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Staying Off Methadone Maintenance Marsha Rosenbaum

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Institute for Scientific Analysis , 2235 Lombard Street, San Francisco , California , 94123 Published online: 20 Jan 2012.

To cite this article: Marsha Rosenbaum (1991) Staying Off Methadone Maintenance, Journal of Psychoactive Drugs, 23:3, 251-260, DOI: 10.1080/02791072.1991.10471586 To link to this article: http://dx.doi.org/10.1080/02791072.1991.10471586

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Marsha Rosenbaum, Ph.D . * Abstract - Methadone maintenance is again rec eiving attention as an intervention for needle use/sharing among intravenous drug users . A major criticism is that methadone has its own addic tive properties; consequently, the client is unable to detox ify and stay off opioids permanently. Study respondents had been off methadone for several years and offered their strateg ies for success. Mot ivating forces included the freedom and rewards, such as pride and respecl. The following help ed individuals to get off and stay off methadone: avoidance of opioids ; treatment affiliation to supply ideology and to structure and fill free time; employment; social supports, specifically family and role models; modest plans to avoid disappointment; effective coping skills to avoid depression; and aging and burning out , In addition, those individuals who had immersed themselves in the conventional world, especially those having a higher social class status, had a less difficult time stay ing off methadone. Keywords - drug free , heroin, methadone, public policy, opioid free, treatment

Over the past decade, the public has defined drug use and abuse as major problems. For example, there is increasing criticism of legal drugs, such as nicotine and alcohol, and harsher penalties for the use of marijuana in Alaska and Oregon, where personal use had once been permitted . In addition, there is great concern with and a broader definition of addiction, as evidenced by the rise in various forms of 12-Step anonymous groups. In sum, the use of drugs is now seen as morally reprehensible as welI as physiologically dangerous. Despite the rhetoric of the War on Drugs and consensus about the evil of drugs, the federal government seems unwilling to support drug abuse treatment in a significant way. States and counties continually face fiscal shortages; consequently, drug abuse treatment is often the first to be cut from the budget. In the midst of these fiscal shortages is the AIDS epidem ic. Intravenous drug users (IVDUs) are the fastest growing group to be infected with the human immunodeficiency virus (HI V) caused by sharing unsterile needles! Put simply, in order to contain the spread of Hl V among IVDUs, the sharing of needles must stop. The ideal scenari o would be for IVDUs to simply abstain from the usc of drugs altogether, but given their life circumstances

this is rarely an option. Instead, using clean needles or noninjectable drugs are options for individuals who cannot abstain. Methadone maintenance treatment (MMl), which has been a viable treatment modality for three decades, is now receiving attention as an intervention for needle use/sharing among IVDUs. As such, it is being reevaluated as a treatment modality. A major criticism, which has been dominant for years, is that methadone has its own addictive properties and consequently the client is unable to detoxify and stay off opioids permanently. Community reticence to support MMT programs stems from skepticism of trading one addiction for another, as welI as an unwillingness to allocate funds for drug abuse treatment. A major problem area regarding support of MMT is the determination of the length of time a client should remain in treatment. There is widespread acknowledgment in the field that methadone is highly addictive. Indeed, getting off methadone maintenance is welI documented as being problematic (Dole 1988; Rosenbaum & Murphy 1984; Hunt, Lipton & Goldsmith 1981; Judson et a1. 1980 ; Stimmeletal.1978;Sutkeretal.1978;BurtetaI.1977; Kleinman & Lukoff 1977; Preble & Miller 1977; Bourne 1976; Brown, Jansen & Benn 1975; Sutker, Allain & Moan 1974; Perkins & Bloch 1971). Whereas detoxifying from methadone has its difficulties, staying off methadone presents an equal if not harder chalIenge. It may be , as

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Staying Off Methadone

Dole argued (1988), that such difficulties arc related to a receptor system dysfunction that is remedied by methadone. If so, efforts to detoxify from and stay off methadone might be fruitless. Indeed , several studies indicated that very few individuals are able to detoxify from and stay off methdone without going back to the use of other drugs (Sorensen et al. 1987; Senay 1985; Cushman 1981; Dole & Joseph 1978). Nonetheless, policymaking bureaucracies continue to move toward short-term MMT despite evidence that this is not pragmatic (Anglin et al. 1989; Murphy & Rosenbaum 1988; Rosenbaum, Irwin & Murphy 1988; Newman 1987; Rosenbaum, Murphy & Beck 1987). As a result, individuals are having to confront not only detoxifying from methadone but remaining opioid fre e. The present article examines the process of staying off methadone maintenance after having been maintained and then detoxified. The analysis is derived from a larger ethnographic study funded by the National Institute on Drug Abuse.' One hundred men and women were inter viewed in the San Francisco Bay Area. Each individual was in one of four stages of getting off methadone: detoxifying from methadone; just off an MMT program; back on an MMT program after having been off for at least two years; and "long gone" (off methadone for a period of at least two years). For the present article, data were analyzed from the long gones (n=32). Beginning with a discussion of the reasons for staying off methadone, the article then addresses the methods for accomplishing this task. Finally, those factors that prove advantageous in the effort to stay off methadone are described.

without being concerned about obtaining methadone or being afraid of becoming sick without opioids . Even if they cannot travel extensively due to other considerations (e.g., children, money, job), the knowledge that they are phys iologically and programmatically free to do so is rewarding in and of itself. One 51-year-old man explained that "Hey, I was telling her last night , ' The best thing that ever hap pened to me was to get off the goddamn juice. I'm certainly glad I'm not tagged with the restrictions.' I mean, I don't have to be here. I don 't have to wake up in the morning and wonder 'Where is my methadone? What bottle is it in? ' Saying, 'I've got to hurry up, we've only got [so much] time to get to the clinic.' Oh, Jesus Chri st, what relief." Furthermore , physical liberation from what some consider the intoxicating feeling of opioids is seen as a tangible reward. Individuals often comment enthusiastically after detoxifying from methadone that they feel "alive." They claim to experienee almost a "high" at having been drug free for an extended period of time. This is especially applicable when the individual has gone on a deliberate health routine and is doing other things for his or her body in an effort to brin g about maximum health . The final tangible reward associated with staying off methadone is a social one, because it mean s finally eliminating the entire issue of opioids from people's lives. It is a part of their life-style that is no longer wanted and no longer needed. When an individual has stayed off methadone, opioids are happily discarded. One is liberated from the whole scene - heroin and methadone - and is able to move on. One 32-year-old man said that "the last six months have been rewarding because when you hurdle something, you go to the next point. But when you 're on drugs, you never get over the first point. It's always the drug problem that prevents you from going to the next stage. So you 're always on step one, whether you're on methadone maintenance or shooting heroin or you're buying [methadone] illicitly. There's always that predominant factor of drugs, the preoccupation with drugs. And I just wanted to go on. And I did."

REASONS FOR STAYING OFF METHADONE People want to stay off methadone for several reasons. The study data revealed three major categories: tangible rewards, intangible rewards, and investments.

Tangible Rewards Perhaps the most obvious tangible reward derived from staying off methadone is a sense of liberation. Individuals who have stayed off methadone claim that they felt a sense of both physical and social liberation from drugs . It is a powerful and exhilarating feeling, somewhat parallel to being released from prison. One 37-year-old man who had been off methadone for three years stated that "I really cherish the freedom - physically. I like windsurfing and there are things I am doing now that I couldn't do if! were high . I wouldn't be involved in the community center. I'm the chairperson on the personnel commiuee. We're doing all this reorganization connected with my community. I'm getting a lot of goodies that way." Physical liberation also involves the release from travel restrictions. Individuals can go where they please JOUTNJ/

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Intangible Rewards Intangible rewards also accompany staying off methadone. Many individuals described the trust and respect that they had gleaned from others after getting off and staying off methadone. The image conveyed to others (and perhaps their self-image) had been transformed. Occasionally, individuals described themselves as emerging from an unscrupulous individual in constant blind pursuit of heroin to a tru stworthy person with integrity. Regardless of the social and cultural restrictions that push users into the former state, once they arc out they tend to feel better about themselves, and others will feel better about them too. It is the new trust and respect that exmethadone clients receive that is a strong incentive to stay 252

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off methadone. One 31-year-old woman reported, "My father gave me the ability to care for myself on the streets. So even as a junkie I got treated very well. Since I've been clean, I'm very loved by my friends and trusted , and I like the relationships I have with people. Like when I go into the supermarket, the manager is glad to see me and we have a friendly conversation. I know if I need to go in there and cash a $300 check, I can. I like the way I'm treated and I like my life." Another intangible reward is a sense of pride at having accomplished a difficult task. Many individuals see the process of getting off heroin and on to methadone and then off methadone for an extended period of time as one of their major accomplishments. It is, indeed, quite a feat. For this, and because so few are able to complete the process, individuals who have stayed off methadone feel particularly proud. It is this pride, and the desire to continue to feel admirable, that provides a reason to stay off methadone. One 32-year-old man said: "I like being an exception. I love being an anomaly. I like the fact that I've been on, I've been involved with opiates for 11 years and I got off of it I feel like Superman that I could do that and not even look back."

clients believed that they could not combine the two . Many individuals have gotten off methadone and have been able to stay off because they formed a new life-style. Those who wanted to hang on to this new life-style felt that they must stay off methadone in order to do so. Many want very badly to continue with their activities and believe that staying off methadone is the key . One 43-yearold man who had been off methadone for many years said: I just made that decision and that was the end of it. I made the decision and I moved forward and things began to happen. I was molding my life . Very shortly after I cleaned up I met a woman that I loved very much . I got married, had children, bought a house, and most of the things that when you' re out there on the streets you think you can never accomplish or achieve. You think you gave it up somewhere because you became the dope fiend. These avenues aren 't open to you . You're not going to be able to buy a house and live in the suburbs and all these ideal things . And then , all of a sudden, here they were happening for me. And I think I got an awful lot out of that success. I got the rewards and nurturance I needed to be able to move on.

One 38-year-old woman talked about her investments when asked if she thought she would ever use opioids again: Respondent: No, I'm quite sure. Never again. No way. And someday I'll probably gel 10 the point where every time I don 'I feel good I won 'I equale it with withdrawal. I'm awfully proud of what I've accomplished here . It may not be so wonderful by other people's standards, but when _ _ and I started living together we were living in a S90-a -month, two-room flea trap and there were a mill ion cockroaches living there with us, and hotand-cold running rats . It was terrible. lraerviewer: And here you are OUl in middle-class suburbia. Respondent: Yes. And I always thought that was kind of a cop out. But not anymore. I like it.

Investments The final reason that was discovered for staying off methadone is the entire package of investments that people make, including children, work , and a new life-style. As documented in earlier studies (Rosenbaum 1982, 1981), children often provide the impetus for making changes. The single greatest reason why mothers on heroin want to get out of the drug life is their children. They often get on methadone because they want to regulate or order their lives to take better care of their children, or just to keep them. A similar occurrence happens when individuals both men and women - get off methadone. Concern for their children - for their well-being but also for their surroundings and social influences - is a major reason for people's desire to stay off methadone. One 33-year-old man said that "my family is what keeps me straight. My kids, lowe it to them not give them a messed-up life. I think I have an important job to do and I think lowe it to them to stay as straight as I can . So what really keeps me off drugs is my children, and myself and my wife. I want a different kind of life for myself." Another factor that individuals find compelling is their work. Many respondents had found jobs that had reshaped their lives and they wanted to keep them. Often, staying off methadone was imperative to keeping these jobs. Either the work routine could not be incorporated into the responsibilities of being on methadone or one's coworkers could not be expected to accept one's status as a methadone client. Whatever the particulars, work was a major reason for staying off methadone because exJOIUNJI of Psychoactive Drug s

But reasons for staying off methadone, however powerful, are not always enough. Many individuals with nu merous good reasons still think about using opioids, some to the point of craving. Thus, staying off involves more than just having reasons to do so. These reasons must accompany actions to accomplish the desire.

METHODS FOR STAYING OFF METHADONE It seems that in order to stay off methadone without relapsing or switching addictions, one must be almost blindly committed and dedicated to the endeavor. Ambivalence and wavering can be dangerous obstacles to staying off. Those individuals in the study sample who were successful claimed that they had to be single-minded in their pursuit of abstinence in order not to be tempted to use heroin or return to methadone. Many claimed to have blinders on and refused to allow themselves to see another way besides continuing on the path to be methadone free . Individuals in the study sample described numerous 253

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Slaying Off Methadone that has to do with some kind of drug . You know , I navigate to ward that kind of people. I don't know why. So I just don't have friends.

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methods by which they (and others) managed to stay off methadone, including a new drug-perspective, treatment affiliation, social supports, modest plans, and coping skills. The following is a description of each approach.

One 32 -year-old woman described her isolation in a "safe" little community:

New Drug-Perspectives Shortly after completion of the study, a respondent who had been off methadone for several years asked the present author, "Will I ever be able to use [opioids] again - even once in a while?" The study data indicated that those individuals who had gotten off and stayed off methadone for a significant period of time had been forced to come to terms with this problem. Without exception, they had coneluded that they could never use opioids again unless it was in a strictly medical context. One 26 -year-old man, currently a counselor in an MMT clinic, put it succinctly when asked to state a formula for staying off methadone: "Well, one thing you have to decide is that you can't chip. As long as you don't come to that realization - that you can't chip - then everything else is a temporary situation. You will go back to using unless you decide that you can't ever chip." One 38-yearold woman who had been ofTmethadone for several years, and was usually more verbose, had just these few words to say about the possibility of using opioids again: "If I go out and get a fix, I'm afraid I won't stop . So I won 't do it. I won't take the first one." In order to stay off methadone, it seems clear that isolation from all opioids (ineluding methadone) is necessary. Those respondents who had been able to stay off methadone fully acknowledged that staying away from opioid users was essential . Some argued that it had become relatively easy to abstain from using opioids because of the difficulty in procuring them since they were no longer immersed in the heroin world. One 37-year-old man compared his situation to that of an alcoholic who has ready access to liquor at all times, and felt fortunate in that "I feci lucky in a way having been a heroin addict because I go into [the grocery store] and there's no heroin on the shelf." Yet the avoidance of opioid-using friends can have its pitfalls. If one does not have nondrug-using friends, one may suffer from loneliness if old friends are avoided. Nonetheless, many endure the loneliness if they are strongly committed to staying off methadone. One 33year-old man made a sad testimonial to isolation for the purpose of staying off methadone:

A lot of times I wish we lived back in San Francisco . That 's probably a little selfish on my part, but I'm more comfortable there. But my son's established here -he's going to school, he's got friends , he' s got a nice house where he doesn't have to worry about getting hit by a car. But I feel like I'm neither fish nor fowl. I'm still more orless hiding out here in Fremont. I don't see any of the old people that I dealt with on the street or in the program. A lot of them just aren't here , and we don't have nothing to say to each other anymore anyway.

Finally, one 36 -year-old man summed it up when asked what he did in his leisure (nonworking) hours: " Nothing really. I just stay around the house. I guess I still don't fecI that confident about being out there on the street Maybe I'm still afraid that I might start chipping again." Individuals who stayed off methadone had to come to terms with not only the opioids but their orientation toward recreational drugs in general. While ruling out opioids as recreational drugs, they had managed to use other psychoactive substances without negative consequences. With the exception of opioids, they could chip recreationally - even use drugs therapeutically - as one 37-yearold man did: I've been drug free, opiate free certa inly. I smoke weed socially and that usually wind s up to be maybe once o r twi ce a week . I've done a little bit of cocaine. Last year my father died , my marriage broke up, and I lost my job. I decided to dull my pain . I was under every stress you can think of. I decided to get high and I got some cocaine and shot it for about three week s, which definitely dulled my pain . I hate cocaine. I really don't like it that much, but some surv ival mechanism told me, "Don't cop heroin." Because if I copped heroin I wouldn't be here talking to you . Back into it for sure.

Although many individuals who have stayed off methadone feel that they can use nonopioid recreational drugs, many of them are cautious. One often hears from clients that they believe themselves to have an "addictive personality." Thus the use of any psychoactive substance would be dangerous. One 33-year-old man is such a case: I think if you can do any drug on a recreational basis you're all right. But I think that a person that gets strung out on heroin has a certain kind of chemistry about him, and I'm speaking about myself. Anything I use I have to watch because I have a tendency to abuse drugs. I have to watch my drinking because I can get into where I'm drinking too much . I got into coke and I overdid it. When I got into Valium I overdid it. Any drug that I've ever used I've taken it to a point where I went over the wall instead of just moderate. like I know some people who snort coke on the weekends and they've been doing it for years. I couldn't do that, I got into it and wanted it every day and it was a driving force with me .

Q : What about your friends right now? A: I don't have any friends . Q : You don't have any friends? A : No, I have associates I know from work, but I have a tendency not to have and keep friends . Q: How come? A: I get too involved with their problems and I seem to have a problem. Once I meet somebody, it's automatically somebody Journal ofPsychoactive Drugs

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"professional ex-addict" ideology, which is not unlike the one mentioned above. The method by which these men (there were no women among them) stayed off methadone was to spend their working days reinforcing their own situation by advising others on how to get off and stay off drugs. It also prov ides a social world in which ex-addicts are respected and paid for work about which they are com petent and knowledgeable. One 43-year-old man, who had been the director of a methadone clinic, provided an overview of the ex-addict counselor experience:

Treatment Affiliation Two forms of treatment affiliation were identified that enabled respondents to stay off methadone for long periods of time: membership in Narcotics Anonymous (NA) and/or Alcoholics Anonymous (AA) and employment in treatment institutions. NA and AA provide both an ideology and activity for abstaining members. Many exaddicts, as noted above, had come to embrace an ideology of total abstinence - often derived directly from such organizations as NA. Using the AA/NA doctrine, they believed that certain individuals (including themselves) were prone to habituation with any psychoactive or potentially addictive substance. It becomes imperative, therefore, that they abstain from even the most moderate use of such drugs. One 38-year-old member of NA aptly described this viewpoint:

I found out very quickly that I loved working with people and in those days the field was in its infancy. Very little knowledge around ... as to what the street life was really aU about, And being able to counsel somebody, to do a group with them or what have you , and just knowing when someone is sitting there bullshitting you about how it was . Okay, when you're running 365 days a year and there's no such thing as Christmas or vacations or anything else, you literally have to get up and go o ut that day no matter what. Some of the pains of the life as well as some of the rewards of the life . On their turf - what kind of identity do they have and what could you offer them that would compensate for that? So anyway, they were gravitating in those days toward the CJ\ -addi cts. Now [counselors) are damn near all professionals. And the only ex -add icts that are surviving are tho se people that bothered them selves to get out there and get other exposure. But the ones that thought they could ju st sit back because they were ex-addicts are do ing som ething else with their liv es at th is point.

I know that I can 't do drugs again . I can only talk for myself . .. . The rea son I don 't drink is because if I did drink , and I do consider myself an alcoholic, too, in addition to - actually it's all drugs . If I drank , I know in my heart that it would j ust be a matter of time before I'd go and start using drugs again. At this point in my life - after having been clean for five years -to have me drinking or using drugs is a total waste of time . I don 't have time. There 's too many things that I want to do with my life other than spe ndin g it 00 the comer, and I know that I'm a compulsive person . I have enough problems to deal with without compounding it by using drugs. People say you have a drug problem. That ain 't the problem - I am the problem - I have always been the problem . Take the drugs away and it's like taking a banana from a go rilla . All of a sudden aU this madness cornes out - aUthe things that you were always afraid of, all your emotions that you ran away from when you were a kid . They're still there when you 're 33 years old and they take the drugs away. That's what you've got to deal with - how to learn how to live with yourself. That's what Narcotics Anonymous is aU about-learning how to live . And do that by sharing with other drug add icts, alcoholics. By applying - living those steps, those Twelve Steps. Narcotics Anonymous helps you deliver yourself, accept yourself, and accept others. Not to be judgmental about other people and to live as comfortably as you possibly can. In the book Alcoholics AlIOllymoW" it says in the beginning the main purpose of this book is to help you find a power, a spiritual power greater than yourself. Period. Nothing else. And whatever happens after you develop that relationship is whatever happens. It's not to stay sober. It 's not to stay clean. It's not to have a girlfriend, a job or any of that stuff . The whole concept ofNA and AA is a spiritual one. It's me of helping yourfeUow man, and the only thing I can say is of all the things I've heard or know about concerning drugs and treatment for drug addicts, that is what, by far , by far, worlcs the best.

Another ex-addict counselor talks about his own personal experience in the field . Of particular import is the kind of support provided by the environment: When I fina lly got off of it and was fee ling okay, I began to really get into my worlc and I met a dude by the name of _ _ that had been with [Chuck) Dederich in Synanon. And then I began to learn a whole new ball game. Then I met _ _ from Herrick [Hospital] - he had been through Synanon. All these guys had been clean and been doing right without any kind of sub stance as a substitute for heroin. I met aUthe guys that had stayed away from drugs and I was worlcing with guys like I am . . . . and so I began to get a new bunch of friends . All of them were doing okay, all of them having families and stuff like that. And what I was doing, I was beginning to appear 00 several Bay Area shows - on radio shows and talk shows, doing a lot of seminars, and then I got on TV.

Although the ex-addict counselor is no longer in such demand, for a period of time it provided a method by which individuals could enter a new career to which they were perfectly suited. This was a successful method, albeit for a select few, to stay off methadone.

In addition to the ideology, a rigorous activity schedule is usually encouraged - much of which is attendance at meet ings of the organization. Thus the individual has a reason to stay off drugs and also has a method: the ideology and activities that accompany membership in the organization. Many of the study respondents who had stayed off methadone were ex-addict counselors in methadone clinics. They had embraced what has come to be called the JOlUNJI ofPsychoactive Drugs

orr Methadone

Social Support Social support is essential for a person who wants to stay off drugs (Waldorf 1973; Brill 1972). This support can and often does include lovers, spouses, mentors, new friends, and other role models. As noted earlier in the discussion of detoxification, having supportive family is essential. Those respondents who had stayed off methadone 255

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often praised family members for their enduring encouragement. The family also forms the core of one's investments, thus being both a reason and a way to stay off methadone. The support can take positive forms, such as praiseand encouragement. It can also be negative, involving threats of abandonment. Both can be effective. One 32-yearold man described his significant other in this way: "Th e other thing is having a support system. A wonderful woman has stuck by me through thick and thin. She's seen me at my best and she's seen me at my worst, and I think that without this person I wouldn't have been able to do it." Role models and mentors often serve as support for the individual who wants to stay off methadone. They provide not only encouragement but proof that it can be done. Often this is essential for the person who wants to stay off methadone but cannot find proof that it can be done .

I think that's given me direction and purpose. I mean it's like my life is full now. I don 't have time." Many clients who had stayed off methadone for long periods of time credited regular periods of recreation. OccasionalIy, this recreation literalIy takes the place of their addictive behavior. One long gone had an athletic schedule that had few breaks. He was involved in softball, volIeyball, and several other activities nearly every night of the week. These activities had become his focus in place of drugs. Another man, who was 37 years old, talked about his addiction to windsurfing: "I 'm a certified windsurfing instructor. That's my positive addiction. I am addicted to windsurfing for sure. I would rather windsurf than do any thing else. I wouIdn 't kill you for windsurfing or steal your calculator for windsurfing, but if I have spare money that's where it goes. In my spare tim e - that's what I do. " Many individuals who had stayed off methadone engaged in physical activiti es that they could do at any time, and especially during period s when they became depressed or discouraged. Some claimed that during the se periods they would have been tempted to use drugs to alleviate their pain, whereas now they could go jogging or play basketball or take a long and vigorous walk - something recreational and physical. This activity seemed to have the effect of taking their mind (and body) off of pessimistic thoughts and away from the temptation to use opioid s. One 36-year-old man talked about playing pool: "That type of anxiety attack would last about eight hours, and during periods like that I found that if I got out and even played pool - not necessarily talking about what happened but being around other people - it helped make it go away faster." Other coping skill s included diversion s, such as therapy or praying. Many individuals who had stayed off methadone had therapists for a period of time after detoxifying, and they would "save up" much of their di ssatisfaction and " unload" at weekly or twice-weekly ses sions. Often, just taking stock of the positive aspects of their life was enough to enable them to cope with stressful periods. The 36-year-old man who was a counselor in an MMT clinic noted:

Modest Plans A great facilitator of staying off methadone is a reasonable orientation toward the future . If one expects that grandiose schemes will materialize, disappointment is almost inevitable. Instead, living day to day seems to be a more productive method by which to maintain optimism and stay off methadone. When one has made modest plans and is able to see them materialize there is great encouragement. It can give the individual the optimism necessary to continue. The positive reinforcement that comes from seeing plans take shape is a necessary component to staying off methadone. One 33-year-old man's plans were very modest , and typical of those who had stayed off methadone: "I want to get ajob that I like and work from 8:00 to 5:00 and just be straight. Go camping on weekends like a lot of people do. " Coping Skills When all else fail s, the ex -client must have coping skills in order to stay off methadone. When confronted with the urge to use opioids there must be some apparatus by which to decline. Many respondents described the mechanisms that got them through difficult episodes, with three coping skills emerging as the most prevalent: general busyness, recreation , and diversions. Staying busy has long been credited for shifting an individual 's attention from one focus to another, with little time to think about opioids. Such is the case with busyness as a coping mechanism for staying off methadone. Many clients noted that they kept as busy as possible for the purpose of coping with the urge to use opioids, which might surface with too much unstructured time . Thus, several people who had stayed off methadone had schedules devoid of break times. One 32-year-old man who had a fulltime job, a personal relationship, and was also going to law school, said that "I haven't thought about drugs. My job has been going well and also I'm in law school and JOUT1UJ/

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Respondent: WI don 't want to use methadone . If the thought comes through, I kick it out real qu ick. Interviewer: How do you kick it out? Respondent: I just let it pass through . When I first notice a thought or urge com ing through like that, I j ust think about what I have to lo se and what I didn't want-that whole life-style ."

A few interviewees used prayer as an effective coping mechanism. When they felt depressed or anxious, they would pray - sometimes for long periods - until they no longer were disturbed to the point that they would consider using opioids. One 40-year-old woman described how she had handled a recent anxiety attack : 256

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phenomenologically removed from their existence. For these individuals, desire for drugs was unlikely to return. One 43-year-old man is a case in point: "One reason I'll never go back is .. . it's going to be more difficult to take a banker and teach him to be a dope fiend than it is to take a dope fiend and walk him through reentry into the mainstream. Okay? And I guess what I'm saying is that I've become that banker. Not really a banker per se, but I no longer know how to be a dope fiend."

I felt this anxiety attack come on and the way to deal with that is to break into a praise song . That's it. That simple. You know, you start praising and it just dispels darkness. Youcan feel the darkness push back when you praise God in any environmenL I put on music that I call "gloom and chase"music. Ijust worship to the Lord and this room fills with the power of Almighty God. And it presses back the darkness .

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The methods for staying off methadone that are outlined above proved useful for those individuals with reasons to stay off methadone, but who still had an enduring, if not overpowering, inclination toward opioids . For them it was a battle to stay off methadone.

Phasing Out Heroin addiction is often referred to as a "career," and has been described repeatedly in this mode (Rosenbaum 1981; Waldorf 1973; Brill 1972; Alksne, Lieberman & Brill 1967). However, this concept is not applicable to all addicts. For some, both heroin addiction and subsequent methadone treatment are better understood as life phases rather than careers. These individuals have been called "flash-in-the-pan" (Anglin et al. 1986) or "situational" (Waldorf 1982) addicts : addiction often comes on quickly as a lark or an adventure and passes with equal speed. Many go through heroin and then MMT, and once that phase is passed it is over - with littl e residue. One 43year-old man said:

ADVANTAGES IN THE PROCESS OF STAYING OFF METHADONE Some individuals are in decidedly advantageous positions when it comes to staying off methadone. While their reasons for wanting to stay off may parallel those of other respondents, they require fewer, if any, methods for doing so. Four major advantages to staying off methadone were identified : burning out (in relation to the heroin/methadone life-style) , building a conventional cocoon, phasing out, and having a position of elevated socioeconomic status.

I have not had the desire to use hero in since the day that I walked away from that judge. It was that swift a decis ion. No doubt it was a long time in coming. I thought of quitting many times, but I think he scared me enough , at that point, to where I was saying, "Hey, you 're 30 years old . If you do seven years , you're going to walk out in you r late thirties after do ing seven years in the penitentiary. What the hell are you going to do with your life?" And all of a sudden , all of the urges went away.

Burning Out Many people who have been in the drug life for 20 or more years get tired of it. They simply bum out from the pace , the risks, and ultimately the drug itself. These individuals are in the fortunate position - having chosen to stay off methadone - of not wanting to use opioids, nor to be involved in the drug life. Some said they have "lost heart" and therefore cannot hustle anymore. Others claimed (often at the age of 35) that they are just too old to go through what it takes to participate in the heroin/methadone life-style. One 33-year-old man reported that "you reach a certain age and like, I'm too old to crawl into other people's windows and to hustle all day long. I got other things to do with my life ."

When asked if he ever thought he would use heroin again, another man, age 29, who had passed through his heroin phase, responded: Never. Reason being now that I can never ever see how I put myself through that. My God, why? I couldn't do that again . I wouldn 't live through it. I'm just too tired . I couldn't handle it. Besides, I don't want that feel ing . That addiction is terrible. The phys ical. The mental. You tum into a fiend . You'll steal, you'll rip off, you'Ulie to aUyour friends. Everything that is held sacred and dear is thrown away. Monetary things , material things don't mean anything. I just don't think I could ever do it again . I'm positive.

Building a Conventional Cocoon Some of the respondents claimed that they were so far away from drugs that no one in their present world would ever guess from whence they came . They had built a conventional cocoon around themselves, one that covered every comer, every angle. Many were completely immersed in conventional activity: having family and friends who had never touched the drug world; having a straight job; and having affiliations, such as church or school, to fill in extra time. For these individuals there is no time, no space, no room at all, even for considering reentry into the drug world. It had been geographically, socially, and Journal ofPsychoactive Drugs

One 32-year-old man equated his heroin phase (and the possibility of going back to it) with seeing an old girlfriend. For him, the phase had passed - just as with a love affair. When asked about the possibility of future opioid use, he responded: "I don't think so. I think for me, symbolically, it would just be a total affirmation of defeat But there's some mystery. It's like seeing an old girlfriend. You know, you think, 'Well, if I ever saw her again, I would just melt.' And then five or six years later there's none of 257

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that feelin g - none of those feelin gs were ex uded. I don 't even want to try and there's no need for it. It was a big part of my life for a while. but why introduce it again?" Counselors can be effective by instilling in clients the notion that MMT is a phase, as one 39-year-old man noted: " My co unse lor said to me, •You shouldn't want to be on this for the rest of your life, and sometime you will have to loo k at yourse lf in the mirror and think of getting off this and going beyond the maintenanc e, going on to somethin g else ." •

the heroin or methad one life-st yle. Few. if any. of their friends are addicts or methadone clients. and they felt lonely in the hero in/methadone world. T hus. to lea ve this world is not particularly difficult and may eve n be plea surable. Besides not ide ntify ing with the heroin world and oth er add icts, many middle-class addict s nev er become co mmitted to the heroin/methadone world . They operate like dilettantes - flitting from one sce ne to the next without ever reall y land ing. Oft en they do not ever earn takehom e do se s of methadone because they never become serious enough about MMT to co nform to the regulations. This lack of commitme nt to the structure of MM T put them in a favorable position when they dec ided that it was time to ge t o ff and stay off the progr am . Middle-class addicts o ften po ssess the resources to reb uild their lives once they leav e MMT. So me arg ue that MM T program s merely provide a breathing space - a cha nce to sto p for a whi le and asse ss o ne's si tua tio n. Perhap s MMT allow s indi vidual s to stop, look , listen, and then move on in directions that they most probably would have gone had they not become addi cted to heroin in the firs t place . Thu s. middle-cl ass ad d ic ts o ften used meth ad one to stop usin g heroin, and then they go on to where they had left off before the hero in episode. If they had num erous life options befor e hero in , middle -cl ass addicts were in an advantageous po siti on when it ca me to drawin g on these options after MMT. Th e following is a frequent scenar io: the long -lost son or daughter returns cleaned up. mature. ready to begin again. and is met with enthus ias m, and most importantly, tangible help. Indeed , if options hav e not been too dra stically reduced throu gh involvement in the hero in wo rld , they can be recouped. If the middl e-cla ss addi ct has not stayed addic ted too long and ha s not don e a lot of pri son time, thereby severing connections with the conv entional world , there is the real possibility of returnin g to middl e-class status. Thi s allows the individual to remain optimi stic abo ut change; there is, indeed. light at the end of the tunnel. The chance for rewards exi sts, and thus the impetu s remains to continue the struggle to stay off methadone. The middleclass addict can look to a future without the MMT cl inic and to be immersed in the conventional world. reaping the rewards that accompany it.

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Socioeconomic Sta tus In terms of getting out of the heroin life-style and staying o ff methadone. the middle-class (and/or upper-class) addic t is perhaps at the most advantage for three basic reaso ns: the lack of a junkie identity, the availability of op ti on s . and th e rel at ed po ssibility of return in g to mid dl e-class status. Ma ny individuals fro m middl e-cl ass backgrounds begin heroin careers by flirting with heroin . Some beco me addicted, but experience this add iction differentl y than the larger population (num erically) of heroin addicts - those from working- and lower-class background s. Middl e- and upper-class addicts are often invisible: they avoid detection beca use they do not , at first, hav e to use illegal means to support their habits . But ultimately. even middle-class addicts have to choo se between the ever-increas ing possibi lity o f detection (and hen ce in carceration ) or the cessation of heroin usc - often through treatm ent. Some choose treatm ent (often methadone maintenance) without ever having been arr ested, without ever having hustled, witho ut ever having experienced the route of the stree t junkie. T hey have never taken on a j unkie identity. Thu s. in terms of identity and its accompanying hook into the hero in world , middle-class addicts could return to an " unspo iled identity" (Bi ernacki 1986). T he implicat ion s of thi s soc ia l re mo va l fro m the heroin world are num erous. Th ese individuals feel non e of the soc ial withdrawal that is characteristic of people who have identified with and have been inundated by the heroin and then the methadone world . For them. getting away from the scene was far from painful; it was a reli ef. Th ese study respondents saw them selves as wholly different from street junkies and other methadone clients. One 31-year-old man described it this way: "I always saw my friend s as junkies. but I didn't see myself as a junkie, for some reason. Beeause I always kept this thought in the back of my mind that this is just for now and not tomorrow. Tomorrow I'm not going to be into it. And they would always say things like. 'once ajunkie, alway s a junkie.' And it seemed to me like they just picked that life- styl e for them selves and I always felt like someday I'm not going to be do ing this." Man y middle-class interviewees felt alienated from J OUTNJ I

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CONCLUSION Whereas detoxifying from methadone can be extremely difficult. staying off requires almost equa l perse verance . Neither ta sk is to be taken lightly. Many respondents in the study sa mple who had accomplished this feat and had been off methadone for several years provided clu es as to how it is done. These lon g gone s noted se ve ra l reasons at the outset for wanting to stay off 258

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ficulty in getting off and staying off methadone for most of these individuals. If the alternative to MMT is an existence devoid of economically sufficient endeavors or socially fulfilling activities, then what is the point of getting off and/or staying off methadone? Why get off or stay off methadone maintenance if the life to which one returns is worse than that which one left? Until more options are open to the entire range of exaddicts, as they can be for middle-class addicts, staying off methadone is usually an accomplishment that only the economically advantaged can hope for and society can expect. Unless society can provide economically disadvantaged addicts with the skills and means to expand their options to get out of the heroin/methadone world , the most drug abuse treatment professionals can do is to assume a posture that is as restorative as possible. If drug abuse treatment professionals want people to get off and stay off methadone, perhaps the way to accomplish thi s difficult task is not to institute limits on the kind and duration of treatment available to their clients, as these measures have been shown to be counterproductive. Instead, if options and choices outside the drug world were available, clients and society at large would be provided a greater service.

methadone and why it meant so much to them to do so. These motivating forces included the freedom they had gained as well as rewards, such as pride and respect They also described the life-style changes they had made since getting off methadone and they talked about wanting to keep these investments. How to stay off methadone was another issue of great import. It is one thing to want to remain methadone free, but quite another to accomplish this. A changed perspective toward drugs seemed to be imperative, and more specifically the recognition that opioids could no longer be a part of one's choices for recreational drug use. Some respondents needed treatment affiliation to supply ideology and to structure and fill free time. Others used employment in treatment agencies as an effective method by which to stay off methadone. Social supports were an important ingredient - specifically family and role models. Modest plans were oft.cnessential to making progress and avoiding disappointment, which is a necessity for staying off opioids. Finally, the use of effective coping skills to avoid depression was vital to get through difficult periods and to remain op ioid free. Several factors gave some respondents an advantage in staying off methadone. In this context, paradoxically, aging or burning out is advantageous. Those individuals who had immersed themselves in the conventional world al so had a less difficult time when trying to stay off methadone. Perhaps the most advantageous position is having a higher socioeconomic status. Those respondents who had stumbled into heroin addiction from the middle and/or upper classes had a much easier time when they attempted to stay off methadone. Unlike many of their working- and lower-class companions, they could resurface into the conventional world with far more options. This made getting off and staying off methadone a more rewarding endeavor. Methadone had provided a respite for these individuals and a chance to pick up their lives where they had left off when they became addicted. They could go back to middle-class pursuits and perhaps would find life without opioids qualitatively better than existence as an addict. This is not always an option for workingand/or lower-class addicts, which may account for the dif-

NOTES I. Needle-sharing drug users have been documented as the second largest group of individuals to be infected with human immunodeficiency virus (Cent.crs for Disease Control 1989). 2. Getting Off Methadone (National Institute on Drug Abuse Grant No . ROt DA02442) , Marsha Rosenbaum, principal investigator.

ACKNOWLEDGMENTS The author would like to thank Sheigla Murphy, Lynne Watson, LeifZerkin, and Jeffrey Novey for their help in the preparation of this article as well as, and most especially, the 32 individuals who had stayed off methadone and openly shared their experiences for this study.

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