I’m currently studying addictions and I’m somewhat confused by different opinions run into about medications like methadone or Suboxone. In some places, maintenance is the preferred treatment for drug addiction. Other experts seem to frown on it. I’m confused.”

No doubt you are. Maybe it’s easiest to think in terms of two disease concepts rather than one. Both view addiction as a chronic disease, but there the similarity ends.


Disease Concept One arose mostly from experience with alcoholism. It was most effectively described by Jellinek in his 1960 book, The Disease Concept of Alcoholism. Jellinek identified five types of alcoholic drinking, two of which he regarded as disease. (See our article here for more detail.) At the risk of oversimplifying: this disease concept treated addiction much as you would an allergy, with avoidance of the allergen (say, alcohol ) as the key to successful treatment . In that sense, it was an abstinence-based or drug-free approach.


Concept Two was derived from the movement towards substitution therapy for heroin addicts, articulated by Dole and Nyswander in the 1960’s. Addiction was seen as a symptom of an underlying neurochemical deficit, possibly pre-existing, that could be effectively remedied through continuing administration of another, safer, opiate. The first was methadone, and it’s being replaced by buprenorphine. This longer lasting, orally administered opioid was intended to block the euphoria from
other opioid use — thereby reducing the incentive for same.

Advocates of Concept 2 pointed to the quick results achieved by maintenance in terms of reduced criminal activity, overdose, and disease risk. Proponents of Model 1 argued that the addict hadn’t really addressed addiction at all, but simply switched dependence to something else. These differences are hard to reconcile, and the disputes that arise from them can become quite acrimonious. In practice, most communities nowadays have developed a workaround–– they provide both options for opioid patients, and lacking a methadone for alcohol or cocaine, use a more traditional abstinence-based approach for those addictions.

I hope you don’t expect me to resolve this debate. I generally avoid long, circular, partisan arguments. If that’s what I wanted, I’d turn on C-SPAN and watch the budget process.