research into LAAM officially ended in 2004, when its sole producer, Roxane Laboratories, halted its sale and distribution, citing evidence of LAAM’s adverse cardiac effects. Methadone, for all its system’s flaws, remains the primary opioid agonist used in substitution therapy.
This is deeply ironic, given that the drugs are fundamentally chemically similar, and the side effects of LAAM aren’t much different from methadone’s. But that’s the irony Methadone so artfully shows: despite the flaws in the clinic system, the daily distribution of methadone was already so established as a treatment modality by the early 1970s that clinics were able to fight off competitors—even ones that might have improved the patient experience—like LAAM. And it’s stayed that way. Today there are over 1,600 methadone treatment programs in 49 states, while LAAM has been led to slaughter.
Fifty-one years ago, Richard Nixon launched his war on drugs by declaring illegal drug use “public enemy number one”—a battle we now know was equally, if not more, focused on reducing crime. But Nixon didn’t immediately use law enforcement to curtail addiction. Instead, he launched one of the most sustained, widespread and well-funded treatment experiments in American history—an experiment that, as Methadone ably shows, didn’t quite live up to its promises.
A half century later, much of the drug war is being reconceptualized. There is a worthy and necessary focus on mass incarceration, racism, and social justice. But there’s more to America’s drug war than law enforcement and arrests, and I hope Methadone’s public return sparks new conversations about the lingering effects of our fifty-year-old clinical treatment system, too. Looking at the BUDA clinic and our system today—a system so ineffectual that over 100,000 Americans died of overdoses last year—should prompt new questions about what went wrong, what went right, and what we should do about it now. Back in the late 1970s, DuPont saw the “methadone clinic as we now know it disappearing.” Maybe, in 2022, it still can.
Editor’s Note: Emily Dufton holds a PhD in American Studies from George Washington University. She is the author of Grass Roots: The Rise and Fall and Rise of Marijuana in America. She was the managing editor of Points from 2014–2016 and from 2018–2020. She also served as the media officer for the Alcohol and Drugs History Society. She is currently working on her next book, a history of how the federal government has handled, and funded, the development of medication-assisted treatment (MAT) for opioid use disorder.