Medication-Assisted Treatment for Opioid Addiction in the United States

Substance Use & Misuse

ISSN: 1082-6084 (Print) 1532-2491 (Online) Journal homepage: http://www.tandfonline.com/loi/isum20

Medication-Assisted Treatment for Opioid Addiction in the United States: Critique and Commentary Karen McElrath To cite this article: Karen McElrath (2017): Medication-Assisted Treatment for Opioid Addiction in the United States: Critique and Commentary, Substance Use & Misuse, DOI: 10.1080/10826084.2017.1342662 To link to this article: http://dx.doi.org/10.1080/10826084.2017.1342662

Published online: 01 Sep 2017.

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Date: 01 September 2017, At: 12:43

SUBSTANCE USE & MISUSE , VOL. , NO. , – https://doi.org/./..

COMMENTARY

Medication-Assisted Treatment for Opioid Addiction in the United States: Critique and Commentary Karen McElrath

Downloaded by [karen mcelrath] at 12:43 01 September 2017

Department of Criminal Justice, Fayetteville State University, Fayetteville, North Carolina, USA

ABSTRACT

KEYWORDS

In the United States, buprenorphine products (namely buprenorphine/naloxone combination) and methadone are the primary forms of medication-assisted treatment (MAT) that are authorized for addressing opioid addiction. Although treatment ideologies differentiate MAT programs, much of the provision in the US reflects a model of “high threshold, low tolerance.” This model is discussed with a focus on structural and programmatic barriers that shape access to and retention in MAT. The critique continues with a discussion of multifaceted stigma that reinforces spoiled identities and diffuses into treatment settings. The social control mechanisms that are imposed in MAT are strikingly similar to those reflected in criminal justice settings, namely probation, parole and community corrections more generally. Parallels are drawn between the “addict” and the “felon” and how they are monitored, tracked, and controlled. These factors have major implications for recovery.

Medication-assisted treatment; opioid dependency; addiction; methadone; buprenorphine; stigma; identity; high threshold/low tolerance

Background Methadone and buprenorphine are widely recognized as important medication-assisted treatments (MAT) for addressing opioid addiction. Several studies have found that MAT can reduce heroin or other opioid use (Fareed, Casarella, Amar, Vayalapalli, & Drexler, 2009; Nielsen et al., 2015; Simoens, Matheson, Bond, Inkster, & Ludbrook, 2005; Teesson et al., 2006), risk behaviors associated with HIV (Corsi, Lehman, & Booth, 2009; Gowing, Farrell, & Bornemann, 2008; Hartel & Schoenbaum, 1998; Otiashvili et al., 2013), crime (Lind, Chen, Weatherburn, & Mattick, 2005; Sheerin, Green, Sellman, Adamson, & Deering, 2004), and fatal overdose (Fugelstad, Stenbacka, Leifman, Nylander, & Thiblin, 2007). In the United States, buprenorphine products (namely buprenorphine/naloxone combination) and methadone are the primary forms of MAT that are authorized for addressing opioid addiction. Much of the provision and delivery of MAT in the US reflects a model of “high threshold, low tolerance.1 ” High threshold refers to the numerous structural and programmatic barriers that impede people’s access to MAT. These structural barriers include, for example, rigid criteria and long wait times for admission, excessive fees, and very limited treatment availability in several locations. Low tolerance denotes the various programmatic and regulatory policies that

hinder patients’ progress after they initiate MAT. The low tolerance component of the model is often tied to MAT attrition. These concepts are illustrated in Table 1 and discussed below. High threshold For several decades, critics have voiced concerns about the structural and programmatic barriers associated with MAT provision in the US (Ball and Ross, 1991; Joseph, Stancliff, and Langrod, 2000; Rettig and Yarmolinsky, 1995). Since 1972, methadone maintenance in the US has been highly regulated with the introduction of stringent controls imposed by the Food and Drug Administration. Vincent Dole (1994) recalled the highly politicized efforts to subjugate maintenance and noted that the medical community was for the most part excluded from official discussions that led to the early regulatory controls. Perhaps the most significant policy changes occurred about three decades later, with the 2001 regulations that shifted the oversight to the federal government agency, Substance Abuse and Mental Health Services Administration (SAMHSA) but also required a minimum number of random urine tests to be conducted per patient per year, and reiterated multiple criteria before patients were eligible for take-home doses. Currently, methadone maintenance

CONTACT Karen McElrath kmcelra@uncfsu.edu Department of Criminal Justice, Fayetteville State University, Fayetteville, North Carolina, , USA.  I learned this concept from two community outreach workers in Belfast where I worked for  years. Iain “Buff” Cameron and Chris Rintoul used the phrase “high threshold/low tolerance” to refer to the rules and regulations imposed by some homeless shelters that attempted to exclude people who were both homeless and experiencing drug (namely heroin) addiction. ©  Taylor & Francis Group, LLC

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Table . MAT in the US: high threshold, low tolerance model. High Threshold Multiple regulatory bodies that oversee and monitor OTPs Travel distance and travel costs to/from MAT programs


High financial costs to patients (limitations relating to insurance and Medicaid coverage) Waiting lists/lengthy wait times for treatment Limited number of buprenorphine-waivered physicians, including the unwillingness of physicians to prescribe Daily medicine collections (methadone in particular) that intervene with recovery goals, e.g., employment, training, education NIMBY-like stigma

Low Tolerance Urinalysis results that lead to punishment, including termination from the program Urine specimens that are required under the watchful eye of treatment staff Punishments imposed for patients who miss appointments or arrive late for appointments One-sided contracts that focus only on behaviors of the patient or mention negative behaviors only Dosage levels that are too low; forced or arbitrary tapering

Power imbalances that reinforce “addict” identities in MAT settings Other hyper-supervisory controls over daily lives

for opioid addiction can only be provided from Opioid Treatment Programs (OTP) that have been certified by SAMHSA. Although the majority of buprenorphine providers are office-based physicians, OTPs can also provide buprenorphine treatment. Additional layers of regulations are imposed by the Drug Enforcement Administration (a federal agency that has authority to conduct on-site visits of OTPs) and by the respective state opioid treatment authority (SOTA). Admission to methadone maintenance treatment is restricted to persons who currently have and have had an opioid use disorder for at least one year (Substance Abuse and Mental Health Services Administration, 2015). Most OTPs are located in urban areas; data collected between 2005 and 2009 found that about a quarter of patients (26%) traveled 15 miles or more to their OTP (Rosenblum et al., 2011). Those authors also found that 8% of patients traveled to another state to access MAT via OTP, and the average distance for those patients was 50 miles. In a separate study, a number of patients at a clinic in Charleston, South Carolina reportedly travelled 3–4 hours for buprenorphine maintenance (Bentzley, Barth, Back, Aronson, & Book, 2015). The financial cost for patients who engage with an OTP epitomizes a high threshold model. Although costs of MAT vary considerably across and within states, out-ofpocket payments are approximately $42 to $166 per week for methadone and considerably higher for buprenorphine/naloxone treatment (Peddicord, Bush, & Cruze, 2015). Patients who need ancillary support services might be required to pay additional fees. In the US, Medicaid

provides for the cost of healthcare to people who meet criteria for disability and for people from low-income backgrounds. However, a number of states as well as programs within states do not permit Medicaid payments for services provided by an OTP. Additionally, several health insurance companies do not cover the cost of treatment provided by an OTP. Consumer-led discussions about costs of and access to methadone and buprenorphine treatment in the US are prevalent among would-be and current patients who participate in online discussion forums and private social media groups. Buprenorphine for opioid addiction has been available in the US since the passage of the Drug Addiction Treatment Act (DATA) of 2000. The DATA legislation allowed physicians who underwent brief training to be certified as buprenorphine-waivered, meaning that they were permitted to prescribe buprenorphine for patients who have an opioid use disorder. For several years, uptake was limited by federal regulations that capped the number of patients to 30 per each buprenorphine-waivered physician. In 2006, the cap was increased to 100 patients for physicians who had been buprenorphine-waivered for at least one year and had requested an increase. Still, there were no buprenorphine-waivered physicians in 43% of US counties during 2011 (Stein, Gordon, Dick, Burns, Pacula, Farmer, Leslie, & Sorbero, 2015). Moreover, during a three-month period in 2014, a total of 133 physicians had prescribed/dispensed buprenorphine for opioid addiction yet nearly half (48%) of the physicians had fewer than six patients (Sigmon, 2015). Access to buprenorphine treatment has been limited greatly by the unwillingness of physicians to prescribe for opioid addiction. Physicians have voiced concerns about patient access to psychosocial and other services, as well as the increased time spent with buprenorphine patients (Netherland et al., 2009). The limited number of buprenorphine-waivered physicians led a treatment/recovery program in the state of Maine to contact over 100 physicians, offering them $5,000 if they completed the eight hours of training required for buprenorphine prescribing; 18 months later – not one physician had agreed to participate (Farwell, 2015). The gap in buprenorphine services has coincided with a number of waivered physicians opening up storefront clinics that accept cash only in exchange for buprenorphine treatment. Patients might present for a prescription once a month. Psychosocial services are not necessarily required nor available. In fact, we have scant information on the types of psychosocial or ancillary services that are available through storefront and other clinics that offer buprenorphine treatment. According to an investigative report by the New York Times (Sontag, 2013, buprenorphine-waivered physicians


SUBSTANCE USE & MISUSE

have been described as “extremely passionate”; others as “intensely commercial.” The report also found that 1,350 of 12,780 buprenorphine-waivered physicians had been disciplined for misconduct, e.g., overprescribing and fraud. This figure is considerably higher than the rate of misconduct among physicians in general. Still, other prescription-only providers might be helpful to individuals who cannot access buprenorphine treatment elsewhere or who have been terminated from other MAT programs. In 2016, new federal regulations allowed for buprenorphine-waivered physicians to increase their patient load to 275 if they have prescribed buprenorphine to 100 patients for at least one year. This change is consistent with one of the three priorities (i.e., expanding access to MAT) announced in 2015 by the United States Department of Health and Human Services (2016). One wonders if the federal government approved the increase in patient load because of the limited number of new buprenorphine-waivered physicians. Low tolerance Patient retention in MAT is important because it reduces the likelihood of relapse into opioid use, and in turn, fatal overdose and injecting behaviors associated with blood-borne viruses. Moreover, retention in MAT has been linked to improved quality of life among patients (Mitchell, Gryczynski, Schwartz, Myers, O’Grady, Olsen, & Jaffe, 2015; Ponizovsky & Grinshpoon, 2007). Leaving MAT prematurely tends to occur more frequently within the first few months of treatment (Farré, Mas, Torrens, Moreno, & Camí, 2002). Among AfricanAmerican MAT patients in Baltimore, treatment dropout during the first six months was twice as high among buprenorphine patients compared to methadone patients (Gryczynski, Mitchell, Jaffe, Kelly, Myers, O’Grady, Olsen, and Schwartz, 2013). Although differences in attrition between buprenorphine and methadone patients were observed in the early phases of treatment, the authors noted that the retention disparity reduced over the course of treatment (Gryczynski et al., 2013). The low retention rates reported in various studies are rather striking.2 Attrition among adult patients in buprenorphine treatment has approximated 50 to 60% at 12 months (Alford, LaBelle, Kretsch, Bergeron, Winter, Botticelli, & Samet, 2011), and 40 to 50% at six months (Saloner, Daubresse, & Caleb Alexander, 2017; Teruya et al. 2014). Similarly, upwards of 40 to 60% of methadone clients were reported to have left treatment within 12 to 

Treatment attrition is also high in programs that do not provide medicationassisted treatment. Among people addicted to opioids, however, attrition tends to be substantially higher for those who do not receive MAT compared to those who do (see for instance, Kakko, Svanborg, Kreek, & Heilig, ).

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14 months (Kellogg et al., 2006; Liu et al., 2009; Nosyk, Marsh, Sun, Schecter, & Anis, 2010). In their review of the literature on methadone maintenance, Fischer and colleagues (2005: 3) concluded that “patient retention . . . is the exception rather than the rule.” Why is the MAT attrition so extensive? Various factors have been found to contribute to treatment drop out (Magura & Rosenblum, 2001). For example, attrition has been linked to individual-level factors (Mancino et al., 2010) such as employment (Hillhouse, Canamar, & Ling, 2013) and daily opioid use in the 30 days prior to treatment initiation (Hillhouse, Canamar, & Ling, 2013). In the US, attrition from buprenorphine treatment has been found to be significantly higher among patients from lowincome backgrounds and/or who have disability status (Saloner, Daubresse, & Caleb Alexander, 2017). Other studies have found that attrition from MAT is fueled by negative interactions between physicians or program staff and patients (Damon et al., 2017; Gryczynski, Mitchell, Jaffe, O’Grady, Olsen, & Schwartz, 2014). In fact, a host of structural-level and programmatic factors create the conditions for leaving MAT prematurely (Ball & Ross, 1991; Bao et al., 2009; Harris et al., 2006; Porter, 1999; Reisinger et al., 2009). Research from various countries has documented that methadone patients experience difficulty with daily collections of methadone (Holt, 2007), limited collection times (Anstice, Strike, & Brands, 2009), lengthy wait times for collections (Fraser & Valentine, 2008), supervised consumption when stable (Stone & Fletcher, 2003), and lack of privacy in pharmacy settings (Anstice et al.; Fraser, Valentine, Treloar, & Macmillan, 2007; Harris & McElrath, 2012; Matheson, 1998; Stone & Fletcher). Additionally, patients have reported the difficulties associated with the control of methadone or buprenorphine maintenance over daily lifestyles (Gryczynski et al., 2014; Reisinger et al., 2009). Dosage levels that are too low also can contribute to attrition from MAT. D’Aunno and colleagues (2014) concluded that 23% of patients in methadone maintenance in the US were in receipt of doses that were lower than the 80 mg/day minimum, as indicated by scholarly evidence for effectiveness. Those authors also found that lower doses were more common in methadone programs that treated a higher proportion of African-American and Latina/o patients.

Enter stigma Stigma has helped to shape and reinforce the high threshold/low tolerance model that has characterized so many MAT programs in the US. Building on the groundbreaking work of Erving Goffman (1963), Link and Phelan (2006) suggested that stigma is best understood as a


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process that consists of interrelated components. The process begins with the way that people identify socially relevant differences between individuals, and continues with the labelling of individuals in negative ways, differentiating between “us” and “them.” Discriminating against and exercising power over the stigmatized represents another component. Power, in fact, is a key component in the stigma process (Link & Phelan, 2006). Without power differentials and the exercise of power, there is no stigma. Multiple sources of stigma are directed towards people who experience drug addiction (Fraser, Pienaar, DilkesFrayne, Moore, Kokanovic, Treloar, & Dunlop, 2017). Stigma can be imposed by individuals, communities, and services, including those that are designed to treat people who experience opioid addiction. In contemporary society, stigma imposed by individuals has increasingly moved into the public gaze. We observe this transition in the comment sections of various online news reports that feature stories of people with opioid addiction. References to “junkie,” “scumbag,” and other disparaging descriptors tend to distance the commenter from the individual so stigmatized. Some of the respondents who participated in the study by Fraser et al. (2017) described that they avoided reading media reports about drug use because the reports tended to sensationalize drug use and reinforce spoiled identities. At the community level, stigma manifests in NIMBYlike attitudes that reinforce the “us” versus “them” distinction. Various communities in the US have sought physical and social distance from people dependent on opioids. Community stigma towards methadone clinics and the patients they serve emerged decades ago (Rettig & Yarmolinsky, 1995), and more recent opposition has surfaced in a range of locales (Jaffe, 2015; Sofastaii, 2016). In Salem, Massachusetts, local politicians unanimously rejected a request to open a methadone clinic in the town. A local resident expressed her relief: “We will sleep better tonight” (Galang, 2010). In parallel, some providers of MAT impose stigmatizing attitudes towards patients. These attitudes might reflect the program’s ideological perspective about treatment and recovery. Alternatively, the attitudes might be imposed by some personnel but not others. In some instances, treatment staff can shame and stigmatize patients without intention (Smye, Browne, Varcoe, and Josewski, 2011). Physician and advocate, Robert Newman (interviewed by White, 2011) described the views of some treatment providers that are at times more punitive than those held by the general public. He noted that the punitive nature of some clinic staff manifests through methadone dosage reductions and forced tapering as forms of punishment. Indeed, “naked power relations” between staff and patients have been said to

guide dosage levels more so than other factors (Bourgois, 2000:182). Over three decades ago, Newman (1976) observed that the rigid structure of methadone maintenance programs in the US deviated substantially from the way that they were originally envisioned. Indeed, Dole and Nyswander (1980) emphasized the importance of mutual respect between treatment staff and methadone patients. They suggested that, without this respect, “an adversary relationship develops between patients and staff, reinforced by arbitrary rules and the indifference of persons in authority” (p. 261). Moreover, Dole and Nyswander integrated treatment-based peer support several decades before US federal guidelines acknowledged the importance of peer-based interventions. Dole and Nyswander hired patient assistants – individuals who had stabilized on methadone – to liaise between new or mistrustful patients and clinic staff. Later, the patient assistants transitioned to counselors or administrators in the clinics (Joseph & Woods, 2006). That was approximately 40 years ago.

The “addict” and the “felon” Stigma and social control are linked through unequal power relations. Power features in stigma theory because stigma emerges from unequal power relations (Gilmore & Somerville, 1994). Social control is fueled by power imbalances whereby those in positions of power can identify, track, control, and punish behavior. Moreover, stigma itself is a mechanism of social control (Mill, Edwards, Jackson, MacLean, & Chaw-Kant, 2010). Major societal and political shifts have led to the diffusion of social control mechanisms that attempt to discipline and regulate deviance (Cohen, 1985). These mechanisms are imposed to define moral boundaries and in particular, to monitor deviants in a panoptic world. In the context of many MAT programs in the US, the mechanisms of social control tend to mirror those that permeate the criminal justice system. Specifically, parallels can be drawn in terms of the hyper-supervision of people who are patients in MAT and those who are under the control of community corrections (e.g., probation, parole, house arrest, electronic monitoring). In both contexts, those in positions of power use their privilege and institutional permission to monitor and sometimes punish (Cohen, 1985) the hyper-supervised. The influx of criminal justice-like surveillance and monitoring of MAT patients commenced several years ago and has expanded greatly. Much like the highly monitored “felon” (Opsal, 2011) whose master status creeps into the domain of disenfranchisement (Uggen & Manza, 2006) and excludes her from housing and employment (Alexander, 2010;


Pager, 2003; Segall, 2011), the “addict” must proactively work to shake off, resist, or manage the spoiled identity. Although preventing overdose and diversion are important, the overreach of social control mechanisms that often characterize MAT programs can impede recovery by reinforcing “addict” identities via the presumption of deviance (Harris & McElrath, 2012). The identity of “addict” becomes salient, and “tends to take center stage to the obscuration of all other facets of identity and personality” (Lloyd, 2010:13). Below I discuss five components of hyper-supervision that jointly characterize MAT and probation/community corrections in the US. All of these components contribute to and reinforce spoiled identities of the “addict” and the “felon.”


Frequent urinalyses Drug screening via urinalysis can be an important tool for adjusting a patient’s treatment plan. For example, patients who test positive for heroin or other non-prescribed opioids after MAT has commenced might respond better to treatment if they were prescribed a higher dosage of methadone or buprenorphine (American Society of Addiction Medicine, 2013). In the past, some programs were known to “punish patients for showing signs of the condition being treated—drug use—by lowering their methadone dosage” (Newman in White, 2011). Presently, patients whose urinalysis results fail to show recent use of buprenorphine or methadone are often suspected of diverting the prescribed substance even though a host of factors can lead to this kind of false negative (Department of Vermont Health Access, 2015: 16). Although the diversion of various medicines is relatively common in the US (Lofwall & Walsh, 2014), the surveillance and punishment of patients is near exclusively confined to MAT settings. Moreover, would the diversion of buprenorphine occur if treatment slots were accessible and treatment were meaningful to patients? The misuse of diverted buprenorphine is often due to the need to avoid withdrawal rather than an interest in getting high (Genberg et al., 2013). MAT patients who test positive for illicit drugs other than prescribed opioids can be terminated from treatment, just as the “felon” under community correctional control can face probation revocation and more stringent punishment in jail or prison. Patients who cannot or refuse to provide a urine specimen are often presumed to have ingested substances that are prohibited. Similarly, at the local probation office in the city where I work, some unfortunate individuals wait endlessly in the front room, making frequent trips to the water fountain in hopes of providing the required urine specimen before closing time.

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My point here is not to argue the benefits or limitations of urinalysis, but to suggest that the mere inclusion of urinalysis in MAT and the way that urine specimens are collected, have the potential for impacting negatively on the patient/provider relationship. The policy invokes a sense of distrust of the patient because deviance frames the “addict” identity. As part of the initial or ongoing assessment in MAT, patients are asked to self-report drug use. They are then asked to provide a urine specimen perhaps only after emptying their pockets and placing their coat and other items outside the bathroom before entering it (e.g., Department of Vermont Health Access, 2015). At times, they are asked to provide a specimen under the gaze of treatment personnel. Urinalysis outcomes that lead to termination from MAT imply that urinalysis is used as punishment as opposed to a tool to enhance the treatment plan. If we are truly concerned that a patient is not engaging well with treatment, why do we force their return to an environment in which relapse and perhaps overdose are highly probable?

Threat of unannounced monitoring At the start of treatment, many MAT programs in the US inform patients that they might be subjected to pill/strip counts (buprenorphine) or bottle recall (methadone) (see for instance, the program described by Alford et al., 2011). These policies are said to be important in order to reduce the likelihood of diversion and overdose. At an OTP that provides buprenorphine (but not methadone) in New York State, patients must agree to the following: “I will submit to unannounced random pill [strip] counts . . . If I fail to come in when called (or if I fail to return the call), I understand that I may be immediately dismissed from the program. Lack of transportation is no excuse . . . ”

Patients are in fact “on call” and must always prepare for “the count” or bottle recall. Patients must have transportation and a phone at hand, and cope with the anxiety of the unknown, much like the “felon”: “While on probation, you must submit yourself, your residence, any vehicle, and any property under your control to random search and seizure for alcohol and/or controlled substances, by any peace officer, at any time, day or night, without a search warrant.” (Department of Alternative Sentencing, n.d.) “Be prepared for your probation officer to make unannounced contacts at your home, place of employment or elsewhere on a periodic basis. These contacts can be at any time and may occur on weekends, evenings, or holidays. Failure to cooperate is a violation of your supervision.” (United States Probation and Pretrial, 2014)

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Confirmation or proof of participation The presumption of deviance encroaches further when patients are required to provide proof of their attendance at 12-step or other ancillary programs. Proof of attendance is ascertained with a signature from the group facilitator or other staff member. The confirmation of attendance is then provided to OTP personnel. In contrast, self-report is nearly always viewed with suspicion; the “felon” must abide by similar rules:


“You are responsible for providing DAS with proof of participation and completion of all court-ordered conditions, including but not limited to counseling reports, enrollments, VIP certificates, community service time sheets, and AA meeting attendance logs.” (Department of Alternative Sentencing, n.d.)

One-sided contracts Several MAT programs require patients to review and sign contracts (sometimes called “agreements”) prior to the commencement of treatment. Similar contracts are required of individuals on probation. In MAT programs, the word “contract” is somewhat of a misnomer because the entire focus of the document is on the behaviors of the patient; rarely does the contract mention the promise of decent and humane conduct by treatment personnel. A contract issued to patients by a buprenorphine treatment provider in New York State includes the following: “I agree to conduct myself in a courteous manner at all times in the office. Disruptive behavior and/or foul language will not be tolerated. This will result in termination of this agreement and may even result in dismissal from the entire practice as well.”

The “felon” is contractually obligated to act in a similar manner: “I will treat all persons with respect and courtesy and refrain from assaultive, intimidating, or threatening verbal or physical abuse.” (State of Iowa, 6th Judicial District, 2012.)

The patient contract also describes the unannounced monitoring (discussed above), proscribes other behaviors, and hints at program dismissal in several sections. Strict regulation over people’s time/lives Just like the rigidity of appointments shapes the everyday routine of people under correctional control, so do the rules and regulations of MAT. Both the “addict” and the “felon” are tied – physically and mentally – to the service: “I will keep all appointments including group sessions. If I must miss a group or individual session I will get prior approval from my counselor at least 24 hours in advance

and provide documentation (i.e., copy of work schedule). I will attend 80% of my scheduled services regardless of the reasons for absence …If I’m going to be more than two hours away from the office, I will notify the office accordingly.” (Patient contract, OTP in New York State) “You will be required to report in person to your DAS Officer according to a specific schedule. You are to report in person, as ordered, to DAS between 9:00 am and 3:00 pm Monday through Thursday and between 9:00 am and 12:00 pm on Friday . . . If you arrive late, you will not be permitted to check in and will be in violation of your probation.” (Department of Alternative Sentencing, n.d.)

Conclusion The layers of stigma imposed on people who experience opioid addiction tend to permeate society. Fraser et al. (2017) argued that despite the attempted diffusion of a model that emphasizes addiction as a brain disease, multifaceted stigma “cannot be remedied by disease conceptsindeed it may be magnified by them.” Stigma moves into treatment provision where the hyper-supervision that characterizes several MAT programs tends to reinforce rather than rehabilitate “addict” identities. Rules and regulations frame “addicts” as deviants and the hypersupervisory monitoring helps to reinforce spoiled identities. The stigma and social control that frame much of the MAT provision in the US have the potential to discredit and negate self-recovery, particularly when individuals internalize the stigma. (Re)developing non-“addict” identities is important for recovery (Biernacki, 1986), and positive self-identities are more likely to surface in the absence of institutionalized and internalized stigma. The paradox is this: Stigma disempowers MAT clients, whereas recovery requires empowerment. Instead of the high threshold/low tolerance model that characterizes so much of MAT provision in the US, we need the opposite. We need programs that are much easier to access, in terms of entrance criteria, location, and costs. And we need programs that are staffed by people who show tolerance and compassion for patients, who embrace the importance of the patients’ values (Marchand & Oviedo-Joekes, 2017), and who recognize that MAT retention is an important goal in and of itself. We need to incorporate a model that reflects low threshold/high tolerance. In many ways, the journey of the “addict” parallels that of the “felon,” whereby individuals are regulated through intensified surveillance and “normalizing judgment.” The “addict” and the “felon” embark on similar journeys as they attempt to negotiate spoiled identities in a stigmatizing world. People dependent on opioids might pursue recovery whereas the formerly convicted might pursue reentry. For the “addict,” treatment can aid


or negate recovery just as probation and community corrections can aid or negate reentry for the “felon.” For the “addict,” we often define “relapse” as failure. For the “felon,” “recidivism” equates to failure. Yet we also emphasize that both relapse and recidivism are normative behavior while ignoring the structural processes that contribute to both. It seems that we have embraced the Durkheimian view, “The way a society reacts to sickness and crime reaffirms its core values” (Freund, McGuire, and Podhurst, 2003:126).

Acknowledgement


Many thanks to Andrew Rosenblum and Herman Joseph for their helpful suggestions on an earlier version of this paper. An earlier version of this paper was presented at the 2016 annual meeting of the Academy of Criminal Justice Sciences, Denver.

Declaration of interest The author reports no conflict of interest. The author alone is responsible for the content and writing of the paper.

ORCID Karen McElrath

http://orcid.org/0000-0003-3578-9008

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