I take issue with the Drs Marsh and Krausz’s opening statement in their rebuttal to CAST concerns [BCMJ 2008;50(1):15-16]. Their assertion that “The most effective and best-studied treatment available in addiction medicine is methadone maintenance treatment (MMT)” is simply false.
The best studied, and in fact the most effective, treatment for substance addiction is abstinence from substances. The basis of MMT as a treatment for opioid dependence is actually the substitution of a less harmful dependence, to methadone, for a more harmful opioid addiction, usually to heroin; MMT does not actually treat the underlying addictive disorder.
I accept that the use of MMT does, in some cases, lead to “a range of benefits for individuals with opioid dependence and society at large,” but the ultimate treatment goal of most opioid addicts is not MMT but abstinence from all substances.
The truly pernicious aspect of MMT and other harm reduction strategies is that they are foisted on already-marginalized people. If you are an addicted doctor, lawyer, pharmacist, pilot, nurse, police officer, or if you work in a myriad of safety sensitive industries, the only acceptable treatments are abstinence-based. Often these expensive treatment programs are funded by employers. But if you are mentally ill, Aboriginal, uneducated, unemployed, or destitute, watch out: chances are you’re headed toward a harm reduction program.
What the harm-reductionists and methadonians among us espouse most vociferously is the “less harmful” use of drugs through such initiatives as needle exchanges, provision of clean crack pipes, so-called “safe” injection sites, etc. Where is their promotion of the only true treatment for drug addiction: abstinence-based therapeutic programs?
—Ian A. MacDonald, MD
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