The Institutionalization/ Medicalization of Opioid Addiction Treatment: Comparing “The Clinics” and “Methadone Maintenance”

The chapter The Clinic in “Addicts Who Survived” by David Courtwright et al. describe the time period in US history where opioid treatment had a “clinic era” (280) from 1919-1923, in which addicts were able to access narcotics in some form from these establishments. This chapter first features an interview with one of the clinic doctors/founders, a person who was addicted to opioids and utilized a clinic, and finally another physician working at a clinic. The first clinic doctor, Willis Butler, a health officer and medical examiner, describes how he was propositioned by the president of the Louisiana state board of health to open a narcotic clinic in Shreveport modeled after an already existing clinic in New Orleans. Butler describes the process of how he did not agree with the process occurring in New Orleans, similar to which also was described to be taking place in the New York City clinic described by S. Dana Hubbard later in the chapter, where addicts were given decreasing amounts of substances, however, in the New Orleans clinic they were deceived and would dilute the vials with water, whereas in New York, the patients knew they were being slowly withdrawn. Themes of stigmatization and the institutionalization of drugs and drug users arise in all three interviews featured in the chapter. In Butler’s interview he describes how every person who came to his clinic had to be fingerprinted and background checked by the FBI (284) and I wonder if this intense screening process that registers the drug user as such was a barrier to treatment for some people, especially in a time with an increasing shift towards stigma towards drug users in light of the Harrison Narcotics Act that was about to be passed. This stigmatization and desire for institutional control was especially clear in S. Dana Hubbard’s testimony about her work in the narcotic clinic in New York and her overall evaluation of drug addicts as a group of people, describing them to be selfish, cunning, and willing to do anything for drugs, a group of people in need of control, as was clear by her endorsement of the Harrison Act. 

The chapter Methadone Maintenance features the stories of three methadone patients, Sam, Red, and Jerry, and then one of the founders of methadone maintenance treatment, Dr. Vincent Dole. One of the biggest common themes expressed by the first three men interviewed was the feeling that although methadone was something that had improved their lives in terms of being able to lead a normal, functioning life, they felt trapped in a way as well because methadone maintenance is a lifelong treatment and requires daily visits to treatment centers or clinics, which are not available in all places so travel can be hard or impossible and also it can be inconvenient in daily life in general. One of the men, Red, also spoke about how methadone was a cheaper alternative to heroin and that this lifestyle was more manageable after spending mounting amounts of money on his drug habit and not being able to predict the quality of the heroin. One of the most interesting and important parts of the chapter is the section with the interview with Dr. Dole, and a point that he speaks about is the metabolic theory of addiction that there are essentially chemical hooks and dependencies involved that were permanent effects of addiction, and methadone was a solution to this, and Dole supported this idea in conjunction with the belief that in addition to methadone treatment there was a need for treatment of the underlying factors of addiction. Another important point that he speaks about is how methadone expanded rapidly in the 70s under Nixon and how this was not necessarily positive because there was not a medical and institutional understanding of the mechanisms of support needed to make methadone treatment effective. 

A major commonality between both chapters are the sections featuring the interviews from Dr. Dole and Dr. Butler, who were both pioneers in their field, and while somewhat controversial figures, they both present the narrative of caring about patients and changing the way that the system was previously set up to treat addicts as test subjects. Dr. Butler was opposed to the idea of trying to trick patients into gradually withdrawing and he was passionate about and believed in his method of treatment so much so that he fought to keep it open despite government warnings. This is similar to Dr. Dole, who describes his feelings about it being necessary to treat addicts as patients and human beings and to treat the underlying emotional causes rather than simply adopting the more standard “prison ward” and “guinea pig attitude” towards the patients (336). He was also instrumental in helping to develop addiction treatment for people who were suffering from withdrawal when they were in jail in New York City, as he described the situation of the people as being in great suffering. Similar to Dr. Butler, Dr. Dole also was not supported by the government and specifically the Federal Bureau of Narcotics tried to stop his experiments and work using methadone maintenance because it was “maintaining addicts.” This once again also highlights the common theme between the two chapters of the stigmatization of addicts as a group of people as well, as in both chapters they were treated as group needing to be controlled by the government and outside medical forces, deemed incapable or undeserving in many situations to make their own treatment decisions. 

In both chapters of Addicts Who Survived, the format is similar in the method of the chapter is to open with an abstract discussing the subject matter and giving a brief history, as well as synopsizing what the conclusions will be from the chapter as a whole, then the rest of the chapter is filled by first hand accounts from the interviewees. I think that they are both very useful and I would not say that one is more useful than the other in general, I think that it depends on the context of what they are being used for. 

One question that I was left with after reading both chapters, was comparing the two, after thinking about Dr. S. Dana Hubbard and others who were highly critical of narcotic clinics and addicts in general, I wonder how they would have felt, or did feel, years later about methadone maintenance and whether Hubbard would have considered methadone a narcotic, evil and reinforcing the identity of the addict that he described, or whether he believed that methadone was permissible under the type of treatment that he described as ideal, wherein people would detox and then go to an open-air farm of sorts until they are fully able to return to the real world and be contributing members of society, drug free (294). 

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