Mainstream science is catching on to what many opiate addicts have known all along-- that for many people, opiate abuse may simply be the most obvious symptom of a pre-existing biological dysfunction of the brain. Many opiate addicts report having persistent feelings of depression, anxiety, and other psychological symptoms long before drug use. The discovery that heroin made them feel "normal," even for a short period of time, precipitated the cycle of addiction, of trying to feel good all the time by administering more opiates (and eventually administering more and more opiates just to avoid withdrawal). Dr. Jean-Jacques Deglon, author of the report A Survey of 40 Years of Methadone Treatment, describes this process: The near miraculous psychological change described by many of our patients with
psychological
difficulties, when they first use heroin, strongly contrasts with the usual
indifference of
patients having received morphine in hospital and who never felt the need to
continue once
outside. For the former, it is as though all their lives they had seen only in
black and white and
that, with opiates, they could at last see in colour. Their determination to
maintain, no matter the cost, this better
quality of life is understandable.
Today, new genetic hypotheses are suggested. Some subjects could suffer genetic defaults from birth. Particularities involving certain genes would entail the dysfunction of certain chemical neuromediators of the brain or their receptors (50, 52). These subjects would then also be particularly sensitive to the effect of drugs and more prone to develop an addiction. Adolescents with psychiatric disorders, such as borderline personality disorder, depression, psychotic symptoms, obsessive-compulsive disorders or hyperactivity with attention and concentration deficit, feel better on a psychological level, at least at first, with heroin, and are then tempted to perpetuate that appeasement.
The unique imbalances experiened by opiate addicts have been historically impossible to correct:
The relative inefficiency of antidepressants and neuroleptics in regulating this state of deficiency compared to the “miraculous” action of substitution medication, that often normalises observed disorders in a few hours, enforces the medical hypothesis of a disturbance in the functions of the opioid and dopaminergic systems (20, 21, 22, 55). (Deglon)
A heightened stress response, hypervigilance, depression, anxiety, asthesia, anhedonia, and sleep disturbance are some of the symptoms caused by these imbalances. Doctors have tried using a host psychological drugs, shock therapy, and even lobotomy to correct the dysfunctions and stop addicts from using to no avail. It seems the only thing that corrects the imbalance is an opiate, but short-acting opiates like morphine fail to stabilize patients. They only create the familiar cycle of euphoria and withdrawal and foster the continued obsession and compulsion that accompanies addiction. Methadone changed all that in the 1960s with Dole and Nyswander's ground-breaking study:
Treating heroin addicts with methadone substitution began in the USA in the sixties after the almost systematic failure of psychotherapies and short term weaning programmes. Prof. Vincent Dole, specialist in metabolic illnesses at Rockefeller University of New York, successfully tested the use of methadone, a substance synthesised by the Germans during the Second World War for morphine withdrawal.The first clinical results are remarkable. Heroin addicts on methadone remain normal, without euphoria or withdrawal, abandon delinquency and are able to reintegrate themselves on a professional and personal level.
Although many opiate addicts may have been born with these genetic dysfunctions, long term heroin addiction also causes biological dysfunctions in the brain.
A state of deficiency is often observed following a fast weaning from heroin or methadone,
more particularly after a long period of addiction (16 to 19). This state is characterised by deep anxiety, sleeping disorders, marked asthenia, fatigue, irritability, low self-esteem, relational difficulties, diminished cognitive functions (attention, concentration, memory), depressive tendencies, etc. This now well defined syndrome can last, in a more or less marked manner, from a few weeks to many months. It sometimes even seems irreversible, evoking a lasting malfunction of complex neurobiological regulation systems in the brain owing to opiate exposure that was either too long or too excessive. The psychological suffering that is brought on by the state of deficiency associated with the memory of pleasure states set off by the drug easily explains the frequent relapses of drug addicts. The relative inefficiency of antidepressants and neuroleptics in regulating this state of deficiency compared to the “miraculous”action of substitution medication, that often normalises observed disorders in a few hours, enforces the medical hypothesis of a disturbance in the functions of the opioid and dopaminergic systems (20, 21, 22, 55). (Deglon)
The dysfunctions caused by long term opiate addiction are similar to the proposed pre-existing dysfunctions, making a case for long term methadone maintenance rather than a prolonged weaning process with total abstinence as the ultimate goal.
The relapse rates of methadone maintained patients have caused a sense of alarm-- that the failure to get off methadone is somehow attributed to the "strong-hold" of methadone and not to the underlying biological processes that have been profoundly damaged by many years of opiate addiction. Subscribers to this distorted thinking tend to view methadone in the same context as illicit drugs, rather than viewing it as a maintenance drug that corrects a dibilitating imbalance. If the brain fails to heal itself, those imbalances will reappear after weaning, leading to relapse in an attempt to correct the psychological symptoms.
Moerover, the state of deficiency reactivates reflexes conditioned by heroin, which often entails relapse (23 to 41). In 1979, Newman published a remarkable study (42) with 50 well stabilised patients using a double blind procedure (both therapists and patients were unaware). After 30 weeks of weaning, 90% of patients relapsed or presented a psychological decompensation. Only one patient (2%) was able to be weaned off of methadone without any problems. The results indicated a 98% failure to wean the subjects off of 1mg of methadone a day. This historical study consolidates the medical hypothesis that an important neurobiological basis facilitates and then maintains addiction (20, 36, 43, 44, 45). (Deglon)
Although the disease concept of addiction has been long-established, it has been tainted by the underlying idea (based on the tenets of the 12 step programs) that addiction is a disease of the "spirit" rather than the physical body and that medical treatments are worthless-- that addiction can only be treated by a spiritual program. If addiction is to be treated as a medical disease, it must be accepted as a disease like any other (that happens to manifest in a unique way). Some addicts can abstain from drugs without the use of a stabilizing medication, but many, who suffer the psychological consequences of brain dynfunctions caused by their addictions, must utilize a medical therapy such as methadone or buprenorphine. This is in no way meant to undermine the importance of psychological therapy and holistic treatment, but to encourage their use in combination with medical treatments. In many cases it is absolutely necessary to biologically stabilize the patient before other treatments have a chance of being successful.
For the last 40 years substitution treatments have proven their efficiency. They have enabled hundreds of thousands of drug addicts in the world to avoid psychological and physical decline as well as fatal outcomes by stabilising them in a lasting fashion and returning to them a sometimes exceptional quality of life. On the other hand, even a very progressive stop in the substitution treatment often entails a loss of this quality of life, psychiatric problems and relapse into alcohol or drugs - this particularly in patients with psychological disorders underlying the addiction. For them, the drug must be understood as an attempt to self-stabilise psychological suffering that, to the professional, seems more and more related to genetical neurobiological dysfunctions. The substitution medication then acts as a corrector of the biological defect that corresponds to a chronic illness. For these patients, substitution treatment must be considered as a medical treatment that rectifies a natural imbalance and that must be maintained over an unlimited amount of time as, for example, must insulin for a diabetic or treatment for an epileptic. (Deglon)
So, posing a chicken-or-egg question is really not important when it comes to methadone treatment, since long term opiate addiction also causes the same problems scientists believe may pre-exist in some addicts. The important piece is to look at methadone as a stabilizing medication for treatment of a chronic medical disease. Attempts to wean must be done carefully and with an open mind to the possibility that it may not be an option for some. The decision to wean must be an informed decision made between a patient and his or her physician, not a decision made lightly to appease friends and family or made in response to the percieved hassles of going to a regulated treatment clinic.
It is therefore of the utmost importance to carry out a complete evaluation in order to be able to identify medical, psychological, affective, social, familial and professional problems involved as pre-existing or secondary factors of the addiction and thus to offer specific therapeutic responses. This evaluation also enables an eventual weaning.To conclude, the most important thing is to enable each heroin addict to have immediate access to a form of therapy that suits him - or to many if necessary - so that he may find a good medical and psychosocial equilibrium as soon as possible and maintain that quality of life in the long term. Substitution programmes have proven these last forty years, to be the most efficient answer to these expectations. (Deglon)
Here is a link for anyone interested in reading Deglon's report in its entirety (I highly reccomend you do!):
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