This post is part of a collaborative narrative series composed of my writing and Chris Arnade's photos exploring issues of addiction, poverty, prostitution and urban anthropology in Hunts Point, Bronx. For more on the series, look here.

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Background

Methadone maintenance was the first widely used opioid replacement therapy to treat heroin dependence, and it remains the best-researched treatment for this problem. Despite the widespread use of methadone in maintenance treatment for opioid dependence in many countries, it is a controversial treatment whose effectiveness has been disputed.

Main Results

Eleven studies met the criteria for inclusion in this review, all were randomised clinical trials, two were double-blind. There were a total number of 1969 participants. The sequence generation was inadequate in one study, adequate in five studies and unclear in the remaining studies. The allocation of concealment was adequate in three studies and unclear in the remaining studies. Methadone appeared statistically significantly more effective than non-pharmacological approaches in retaining patients in treatment and in the suppression of heroin use as measured by self report and urine/hair analysis (6 RCTs, RR = 0.66 95% CI 0.56-0.78), but not statistically different in criminal activity (3 RCTs, RR=0.39; 95%CI: 0.12-1.25) or mortality (4 RCTs, RR=0.48; 95%CI: 0.10-2.39).

Authors' Conclusions

Methadone is an effective maintenance therapy intervention for the treatment of heroin dependence as it retains patients in treatment and decreases heroin use better than treatments that do not utilise opioid replacement therapy. It does not show a statistically significant superior effect on criminal activity or mortality.¹

There's a bottle of burnt-pink liquid waiting at the front of a line of deviants with rough faces. There must be 50 or more of them standing there under the elevated train in black or dirt-colored clothes.

It's a line you stand in every day at dawn while passerby shuffle their kids past to school. They move quicker, hands locked, by you. You think of your own kids, the five scattered little beings you no longer know.

You forget all that as you shift from foot to foot, in need. Neurochemical impatience. Finally, minutes, hours (years, decades?) later, at the front of the line, you're made to swallow the pink in the bottle in the presence of a now-familiar stranger.

"Let me see you swallow."

The daily migrations to the clinic blot out your sense of escape. A daunting procession of milligrams that even as dosage lowers stretches to feel of infinity.

Infinity isn't you. Never has been as you've moved around the country, skipping to Rhode Island, Louisiana, Florida. Even the good "forever" things have been long since abandoned: first husband, ranch house, kids.

The choice is to be without those things. To be strong. Stronger.

I'm not staying on methadone my whole life.

Sonya's strong -- she lives on the street, a new-ish thing, behind a plywood partition on the expressway.

If she were to get clean, she would cut off fixes cold turkey, just deal with the sweating, nausea, sleeplessness. The nights spent thinking of nothing but the pains of where her body meets the bed. No, not bed. Ground. Road dust.

If she were to get clean, it would be the cravings that would draw her back. Not cravings for heroin but cravings for something to forget a life lived under her blanket-made tent.

Sonya inside tent

Sonya Inside Tent: Hunts Point, Bronx. Courtesy of Chris Arnade.

There's a person around the corner with decent stuff. I can count the steps. Another four people I can call. I'd have something in 10 minutes.

She would have to keep the vomit of withdrawal on the far side of the dirt patch.

Why put myself through this to get clean anyway? What's the point? My kids hate me. The state took my youngest ones.

Every night and day her concrete bed, the plywood partition quiver as semi-trucks roll by. Latin music bleats at 1 a.m. engulfing the world of the median's ensconced construction crew and reaching beyond it.

If she were to choose methadone, she would oscillate between a depressed brown building and her roadside kingdom. Best to keep on the roadside, use the time to panhandle. She could make enough money to get out, move on.

A hit's only $10. I can make that in an hour panhandling.

What's one hit?

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