Updated: Jul 24
“To what extent can social problems be circumvented by reducing them to technological problems? Can we identify quick technological fixes for profound and almost infinitely complicated social problems, fixes that are within the grasp of modern technology and which would either eliminate the original social problem without requiring a change in the individual’s social attitudes or would alter the problem as to make its resolution more feasible?”
Dorothy Nelkin asked the questions above in her slim volume, Methadone Maintenance: A Technological Fix (New York: George Braziller, 1973), where she argued the practice would have a tenuous future as a “chemotherapeutic ‘fix’” for heroin addiction. The latter, she wrote, was an “adaptive response to real and overwhelming social or psychological difficulties that cannot be resolved by a simple technological fix” (3, 152). But methadone was no simple technological fix. Programs developed in a “climate of conflict extending from the level of policy down to the actual operation of individual clinics” (8). The Dayton, Ohio, methadone clinic where James Klein and Julia Reichert shot their film Methadone: An American Way of Dealing is a Black space full of energy and music—even as no-nonsense white nurses refuse to disclose to Black patients the dosage they are serving up in their “free cup of methadone.”
Progenitors of methadone maintenance Vincent Dole and Marie Nyswander aimed to reduce crime and render “the addict . . . a socially useful citizen, happy in himself and in society” (Nat Hentoff, A Doctor among the Addicts, Grove Press 1970, 117). Metabolic realignment was designed to render “addicts” “straight” and “therefore able to lead normal lives.” The intolerable postindustrial normalcy of mid-1970s Dayton, Ohio is presented in Klein and Reicher’s film via visual and verbal forms ranging from factory work to night-time montages of bars and sex shows to spaces of Black evangelism.
By the mid-1970s the sheer scale of methadone maintenance had outstripped the short-lived early 20th century experiment with morphine maintenance clinics. What Addiction Research Center director Harris Isbell once called “the methadone mess” was pre-scripted by that episode half a century earlier. Morphine maintenance clinics ended in disgrace, and were continually constructed not as treatment but as “coddling” addicts and “substituting” one addiction for another. Hardly coddled, Klein and Reichert’s disenchanted methadone subjects had been sold a “wonder drug.” Hoping to be “free” again, “normal,” they instead found themselves “hooked on [methadone], worse than . . . [on] heroin.”
And just why, the filmmakers patiently inquire, do they need to use drugs while working at the factory? “To whitewash it,” “to paint over the factory,” “to make it your own little world.” The degrading nature of factory work would soon end, they predicted, along with the assembly lines to which their fathers had gone off each morning “like sheep,” “dressed in grey with their little black lunch buckets,” coming home “like vegetables, almost.” Make no mistake, this film documents the declining quality of work in mid-1970s Dayton just as surely as it documents conflicting frames and feelings about methadone. These young people fail to see why anyone would opt for an intolerable normalcy to which they are supposed to aspire. Yet normalization was—and is—the goal of methadone maintenance.
“Methadon” was a synthetic analgesic developed at I.G. Farben and rediscovered during a U. S. Department of Commerce investigation of German wartime industries.[i] Clinical trials were conducted at the Addiction Research Center (ARC) at the USPHS Narcotic Farm in Lexington, Kentucky, where the compound was made in large quantities for a two-week detox for actively addicted patients. The compounding pharmacy at the narcotic farm made everything from shampoo, cough syrup, and colored aspirin to cherry red liquid methadone. But the ARC considered methadone an “addiction-producing drug,” advising that the “same precautions should be observed in prescribing methadone as are used in prescribing morphine” (Archives 1948, 392). This, then, was the first “American methadone.”[ii]
There is some evidence that physicians prescribed “Dollies” during the early 1950s, when the occasional “primary methadone addict” was admitted to Lexington. But physicians who prescribed it were harassed by the rabidly anti-maintenance Federal Bureau of Narcotics (FBN). There was also a New York state-sanctioned dolophine maintenance program organized by the New York State Department of Mental Health in 1959 under direction of Dr. Harold Meiselas. Herman Joseph, a New York City probation officer who later worked with Dole and Nyswander, lamented the loss of program records but interviewed Meiselas for his 1995 dissertation. According to Joseph, “Meiselas did recall that addicts were initially given methadone in a hospital on Ward’s Island in a building owned by the state but which was subsequently turned over to a therapeutic community. After an unknown period of hospitalization, the patients received methadone in the community in outpatient clinics that were operated by the Department of Mental Hygiene.
Administrative arrangements and permission to proceed with this pilot were made by Dr. Henry Brill. There were about 30 patients enrolled in the program. Meiselas advised that there are to his knowledge no existing records of how this project began or ended. However, he believes that some of the patients may have entered the Dole-Nyswander program that was established in the 1960s. He does recall having meetings about the program and that methadone was chosen for the program since it was a long-acting drug.”
Vincent Dole and Marie Nyswander championed the second American methadone. Together they painted the ARC as a “research establishment” hostile to innovation in Addicts Who Survived (1989), in an interview with David Courtwright. Dole and Nyswander claimed that a “guinea pig attitude” prevailed at Lexington, where ARC investigators ran a prison ward that locked them into an “adversary relationship,” foreclosed “cooperative relationships,” and prevented them from knowing their patients as human beings (Addicts Who Survived, 336). Eric C. Schneider’s masterful Smack: Heroin and the American City (2008, 166-167) described Dole’s early observational studies involving morphine maintenance, stressing subjects’ immobility by contrast to the cheerful industry of patients on high-dose methadone. In 1964, Dole and Nyswander launched the experiment that yielded the second American methadone.
Outsiders to the “addiction research establishment,” Dole and Nyswander were criticized for “premature” efficacy reports and lack of “pharmacological results” (Addicts Who Survived, 337). Friction cut both ways. Disdain shone through in Dole’s disparaging remarks, noting that there “was no research talent in the field, just some pharmacologists working with animals who didn’t have a concept of human epidemiology” (Addicts Who Survived, 332). Late in life, Isbell revealed his view that addicts were apt to “indulge in a parasitic existence” motivated only by “artificially biologically determined need” for drugs.[iii] He recalled preventing Nyswander from distributing morphine shots to Lexington inmates at Christmas (Senechal in Patey 2003, 193).
Although he respected Lawrence Kolb as Lexington’s first Chief Medical Officer, Isbell deplored Kolb’s “soft spot” for addicts and his notion that “street criminals” were “good people, which of course they weren’t.” He portrayed Kolb as “obviously so caught up in the problem you couldn’t really depend on him” (Senechal interview with Isbell, 28 June 1986). Although Isbell and neurophysiologist Abraham Wikler, his colleague at Lexington, both opposed maintenance and favored short-term and even single dose studies, the next generation of addiction researchers, including Wikler protégé Jerome Jaffe, credited the institutionalization of methadone maintenance with propelling a sea change in drug treatment (Griffith Edwards 2002).
Dole himself was an established Rockefeller Institute specialist on appetite, hunger, and satiation in obesity and metabolic disease who based his theoretical model of addiction on diabetes,[iv] extrapolating diabetics’ needs for regular infusions of insulin to the “maintenance” behavior of heroin users. He consulted psychiatrist Marie Nyswander, who was key in transitioning between psychiatric constructions of addictive disease heavily based on “personality theory,” and today’s metabolic, behavioral, and neuroscientific constructs of disease. In The Drug Addict as Patient (1956), Nyswander lamented the lack of psychotherapy at the US Narcotic Farm, but she shed psychoanalysis after marrying Dole in 1965. Together they linked metabolism to drive and behavior, minimizing ARC research and moving into “uncharted territory.” They described their initial “humdrum observational” studies as similar to those routinely undertaken at the ARC.
The Rockefeller breakthrough came when Dole learned that his subjects felt more stable on longer-acting methadone than on shorter-acting morphine or heroin. He produced dosage schedules and fashioned the regimen that later allowed rapid scale-up of a national freestanding clinic infrastructure in the early 1970s. However, this system did not suit Dole, who believed it gave “the feds” unprecedented entry into medical practice (Addicts Who Survived, 341). Methadone maintenance was the Nixon administration’s pragmatic response to the spectacle of Vietnam veterans returning addicted to heroin. Some of its strongest proponents—including “drug czars” Jaffe and, later, another “two-year wonder” from the Narcotic Farm, Herb Kleber—believed that methadone had to be delivered in conjunction with psychotherapy in order to be truly effective. But the regulatory regime through which methadone reached its consumers delinked it from routine medical practice. Although methadone began as an “office-based” technology, and may someday return to that more normalized status, for much of the past half century it has been “untouchable” by self-respecting physicians due to the focus on illicit diversion and overdose.
James Klein and Julia Reichert’s revelatory documentary showed a freestanding methadone clinic in Dayton, Ohio, caught on the horns of methadone’s dilemmas. She captured her subjects’ boredom with jobs, schools, home lives, a boredom that set in motion their turn to “smack,” “syrup,” and stimulants. Half an hour into this slice of the life of the second American methadone, that “bitter ironist” Randy Newman sings “Sail Away,” a song about the Black Atlantic slave trade, as viewers take in the choreography of parking lot deals. From his White House office, Peter Bourne insists that methadone “eliminates the craving for heroin.” Cut to an interview with a young white Dayton couple and their child, who muse that “it’s always in the back of your mind—you wanna get high.”
Without objectifying, moralizing, or further comment, Reichert draws people into conversations about the forms of bondage they experience on methadone. Women say they know no one who has detoxed from it, describing “how they done swolled up” with weight gain to the point of feeling they cannot move. Others casually note that methadone “quiets you down,” noting that there have been no race riots since the clinic opened. “I believe that the white man put it here. . . it wasn’t intended to help me, it was intended to make me stop stealing.” Methadone was characterized as pacifier and tranquilizer: “after I get my medicine, I don’t feel like doing anything.” There is considerable footage of dozing, nodding off, and hanging about until the segue to the bustling activity of RAP, Inc., in Washington, DC. When American Way of Dealing was made, methadone maintenance was but a decade into its life. Its clinical logic was that of a “narcotic blockade,” schematically represented as The Donut Theory of Heroin Addiction by Joycelyn Woods and Herman Joseph (see Figure 1).
The freestanding methadone clinic infrastructure built in the 1970s was plagued by problems, including everything from NIMBY attitudes to charges of corruption to highly publicized overdose deaths. As Joseph wrote, “it must be emphasized that methadone maintenance did not expand because society wanted to provide treatment for heroin addicts. To the contrary, the main concern was reducing the number of crimes committed by addicts.” Reichert’s subjects embodied so many of the contradictions of methadone maintenance. Their Dayton clinic was clearly the social hub around which their daily routines revolved.
Methadone’s early proponents proposed that employed, socially and medically stable patients be treated as part of routine, private medical practice as long as relapse could be avoided. “Neuroscience research has shown that there may be a physical explanation for relapse, namely a dysfunction within the opiate receptor system which methadone normalizes as long as the patient takes the medication” (Dole, 1988; Kreek, 1988). Many remain ambivalent about methadone, making moral assumptions that mitigate against long-term maintenance, “seen as suggesting a certain lack of personal integrity on the part of these clients as compared with clients who have become abstinent. It is as if ‘treatment’ or ‘cure’ is incomplete until the client is completely drug free” (Beny Primm, quoted in Joseph 1995). As long as such attitudes prevail, the social travels and historical travails of this most contested molecule and practice of maintenance will be part of the culture of drug treatment in the United States. American Way of Dealing closes with a prescient line: “American doesn’t have a drug culture, it is a drug culture.” Methadone—and medical maintenance—is integral to that drug culture.
[i] Harris Isbell, Abraham Wikler, Anna J. Eisenman, Mary Daingerfield, and Karl Frank, “Liability of Addiction to 6-Dimethylamino-4-4-Diphenylheptanone (Methadon, “Amidone” or “1820”) in Man,” Archives of Internal Medicine, v. 82 (October 1948): 362-392.
[ii] Emilie Gomart, “Methadone: Six Effects in Search of a Substance,” Social Studies of Science 32.1 (2002): 93-135. Gomart compared “American methadone” to “French methadone.” Adopting the work of Annemarie Mol, The Body Multiple: Ontology in Medical Practice, Durham, NC: Duke University Press, 2002, particularly pages 46-48), I argue there are multiple American methadones, staged in two articles that appeared twenty years apart in Archives of Internal Medicine.
[iii] Harris Isbell, “Meeting a Growing Menace,” The Merck Report, July (1951): 4-9.