Vincent Dole

Vincent Dole (18 May 1913 in Chicago – 1 August 2006) was an American doctor, who, along with his wife Dr Marie Nyswander (died 1986), pioneered the practice of using the synthetic narcotic agonist methadone to treat heroin addiction. Drs. Dole & Nyswander, in establishing Methadone maintenance treatment (MMT), revolutionized addiction medicine which for a century had been based on the conventional and widely held view (circa 1965) that narcotic addiction was the result of an intractable moral defect. His work resulted in the partial re-legalization of opioid maintenance in the United States. For this contribution he was a recipient of the prestigious Lasker Award for Medicine, sometimes referred to as "America's Nobel Prize".

Early life

Dole was educated at Stanford University and Harvard University, earning degrees at both and joining the Rockefeller Institute for Medical Research in 1941. During World War II, he was a lieutenant commander at the Naval Medical Research Unit at The Rockefeller Hospital.

Approach to therapy

Dole & Nyswander's skeptical approach to the view that addicts of (certain) drugs were morally unfit, criminals in our midst helped to return the treatment of chemical dependency to doctors, from whom it had been usurped by the anti-narcotics constabulary.

Drug-seeking behavior, like theft, is observed after addiction is established and the narcotic drug has become euphorigenic. The question as to whether this abnormality in reaction stems from the basic weakness of character, or is a consequence of drug usage, is best studied when drug hunger is relieved. Patients on the methadone maintenance program, blockaded against the euphorigenic action of heroin, turn their energies to school work and jobs. It would be easy for them to become passive, to live indefinitely on public support and claim that they had done enough in winning the fight against heroin. Why they do not yield to this temptation is unclear, but in general they do not. Their struggles to become self-supporting members of the community should impress the critics who had considered them self-indulgent when drug-hungry addicts. When drug hunger is blocked without production of narcotic effects, the drug-seeking behavior ends.^[1]

Their achievement was made at a time before the discovery of stereo specific opioid receptor sites distributed throughout the central nervous system, brain and spinal cord, which were activated by naturally produced ligands called endorphins (for "endogenous morphine") & enkephalins to facilitate the body's own process of modulating painful stimuli from acute and/or chronic trauma. It was soon discovered these endogenously produced agents had important molecular similarities to the plant-produced alkaloids morphine & codeine. The discovery allowed Pharmaceutical Companies to create new generations of semi-synthetic and synthetic opioid agonists (agents which mimic the effects of endorphins), antagonists (agents, such as naloxone (Narcan) which reverse the effects of agonists, essential in treating overdose), and even a separate category of "agonist-antagonists" which possess properties across a broad spectrum of different receptors (e.g. Mu, Kappa). Researchers continue to expand our understanding of how the human body regulates everything from reaction to noxious & pleasurable stimuli, temperature, pressure, emotions, learning, and many other physiological processes. The scientific leap also has doubled the choices available to opioid addicts with the availability in recent years of treatment from individual medical practitioners dispensing sub lingual buprenorphine HCl in the form of (Subetex & Suboxone), following the same principles discovered by Dole & Nyswander.

Heroin treatment

Supreme court interpretations of the 1914 Harrison Narcotics Tax Act had criminalized opioid dependency as well as the use of any opioid "for the sole purpose of maintenance." The criminalization and stigmatization of dependent individuals also influenced medical practice. Physicians and pharmacists, who risked being investigated by the Treasury Department officials that monitored their prescriptions, were wary of placing many patients on maintenance. Medical schools provided almost no instruction on addiction.^[2]

In 1964, at Rockefeller Institute (now known as Rockefeller University), Dole and Nyswander initially treated six addicts during the first year, but the results of this work "were sufficiently impressive to justify the trial of maintenance treatment of heroin addicts admitted to open medical wards of general hospitals in the city."^[1] By 1967 over 300 patients were receiving daily doses of methadone, a potent synthetic opioid with an especially long half-life. "After the patients had reached the stabilization level (80 to 120 mg/day methadone) it was possible to maintain them with a single, daily, oral ration, without further increase in dose."^[1] Dole's patients not only largely stopped heroin use, they expressed an interest in family, friends, work, and becoming fully engaged members of society once more. Though psychiatrists were available counseling was not mandatory. Dole found that the shift of priorities from daily drug-cravings and the endless quest to keep the abstinence syndrome at bay restored to these individuals an inherent sense of self-worth; they resumed family responsibilities as well as employment. The doctors noted that although methadone satisfied the physical cravings of heroin addiction, patients soon became completely tolerant to its effects. Patients would remain "dependent" on methadone but could otherwise live normally.^[3]

Habituation results from exposure to any stimulus for long enough. The body always strives for homeostasis or balance, which is why the sudden withdrawal of methadone, morphine, alcohol, cigarettes, precipitates what is called the withdrawal abstinence syndrome.

Legacy

In 1967, Vincent Dole and Marie Nyswander wrote:

"Those of us who are primarily concerned with the social productivity of our patients define success in terms of behavior–the ability of the patients to live as normal citizens in the community–whereas, other groups seek total abstinence even if it means confinement of the subjects to an institution. This confusion of goals has barred effective comparison of treatment results."^[1]

Today, medically supervised methadone maintenance programs are available throughout the United States. A census of certified Opioid Treatment Programs conducted by the US's Substance Abuse and Mental Health Services Administration in 2011 found that 268,208 patients were receiving methadone maintenance at the time of the survey.^[4] Yet, according to a 2008 report by the World Health Organization, “substitution therapies such as methadone are still the most promising method of reducing drug dependence, but getting access to treatment is a global problem.”^[5]

Death

Dole died in 2006 at the age of 93, from complications of a ruptured aorta, survived by his third wife Margaret Cool, his three children, and five grandchildren.

References

1. Dole, Vincent P (MD); Nyswander, Marie E. (MD) (July 1967). "Heroin Addiction – A Metabolic Disease" (PDF). New York Arch Intern Med –Vol 120.
2. “The Opium Problem and the Clinician’s Dilemma,” Caroline Acker, Creating the American Junkie: Addiction Research in the Classic Era of Narcotic Control (Baltimore: Johns Hopkins University Press, 2002), Kindle e-book.
3. Vincent P. Dole and Marie Nyswander, "A Medical Treatment for Diacetylmorphine (Heroin) Addiction: A Clinical Trial With Methadone Hydrochloride" Journal of the American Medical Association, August 23, 1965, 80-84.
4. Substance Abuse and Mental Health Services Administration, 2011 Opioid Treatment Survey, http://www.samhsa.gov/data/DASIS/OTP2011_Web.pdf
5. “The methadone fix,” Bulletin of the World Health Organization, March 2008, http://www.who.int/bulletin/volumes/86/3/08-010308/en/

External links

• A film clip "The Open Mind - Addiction: A Medical Rather Than A Moral Issue (1988)" is available for free download at the Internet Archive