NAMA Policy Statement: Blind Dosing and Patient Dignity

addiction to heroin resulting the cessation of heroin use and criminal behavior.

Prior to the development of methadone maintenance treatment over 28 years ago

narcotic addiction was considered incurable and a behavioral disorder under the

control of law enforcement. Drs. Dole and Nyswander brought the treatment of

heroin use back into the doctor’s office treating the addict as any other

patient with a chronic disease. However, the original methods employed by Dole

and Nyswander have sometimes been misunderstood often impacting negatively on a

New York City area employ for various reasons. Several basic characteristics can

be found within programs with blind dosing policies: 1) an adequate dose is not

prescribed, 2) dosage has become a problem and 3) the program does not believe

in the disease concept of addiction, 4) the program views methadone as a

substitute drug, 5) the program does not understand the physiological

differences found in addicts, 6) the program does not follow a medical model, 7)

the program does not appreciate or understand the biological determinants of

drug craving, and 8) the program is basically administered by behaviorists who

the issue of depending on a chemical substance for support, to make them feel

normal and to get them through the day, so the addict can begin to look to

oneself instead. Unfortunately, it has the opposite effect of being destructive

to the therapeutic relationship between the patient and counselor and the

patient and program. The trust that is necessary for quality methadone treatment

is never developed because the patient feels betrayed and maligned by the one

thing that is suppose to understand them. And patients who are truly a very

small minority and may have problems such as competition with other patients for

the highest dose never have this problem dealt with in a therapeutic manner.

Blind dosing is the program’s way of avoiding the problems that these patients

motivated patient who is determined is able to change their life may be able to.

This is not to say that blind dosing is inconsequential to these patients,

rather they are better equipped for rehabilitation and able to overcome their

feelings of anger toward the clinic. For the unmotivated and ambivalent

methadone patient with low self esteem blind dosing can be disastrous for their

response to treatment. These patients come into treatment with feelings of low

self esteem and hopelessness and need to develop a trusting relationship with

their counselor and the program, which is thwarted. The majority of these

patients could be successful too, but without their development of trust in the

program they can never begin to acquire the necessary attributes such as

According to Rosenbaum (1985) while the reformist treatment style may work for a

short period of time, but eventually the patient will become angry and feel left

out of treatment decisions. The reformist philosophy is too damaging to one’s

self worth for any extended period of time resulting in a low retention rate for

these programs. Those in need of help may accept degrading definitions of

themselves temporarily, however the human psyche will attempt to maintain one’s

integrity and dignity, and will not tolerate long-term degradation, at least not

happily. Thus patients become embittered and resentful toward the clinic

eventually realizing that the program is wrong about many things, including

their treatment. The patient no longer takes their treatment seriously and

becomes frustrated and ambivalent. They can no longer be engaged in

the best liked and most useful aspect of treatment (Stark & Campbell, 1991).

Studies indicate that patient’s awareness and influence in dosing decisions are

important treatment practices and related to retention in treatment (D’Annuno

and Vaughn, 1992; Watters, 1986). D’Annuno and Vaughn (1992) studied 172

methadone programs and found that many have policies that are not effective,

including blind dosing and the patient’s noninvolvement regarding dosing

decisions were noted. For over a decade HIV has been spreading through the

injecting drug user community thus emphasizing the importance of retaining

patients in treatment. Methadone when given in a adequate dose will block the

craving for heroin resulting in the cessation of heroin use and criminal

activity (GAO, 1990). Therefore, if for no other reason retention in methadone

treatment should be a priority for programs (Schuster, 1989). From the patient’s

point of view they have a right to know that they are receiving an adequate

of, perhaps because they know very little about methadone themselves and which

places them in jeopardy. If a patient is blind dosed and not receiving a

blockade dose of methadone and then overdoses they, or their family should they

die could sue the program. There would be little for the program to protect

itself with in such a legal matter, since the National Institute on Drug Abuse,

the Center for Substance Abuse Treatment and the American Methadone Treatment

Association all have policy statements which say that blind dosing in

ineffective and wrong. A second problem is the diversion of methadone by staff

which is very tempting in such a situation. If patients do not know their dose

it would be very easy for program staff to take a few milligrams from every

dose. At the end of the day these few milligrams per patient would become a nice

perk for the employee, especially considering the cost of illicit methadone in

some locals. For the safety of the program it is common sense that patients

has been so successful in treating heroin addiction. Dr. Nyswander believed and

taught other professionals to “…first listen to your patient and you will

never make a mistake” (Dole, 1992). She treated her patients with dignity

and respect, as worthy individuals deserving of medical care and treatment and

as valuable as any other individual receiving treatment for a chronic condition.

And that was why the Dole – Nyswander program was so successful. Now I ask you,

if you went to a physician who prescribed a medication that is described as a

“powerful narcotic” but would not tell you the dose, how would you

feel? Would any responsible adult in their right mind take it? Would you go back

right to know their dose. Program staff that believe in these antiquated

policies need to look within and ask themselves how they would feel if they were

the patient. They need to realize the destructive effects of blind dosing on the

treatment process and have the courage to reverse the policy. In doing so

programs will give the patient’s the dignity that they deserve thus allowing

patients to go on with the difficult task of changing their lives instead of

being concerned with “What dose am I on?”