February 14, 2002

Re: Methadone Treatment and Methadone Detoxification for Opioid-Dependent Offenders.

Dear Chief Justice George and Judge Manley:

In recent years, nearly 50% of the patients admitted to publicly funded drug treatment programs were addicted to heroin. It has come to our attention that many courts in California – particularly the “treatment” courts which oversee drug offenders as part of PC 1000 (deferred entry of judgment), Proposition 36, and the Drug Courts – are denying heroin-dependent offenders access to the most effective and proven form of treatment for heroin addiction: opioid agonist replacement therapy, including methadone treatment. We are compelled to write you because courts’ refusal to permit criminal offenders who would benefit from opioid agonist replacement therapy to obtain such treatment should not be countenanced as a matter of medicine, public health, or public safety. Accordingly, the California Society of Addiction Medicine (CSAM) invites the state judiciary to reassess and reform its practices in this area.

The California Society of Addiction Medicine represents approximately 400 physicians of diverse specialties active in substance abuse treatment, research, and academia across the state. CSAM’s mission is to increase access to and improve the quality of addiction treatment through education and research, to reduce the stigma and prejudice commonly associated with addiction disorders, and to promote evidence-based treatment and interventions, of which opioid agonist replacement therapy is a prime example.

Methadone treatment is widely employed throughout the world and is the most effective known treatment for heroin dependence – yielding better results than drug-free outpatient treatment, therapeutic communities, and chemical dependency treatment. The benefits of methadone treatment are established by hundreds of scientific studies. Those studies make clear that methadone treatment is not only the gold standard intervention for heroin dependence, it is also effective at preventing HIV/AIDS, reducing criminal behavior, promoting health, and improving social productivity. What is more, there are almost no negative health consequences of long-term methadone treatment, even when it continues over an extended period of time.

For these reasons, methadone treatment, including methadone maintenance, is endorsed by the World Health Organization, Institute of Medicine, National Institute of Drug Abuse, Center for Substance Abuse Treatment, Department of Health and Human Services, and California’s Department of Alcohol and Drug Programs (among others). Methadone is also endorsed by the former Drug Czar, Gen. Barry McCaffrey, a strong proponent of Drug Courts around the country. And methadone treatment, a form of opioid agonist replacement therapy, is expressly provided for by Proposition 36 (“Prop. 36”), which was endorsed by 61% of the electorate.

Just as the data is uniform regarding methadone’s efficacy, substantial evidence shows that the vast majority of opiate detoxifications lead to relatively prompt relapses. Put differently, clinical consensus and available research indicate that the majority of patients fail to complete detoxification or relapse shortly after completing the detoxification period. Thus, the medical detoxification from methadone of patients on methadone is often inappropriate and ill-advised. Rather, heroin addicts who have shown both long histories of addiction and multiple failures of detoxification are, in the main, much better managed through methadone maintenance.

Like any other aspect of medical practice, treating the heroin-dependent patient is a matter of individualized medicine that must be tailored to the specific patient’s circumstances. The proper dose of methadone, whether the patient should be tapered from methadone, and whether and how long a patient should be maintained on methadone are all issues that should be decided by the patient in close consultation with a skilled medical practitioner who is versed in substance abuse treatment and is experienced in the provision of opioid agonist replacement therapy.

Methadone, a synthetic opioid, does not create euphoria, sedation, or analgesia when taken as a part of a maintenance regime. As a result, methadone maintenance can and does allow individuals to get back on their feet – to obtain and maintain employment, to get and keep housing, to achieve greater social stability, and to lead fully productive lives. In fact, scientific studies show that the most significant health consequence of long-term methadone treatment is a marked improvement in general health.

The California Society of Addiction Medicine is aware that many Drug Courts in California prohibit offenders from participating in or continuing with methadone treatment while part of the Drug Court program. For example, none of the drug courts in Los Angeles County, the state’s most populous county, permit offenders to begin or remain on methadone treatment. Similarly, notwithstanding the clear language and intent of Proposition 36, we have heard of certain courts requiring methadone patients sentenced under this new law to wean themselves from methadone as a condition either of participating in Prop 36 or successfully completing their Prop36 treatment. 

As a matter of medicine, science, public health and compassion, methadone treatment – including methadone maintenance – must be a medical option for all heroin-dependent persons who could benefit from such treatment, regardless of whether they are part of the criminal justice system. To the extent that California’s specialized treatment courts seek to address the needs of heroin-dependent offenders or adhere to evidence-based models for providing substance abuse treatment, policies or practices that inhibit access to methadone treatment run counter to the advancement of public health.

In light of methadone’s proven efficacy, and the unfortunate but widespread reluctance of California’s Drug Courts and many jurists adjudicating sentencing under Prop. 36 to offer methadone treatment, CSAM stands ready and willing to work with California’s judiciary to increase their understanding and acceptance of methadone treatment as a critical tool in the arsenal of substance abuse treatment. We welcome your thoughts and suggestions on how we can provide assistance to you and your colleagues.

Sincerely,

Gary Jaeger, M.D., FASAM

Chief of Addiction Medicine, Kaiser Foundation Hospital and President, California Society of Addiction Medicine