Review of Liquid Handcuffs: Policing and Punishment in Methadone Clinics and the Future of Opioid Addiction Treatment
Liquid Handcuffs: Policing and Punishment in Methadone Clinics and the Future of Opioid Addiction Treatment by Helen Redmond, LCSW, North Atlantic Books 2026
I have only worked with a handful of clients on prescribed methadone, as opposed to hundreds if not thousands prescribed buprenorphine– and that's not by happenstance. At least in Maine, methadone patients generally cannot receive intensive substance use services from any provider other than their methadone clinic (by which I mean, insurance won't pay for such services). I have looked up and down for a clinical justification for this rule, but haven't found one. (Anybody???)
Author Helen Redmond would likely blame the "methadone mafia." Liquid Handcuffs shows why, even in the shady industry of addiction treatment overall, methadone clinics are particularly brazen in prioritizing revenue over patient care. Redmond, a journalist and senior editor at drug-themed Filter magazine, clearly expresses her mission in Liquid Handcuffs: to abolish the methadone clinic system.
For Background: An Intro to Opioid Maintenance Medications
Methadone is a full opioid agonist, meaning it binds "tightly" to opioid receptors in the brain for maximum effect. In this sense it belongs to the same class of opioids as morphine, heroin, and oxycodone (among others). Methadone was developed in the 1940s, and after World War II, manufacturers worldwide were authorized to produce it for only a nominal fee– meaning the drug itself could never make much money for anyone.
Buprenorphine is a partial agonist, binding only "partially" to the opioid receptors for an effect expected to plateau at higher doses. Pure buprenorphine is also known by trade name Subutex. Buprenorphine was first developed in the 1960s, and various patented formulations have been hugely profitable for manufacturers. Its clinical nickname is "bup," pronounced "byoop."
Suboxone is a mixed agonist and antagonist: buprenorphine (i.e. Subutex) combined with Naloxone, hence its name. The antagonist effect of Naloxone is meant to block binding with some opioid receptors, protecting against overdose and limiting euphoric effects. Pure Naloxone is also known as Narcan, which is used to reverse opioid overdose. In my experience, addiction prescribers prefer Suboxone over Subutex because it is harder to use recreationally and has a lower "street" (illicit resale) value. In this post I'm discussing "buprenorphine" as an alternative to methadone, but I wanted curers to know know the difference between buprenorphine drugs.
Separate and Unequal
So we have an old, unprofitable medication and a newer "blockbuster drug." Can you guess who's ended up on which one? I often write about de facto segregation in addiction treatment, and it applies just as well to opioid maintenance meds as to any other service.
Methadone was conceived as a tool to combat urban crime, with patients required to attend clinic in person every single day for observed dosing. The term "liquid handcuffs" originated among early methadone patients, but still accurately describes the protocol: anything less than perfect attendance, and your prescription can be yanked. "Take-home" doses are a rare privilege, so being on methadone means building your daily schedule, indefinitely, around your clinic's limited hours, and never traveling for any reason. The rules for conduct within the clinic are so strict that Redmond convincingly presents it as a prison-like environment in which patients are treated like criminals.
Buprenorphine, on the other hand, was FDA-approved for opioid use disorder in 2002. At the time, powerful, well-connected people were frantic over the "opioid epidemic," in which young white people (like their own children) had become "the new face of addiction." From the start, it was presumed that this "new" patient population needed a more dignified, individualized, and discrete approach. Meanwhile, maintenance medication was for the first time poised to generate profit: by marketing patent-protected buprenorphine drugs to patients with private insurance. Under the law, buprenorphine could be prescribed by anyone with a required waiver (a qualifier that has since been eliminated). Patients can simply pick up this prescription at the pharmacy and take it on their own time. For more on this "whitening" of opioids and maintenance medication, I recommend Whiteout by Hansen et al.
Redmond highlights how intentional is this discrepancy, i.e. racism, in opioid prescribing. Even some of the same people advocating for laxity in buprenorphine protocols– for the reasons above, which are just as true for poor patients of color as wealthier white patients– were content to leave everything status quo with methadone. Some buprenorphine patents have since expired, meaning generics are becoming available.
But differential rules, and the associated segregation, remain: as of 2023, white patients across the US were 3-4 times more likely than Black to get prescribed bup. And the methadone mafia– the political lobby for owners of these clinics, which are now 65% for-profit– aggressively works against any relaxation of rules around methadone because their revenue model relies on forcing people to attend clinic as often as possible.
Parallels Between Methadone and Buprenorphine Treatment
Again, most people I have worked with on opioid maintenance have been prescribed buprenorphine. But it's not an elite population: I'm talking about primarily white Mainers, covered by Medicaid or grant-funded care, receiving prescriptions in a group setting at a dedicated addiction treatment facility. Generally, attending several times weekly is required for a new prescription. In other words, these white people on buprenorphine have little of the discretion and freedom associated with that status.
Here are some additional ways I've seen buprenorphine protocols for poor white patients mimicking what Redmond describes with methadone:
Pro forma counseling: Patients who just want buprenorphine are forced to participate in psychosocial treatment that they don't want– just like methadone patients. For fear of losing their prescriptions, they play along, but they share very little with counselors in a waste of everyone's time.
Concerns about diversion: Methadone daily dosing, in front of clinic staff, is rationalized with the risk of diversion (patients trading or selling their meds). Diversion risk is also the rationale for dispensing methadone in liquid form, as opposed to in pills or dissolving strips like buprenorphine. I've never been involved in daily dosing for bup, but patients on bup or who have take-home methadone may both be subject to "med counts:" asked at random to present the remainder of their meds to see if what they have matches up with the date and amount of their prescriptions.
Redmond emphasizes research findings that concerns about med diversion are overblown. This kind of policing certainly reifies the idea that people on opioid maintenance meds are untrustworthy and prone to crime. I can't speak to methadone diversion, but in my experience bup diversion is a thing– and the illicit users are not, as often claimed, all other opioid-dependent people who just couldn't get prescriptions. I've had several folks who started buying illicit Suboxone for recreational use, with no prior opioid experience, and got addicted to opioids through this drug intended to treat opioid addiction.
The way out of this morass, in my opinion, is not ever-tighter controls on patients or on prescribing. It's safe supply: a legal, regulated supply of drugs that are currently only available on the illicit market. We'd get to stop scrutinizing why each person wants each drug, stop pretending treatment or therapy is going on when it isn't, and just let people ingest what they please with transparency as to what's in it.
Rosalie Genova
Controversy around chemical dependency: Liquid Handcuffs describes methadone clinic staff pressuring patients to taper off the medication. She reports that inappropriately enough, clinic staffers are often traditional "drug-free" recovery advocates who don't believe in maintenance medication at all. No one should be pressured off these medications, as it may well destabilize their lives and increase their risk of overdose. Furthermore, being "drug-free" or "not dependent on anything" is neither an objective virtue nor a universal goal.
But with buprenorphine, in my experience, clinical advice has moved too far in the opposite direction: pressuring patients to keep taking it when they express a wish to get off. Many clients have told me that their bup prescribers won't even discuss discontinuing their prescription, although the patient wants to. Getting off maintenance medication carries risk, of course. But patients need to feel they can weigh that risk for themselves. And if they do aspire to be "drug-free" or "not dependent," that needs to be respected– not dismissed as an outmoded or uninformed idea.
My one quibble with Liquid Handcuffs relates to this controversy around dependency. Redmond does not acknowledge that some patients have real convictions about getting off all opioids, forever. She goes so far as to say that the Young Lords, some of the first organizers focused on addiction treatment, misunderstood the role of methadone in the social control of urban people of color. Redmond asserts that the Young Lords mistakenly blamed methadone itself when they should have recognized clinic protocols as the real problem. If methadone were more freely accessible, she argues, it could have been embraced from the beginning as a form of care and liberation for all people with opioid addictions.
I don't think this is a fair assumption, and I think it underestimates the insight and sophistication of community advocates like the Young Lords. Whether you agree with it or not, in my experience and research, many people with addictions want total freedom from all drugs, illicit or prescribed. When race and poverty are factored in, it becomes especially sensitive: drugs certainly have a history of subordinating certain populations. It's not all about clinic protocols. And if we really respect the autonomy of people with addictions, that needs to extend to respecting the wish not to be medicated.
This one oversight does not diminish the strength of Redmond's arguments. I'm on board for abolishing methadone clinics, along with the rest of the addiction treatment industry in its current form!
