Helen Redmond, "Liquid Handcuffs: Policing and Punishment in Methadone Clinics and the Future of Opioid Addiction Treatment" (North Atlantic Books, 2026)

Summary

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Podcast Summary:

New Books Network - Helen Redmond, "Liquid Handcuffs: Policing and Punishment in Methadone Clinics and the Future of Opioid Addiction Treatment"
Date: March 3, 2026
Host: Emily Dufton
Guest: Helen Redmond

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Episode Overview

This episode features clinical social worker, filmmaker, journalist, and activist Helen Redmond discussing her new book, Liquid Handcuffs: Policing and Punishment in Methadone Clinics and the Future of Opioid Addiction Treatment. The conversation explores the punitive and carceral nature of the American methadone clinic system—how its origins, policies, and private interests have compromised both the dignity and effectiveness of opioid addiction treatment for decades. Redmond, a self-described "clinic abolitionist," shares her vision for radical reform and situates methadone's problems within broader social, racial, and political contexts.

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Key Discussion Points and Insights

Helen Redmond’s Background & "Clinic Abolitionist" Perspective

• [02:56] Helen’s Professional Journey

  • Began in Chicago during the AIDS epidemic, working in medical and emergency room social work.
  • Early experiences were marked by difficulty referring patients to methadone clinics—poor communication, negative and judgmental staff attitudes, and horrifying stories from patients.
  • An ethnographic study in a Chicago methadone clinic confirmed her sense that the system was "very punishing and controlling."

    "What patients were telling me were just horrific... I saw this structure as being very carceral and very punitive." —Helen Redmond [04:52]

• [06:51] Motivation to Document Methadone

  • Methadone patients are among the most oppressed; being required to attend clinics almost daily amounts to a loss of freedom.

  "If you have to be somewhere six or seven days a week, you're not free." —Helen Redmond [06:59]

Methadone Clinic Experience – The "Culture of Cruelty"

• [07:27] Daily Life for Patients
  • Requirements differ by state, but many must appear daily for supervised dosing ("witness dosing").
  • Patients consume their dose under surveillance, sometimes proving they swallowed via inspection or speaking.
  • "Witnessed urine toxicology" involves staff supervising urination—degrading and traumatizing.
  • Take-home medication privileges are rare and easily revoked for minor violations.

  "It's degrading, it's traumatizing. And this is because they're concerned that people would bring in urine from the outside that doesn't have drugs in it." —Helen Redmond [08:21]

History and Inception of the Methadone Clinic System

• [10:35] Emergence in the 1970s

  • Methadone maintenance started in NYC via doctors Vincent Dole and Marie Nyswander.
  • The Nixon administration expanded clinics nationally to address heroin-addicted returning soldiers and urban heroin crises.
  • Methadone's goals included reducing crime—distinct among medications.

  "No other medication has been tasked with lowering crime rates. Not Viagra, not Crestor, not insulin." —Helen Redmond [12:43]

• [13:34] Early Clinic Culture

  • The "culture of cruelty" has persisted since inception, shaped by the DEA’s involvement and the embedding of medical redlining (clinic placement in marginalized communities).
  • Clinics were ultimately about control, not healing.

Regulatory Structures and Their Consequences

• [21:37] Quarantine and Surveillance

  • The DEA, in tandem with psychiatrists, constructed a system predicated on mistrust of drug users, treating them as criminals.
  • Fear of diversion (methadone ending up on the street) drove excessive regulation.

  "When you get a criminal designation, all kinds of bad things can happen to you and people don't care." —Helen Redmond [22:16]

• [24:56] Privatization Post-Reagan

  • The shift from publicly funded to privatized clinics in the 1980s was devastating: patients unable to pay were "fee-toxed" (detoxed for nonpayment) and often relapsed or died.
  • Privatization led to high profits, heavy patient loads, and diminished care quality as private equity entered the industry.

  "It was a tragedy really, when it went from free to fee and Reaganomics." —Helen Redmond [25:01]

• [33:12] "Regulatory Fog"

  • Multiple overlapping agencies (DEA, SAMHSA, state and local authorities) create a regulatory hellscape.
  • Conflicting regulations stymie reform and entrench the system.

  "It's just this morass of rules and regulations... This is why I truly believe that reform is impossible." —Helen Redmond [35:35]

Technological Surveillance in Modern Methadone Treatment

• [37:43] New Tech = More Surveillance
  • Innovations like video-dosing apps (Sanara) and GPS-equipped lockboxes (Veronetics) purportedly offer more flexibility, but only relocate surveillance from the clinic to the home.
  • For-profit tech companies, often led by physicians, continue the "methadone surveillance state" under the guise of progress.

  "It's very much like the ankle bracelet. I can get out of jail, but I'm going to be monitored... It's a Faust bargain." —Helen Redmond [40:29]

COVID-19 and Methadone Reform (or Lack Thereof)

• [42:59] The Pandemic’s Impact
  • COVID forced temporary increases in take-home doses, but meaningful change was limited and short-lived. Most patients quickly returned to stringent clinic attendance.

  "It took a global pandemic to make clinics... look at take home medication." —Helen Redmond [43:44]

Methadone Advocacy and the Limits of Reform

• [45:56] Critique of Patient Advocacy Groups
  • Redmond argues that some patient organizations (e.g., NAMA-R) collaborate with clinics and accept the punitive structure, advocating only for "model patients" and not for true structural change.
  • She describes deep conflicts of interest: advocates who also own or work in clinics.

  "Their activism is very strange... They have collaborated with the clinics, and they have collaborated with the American Association for the Treatment of Opioid Dependence, ATOD. And ATOD is the trade group for clinics. So in my estimation, they are the enemy." —Helen Redmond [48:20]

Vision for the Future: Prescription Parity and Abolition

• [50:41] Abolitionist Roadmap
  • Calls for a complete abolition of the specialized methadone clinic system.
  • Advocates for "prescription parity" — methadone for addiction should be available by prescription from any healthcare provider, dispensed at any pharmacy (as in other countries).
  • Clinics are “a relic… the embodiment of stigma,” and integrating methadone into mainstream healthcare would erase much of that stigma and many barriers to care.

  "The clinic system is obsolete. It's outdated. It is violent, it is abusive... It never should have been created. Methadone to treat addiction should always have been part of, of, of the healthcare system." —Helen Redmond [51:20]

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Notable Quotes & Moments

• "I saw this structure as being very carceral and very punitive." —Helen Redmond [04:52]
• "Witnessed urine toxicology... is degrading, it's traumatizing." —Helen Redmond [08:21]
• "No other medication has been tasked with lowering crime rates. Not Viagra, not Crestor, not insulin." —Helen Redmond [12:43]
• "When you get a criminal designation, all kinds of bad things can happen to you and people don't care." —Helen Redmond [22:16]
• "It was a tragedy really, when it went from free to fee and Reaganomics." —Helen Redmond [25:01]
• "Their activism is very strange... They have collaborated with the clinics... So in my estimation, they are the enemy." —Helen Redmond [48:20]
• "The clinic system is obsolete... It never should have been created. Methadone to treat addiction should always have been part of the healthcare system." —Helen Redmond [51:20]

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Key Timestamps

| Timestamp | Segment | |-----------|-----------------------------------------------------------| | 02:56 | Helen Redmond’s background and the origins of abolitionism | | 07:17 | Detailed description of clinic surveillance and patient life | | 10:35 | Origins and social context of methadone maintenance | | 13:34 | Early clinic culture, redlining, and DEA involvement | | 21:37 | Justification for clinic quarantine and "surveillance state"| | 24:56 | Effects of privatization and "fee-tox" | | 27:59 | Private equity and the commodification of methadone | | 33:12 | The regulatory morass of methadone governance | | 37:43 | Tech-based surveillance (e.g., Sonara, Veronetics) | | 42:59 | The limited impact of the COVID-19 pandemic on reform | | 45:56 | Methadone advocacy groups and structural critique | | 50:41 | The abolitionist vision: prescription parity | | 53:44 | Redmond’s next project: an oral history of methadone users|

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Conclusion

Helen Redmond's interview is a sweeping, impassioned indictment of America’s methadone clinic system. By tracing the roots of methadone’s carceral management, she challenges the foundational logic of both the system and the reform efforts that leave it intact. Her call is for nothing less than the abolition of clinics, a shift to mainstream healthcare models, and an end to stigma through full integration—an urgent, deeply informed critique at a moment when regulatory change is finally on the table.

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Transcript

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[New Books Network Announcer]

Welcome to the New Books Network.

[Emily Dufton]

Hi, and welcome to New Books in Drugs, Addiction and Recovery, a podcast channel on the New Books Network. I'm your host, Emily Dufton, and today I'm happy to welcome Helen Redmond back to the show. Helen is a licensed clinical social worker and adjunct assistant professor at NYU's Silver School of Social Work and a documentary filmmaker, journalist, and activist. Now, she's also a published author. Her new book, Liquid Policing and Punishment in Methadone Clinics and the Future of Opioid Addiction Treatment was just released this month from North Atlantic Books. The last time I interviewed Helen for New Books Network, it was back in 2023 after she released her film Swallow this, a documentary about methadone and COVID 19. We discussed the problems plaguing America's methadone clinic system and how they were and weren't affected by the pandemic. In her new book, Helen expands on these ideas, documenting both the American methadone clinic system's history and its many hang ups. It's a thorough investigation of a system that hasn't changed much over 50 years and which Helen argues causes more harm than healing and clearly hasn't helped America's devastating rates of opioid overdose deaths. Helen calls herself a clinic abolitionist, and Liquid Handcuffs argues that America's current methadone system needs to be eradicated entirely. These are strong words, but they're coming at a useful time. As Helen notes, legal changes are being discussed today to alter a system that's kept methadone sequestered in specialized clinics for over 50 years. The question Liquid Handcuffs asks is which changes will actually help to discuss all this and more. I'm thrilled to welcome Helen Redmond back to the show.

[Helen Redmond]

Thank you for having me.

[Emily Dufton]

Oh, it's such a joy to have you. I'm thrilled. So let's start at the beginning, right before we get into your books, before we get into your documentaries and all of your work, how is a clinic abolitionist formed? You mention in your book that you got some Training in Chicago before you moved to New York, which is where you're still based. But tell us your backstory. Where does a clinic abolitionist come from?

[Helen Redmond]

Well, it starts back in Chicago, Illinois. I, as you said, I'm a licensed clinical social worker, and I started out my career in social work as a medical social worker. And I worked at the University of Illinois at Chicago Medical center for many years. And then at one point, I transferred to Cook county, the emergency room, the legendary Cook County. And I worked in their clinic system. And this was during the 1990s, and it was the AIDS crisis. It was a time of, you know, mass death. Right. And my job in the clinics that I was working in, I was seeing a lot of people who were injecting drugs, and that's how they got the virus. They were feeling, I'm sorry, sharing needles. One of the number one ways that it was transmitted. So my job, one of them was for patients who wanted to take methadone, is to help them get into a clinic. And right away, I found it was really difficult. The social workers who work in healthcare, we develop community resources, and they're people that we rely on to send our patients to. And right away, I found it very difficult to communicate with clinics to get the staff to call me back. You leave voicemails, you send emails, and very, very difficult to communicate with them and get answers out of them. You know, there are waiting lists. And then when I did talk to them, I didn't like a lot of them because of the way they talked about my patients. Very negative, very judgmental. And then along with that, the stories that my patients would tell me once they got into the methadone program, and the stories that they told me were just horrific. And I became a harm reductionist during the AIDS crisis. And when I looked at this clinic system, from my. My observations and what patients were telling me, it was the opposite of harm reduction, in fact, was harm reduction. We always say that methadone is harm reduction. You know, it's the gold standard of treatment. But I saw this structure as being very carceral and very punitive. And then just one more thing I will add to that. I tried to do a PhD, but I didn't end up getting my PhD. But one of the things that I did was just a very short ethnographic study in a methadone clinic. So I went there a couple of times. I sat in the waiting room. I just observed. I took notes. Then I met with staff. I sat in on counseling. There's a lot of group counseling in methadone clinics. And I got to see for myself, just kind of like a fly on the wall, how very punishing and controlling the system is. So that. That was. That was my beginning. That was my baptism into methadone.

[Emily Dufton]

And was that in Chicago or New York, where you did that ethnography?

[Helen Redmond]

That was in Chicago.

[Emily Dufton]

That was in Chicago. Great. Well, so then you come to New York, where you're still based, and you see that things aren't much better there. But before we get into the various problems that you found with the system, I want to focus a little bit about how Liquid Handcuffs. The book is not the first time you focused your work on methadone. You write about methadone quite often for Filter, a web magazine about drug culture. And you made two documentaries about methadone, including Swallow this and Liquid the Movie, which was subtitled A Documentary to Free Methadone. What drew you to methadone as a subject, and why do you feel this need to document it in so many different ways?

[Helen Redmond]

Right. I like to say that I'm on the methadone train, and I've been on this train for about a decade now. And what I realized, being a harm reductionist, but also an. An anti racist, is that people who take methadone are oppressed. They are oppressed. They're. They're not free. The clinic system really controls your life. If you have to be somewhere six or seven days a week, you're not. You're not free. Yeah.

[Emily Dufton]

Can you describe a little bit what a typical methadone experience is for maybe listeners who aren't familiar or aren't as familiar with methadone as you are?

[Helen Redmond]

Well, depending on what state you're in, you might have to go six or seven days a week to get one dose of medication. When you're in the clinic and you get your dose, the nurse. It's called witness dosing. The nurse, who is behind a bulletproof plexiglass window, hands you one dose of liquid methadone and you swallow it. And then you either have to lift up your tongue and she inspects your mouth to see if you swallowed it, or she asks you to speak because they're very concerned about diversion and they want to know that you swallowed the medication. Now we're talking about adults. So that's part of what we call the culture of cruelty. Another aspect of the culture of cruelty is witnessed urine toxicology. So a staff person goes into the bathroom with every patient and watches them urinate, actually looks at their genitals. It's degrading, it's traumatizing. And this is because they're concerned that people would bring in urine from the outside that doesn't have drugs in it. So there's. And there's mandated counseling. And from the minute you step into that door, you are controlled by the system. If you want to get take home medication. In the past, it's taken years to earn more take home medication. There's a series of hoops you have to jump through in order to get take home medication, which is the goal of every person, because who wants to go and dose seven days a week? It's an enormous hardship. And even when you do get take homes, they can be taken away from you. If you have a positive urine toxicology, if you miss a counseling appointment, if you happen to miss a dose, they can take them away. So you're never guaranteed your medication.

[Emily Dufton]

Right, Right. And yet people subject themselves to this system because methadone is so effective at controlling withdrawal, because if you take it every day, you won't have to, you know, experience this, this sort of awful experience. And it effectively keeps people away from the illicit market, which, as we know, is getting more dangerous and deadly as the years go on with the introduction of new synthetic opioids like fentanyl. So there's a lot of myriad benefits to methadone. And yet the system as you describe it, is very punishing, it's very punitive and deeply insufficient to the problem at hand. So, as we said, clearly you don't like this system very much. You call yourself a clinic abolitionist. But before we talk about abolishing clinics, I think it would be nice to understand where they came from. So you write in liquid handcuffs about the early history of the drug and how the founders of methadone maintenance, which were doctors Vincent Dole and Marie Niswander, initiated the treatment protocol in the mid-1960s in New York. And you call Marie Niswander a harm reductionist. Before that was a thing which I really loved. I really enjoyed that part. Can you tell us a bit more about what you mean by that and how methadone maintenance came to be methadone?

[Helen Redmond]

The methadone clinic system came into existence in the 1970s, and it was during the Nixon administration. This is just a very short thumbnail sketch, and there's many threads that come together to create the system. In the early 1970s, soldiers were coming back from Vietnam. Remember that Vietnam War that the United States was involved in?

[Emily Dufton]

I recall, I believe there was some involvement, yes, for many years.

[Helen Redmond]

And soldiers became addicted to heroin in Vietnam. It was cheap, very pure. And Nixon's advisors said, we can't have soldiers coming back who are addicted to heroin. This is a very dangerous situation. So that was one of the considerations that went into how can we help people who have an opioid addiction. The soldiers coming back. The other one is in large cities, places like dc, New York City, Philadelphia, on the West Coast, Oakland and San Francisco had large populations of people who were using heroin. You know, heroin was much more widely available in those days. Right. The good old days of plant based heroin. Right. All we have now, at least in United States, is fentanyl. And so you've got the soldiers, you've got an increase in heroin use. And Nixon wants to get reelected. How do you get reelected? Well, one way is you can link crime with people who use heroin. They steal, they do all kinds of terrible things. And this is really the linking of people who use heroin in crime is really coded racism. Nixon and many in his administration, they were racists and they're linking crime to heroin use. And so he wants to get elected if he can reduce crime and they discover methadone. And so they decide, let's make methadone widely available for free. We can lower the crime rate. He can get reelected. Of course, the other side of that, it's, it's, it's a complex, nuanced relationship, to be sure. It will help people. Right. People get methadone don't need to do illegal things. They can get their lives together. It, it's, it's often called the miracle molecule. But the thing to keep in mind here is no other medication has been tasked with lowering crime rates. Not Viagra, not Crestor, not insulin. And again, it's a nuanced conversation, but those were some of the threads that came together that brought the methadone clinic system into existence.

[Emily Dufton]

Right. That's a big shift. Right. But it's also really controversial. Can you talk a bit about that early clinic culture and why government sponsored methadone was so upsetting to people?

[Helen Redmond]

Well, let me, let me just. I wanted to say something about Marie Niswander first. She is such an interesting person. It's so great that there's been more interest in her work. And she had a clinic in East Harlem. And the reason, I think that she was a harm reductionist and that wasn't a thing during the 60s or 70s. Harm reduction really came to the United States during the AIDS crisis. And so she had, you know, I use this, I have this quote in the book where she Basically says about the patients that she's seeing in her clinic, she said, you know, I like them whether they're on or off drugs. And that's harm reduction. That's meeting people where they're at. That's like saying, come as you are. And that, that's how her clinic, which was essentially a drop in clinic in East Harlem. You know, appointments are the enemy of people who use drugs. So people would drop in. And she partnered with a community organization. And this is why I believe she was an early harm reductionist. But I want to just qualify that by saying she also believed in some of the elements that constitute the cultural cruelty. You know, continuously drug testing, witnessed dosing and some other aspects. And then at one point she kind of shifted again and began to see how punishing, incarcerable the system was becoming. And she began to speak out against that. You know, unfortunately she died in 40 years ago.

[Emily Dufton]

She died in 1986. Yeah, it's the 40th anniversary of her death. Wow.

[Helen Redmond]

Yeah. So I just wanted to say that about her because she's, you know, she was one of the discoverers and we should look at, look at her work more closely. And I'm glad that some people are right.

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[Emily Dufton]

Right. Shout out to Melody Glenn, who has a wonderful biography of Marie Niswonder. And I was able to talk to Melody for New Books Network a short while ago. So if you have any interest in more Marie Niswonder information, you can go check out that interview as well. But like you were saying, and like Liquid Handcuffs points out, right. So we have methadone maintenance, which is sort of being introduced and studied in the mid-1960s in New York by Nyswender and Dole, but it's a really small experiment. But then as you said, the Nixon administration comes in in 1971 and says, well, why not sponsor a nationalized clinic system to respond to the threats of drug use and heroin and rising rates of heroin use and crime, or heroin use in Vietnam, excuse me, and rising rates of heroin use and crime here in the States. And so the United States does become actually quite swamped with clinics. I mean, the Nixon administration is funding lots of treatment programs, Right. There's a lot of abstinence based stuff, too. But there are clinics, methadone clinics, and this is a big change, right? You talk about how upsetting it was for neighborhoods to suddenly have clinics that were handing out free narcotics nationwide. People didn't quite know what to make of it. Can you talk a little bit about that early clinic culture and why it was so upsetting to people?

[Helen Redmond]

Well, the early clinic culture is the culture we still have today, and that's the culture of cruelty. So the minute you and I have to say right here, you know, the Drug Enforcement Administration, a police agency that is carrying out a worldwide war on drugs, was central to the construction of this system, and they still are. And that's one of the biggest problems is their involvement and their shaping. So don't be surprised if it's a carceral punishing system because the DEA drug warriors are involved in it, so they.

[Emily Dufton]

In creating its policies. Right, Exactly.

[Helen Redmond]

I mean, it is, it's an outrage. I mean, police, not doctors, not pharmacists making rules and regs. I talk about that in the book. But the.

[Emily Dufton]

This.

[Helen Redmond]

So you have. When you have a clinic coming into a community and you know there's a lot of medical redlining. So where you find methadone clinics are in black and brown neighborhoods and poor neighborhoods, at least in inner cities, is it. It's a little bit different when you go outside and go to suburbia or you go. Go into rural areas. And so you have hundreds, maybe even a thousand people coming into a neighborhood, lining up. Right? You have to line up outside until the door opens. And all kinds of things can happen. Drug dealers know where methadone clinics are and they can deal, right? They can compromise people's recovery. It's a very bad dynamic. So there's that. But. But also you said abstinence is always for the American government and drug treatment. Abstinence is what they want. And they have not been able, we have not been able to break through this notion that methadone is just substituting one drug for another. And you're not really, quote, clean. And you have to taper methadone, like you can be on methadone, but you have to taper down. And that's all wrong. That's all words for many people. This is a maintenance medication. So you've had that tension since the beginning. This is not abstinence. You're still on a drug. You have to be drug free. Also at the time, the therapeutic communities, which were also opening all over the place, therapeutic communities are based on abstinence. And so they don't like methadone for that reason. And then the other reason is they saw the clinics as competition for them. They want those patients, they don't want them to go into methadone maintenance.

[Emily Dufton]

Right? So you have this extremely controversial drug being sponsored by federal dollars in these clinics that are starting to spread. And as you say, they were quickly shackled by really stringent government regulations. By 1973, methadone was quarantined to isolated clinics and patients were forced to jump through numerous hoops for treatment. Then you talked a little bit about the DEA's role and other organizations. But where did this quarantining come from and why was it enacted?

[Helen Redmond]

These regulations were enacted because drug users, especially people who use opioids, they're not trusted because they've been criminalized, which means there's a war on drugs, which is a war on people, which is a war on people who use illicit drugs. So not trusting people who take illicit drugs, and now you're Giving them methadone, they're not trusted. So if they're not, you have to build essentially what I call the methadone surveillance state. And again, you have the DEA involved and they have, at that time, they're working with physicians. They're both psychiatrists. Dr. Robert Dupont, Dr. Robert Jaffe, I'm sorry, Dr. Jerome Jaffe. And they're on board for the construction of this kind of a clinic system where patients are surveilled. So it really goes back to the criminalized status of people who use drugs. They can't be trusted. And when somebody, unfortunately, when you get a criminal designation, all kinds of bad things can happen to you and people don't care. And I think that in our country, probably most countries, people who use drugs are so discriminated against, hated, feared stigma and discrimination. So that's a lot of what was happening. And then also diversion, the D word, right? The DEA said there was a lot of diversion of methadone happening at that time. Now, I believe that there was some diversion. I think that it was exaggerated. But even if there was, that is not a reason to lock people down, to destroy their lives essentially by forcing them to make the clinic the center of their lives. Not work, not family, not leisure, not anything. It is the clinic. You have to get there six or seven days of the week. And that's about control. And so you have to control these people who are disproportionately black and Latino, which then sets up a whole other dynamic in communities of color and their attitude towards methadone.

[Emily Dufton]

Totally. Totally. So by the mid-1970s, the methadone clinic system has been created, it's spread nationwide. It's trapped by these really strict regulations, and it kind of becomes basically what we still have today, in large part. But then you mentioned that during the Reagan administration, a really big shift happened, which was that federal funding for methadone basically disappeared and methadone clinics privatized to survive. That's a huge shift. Right. This is a formerly nationalized system where the federal government paid for everything. And now all that money had to come from the patients themselves who came every day for a drug they had to take or they would go into debilitating withdrawal. It's a pretty handy customer base. What was the effect of privatization on these clinics and how does it continue to affect them today?

[Helen Redmond]

It was a tragedy really, when that, when it went from free to fee and Reaganomics. I mean, Reagan was a monster. He defunded everything that would help poor and working class people. The defunding of housing. We're still living with the consequences of that. Right. He cut funding and the rates of homelessness go right back to that defunded education, legal services, mental health and methadone. And it's just been, it's been a disaster. I think it was for him and his administration. It was a turn away from helping people and saying the government is no longer in the business of helping people. And then of course, his horrid wife Nancy in the. Just say no. Just say no to drugs and the ramping up of the drug war and the government's not going to help people. You're on your own. And so of course what that did is, well, now you have to pay a fee to get your dose. Well, a lot of people couldn't pay it, so they dropped out, went back to a street supply, which might be cheaper depending on where you are in the country. People died. You know, I, I want there to be an accounting for all the people who have been either pushed out of treatment or fetox. We call it a fee tox. You can't pay. We're going to talk about detox you and so overdose death. Some women turn to sex work. I'm thinking about the work of Marsha Rosenbaum in California and in her colleagues documented what, what this meant to, to people. And it was, it was a tragedy that that happened. I think it also for me, it just speaks to the absolute need for a national health care system. Everybody in, nobody out, everybody has health care. It's a human right. And methadone and, and other treatment for, for drug addiction is part of the healthcare system. And so when you go at, you know, at the point of service, you don't pay any money. You know, we pay with our taxes like, like other civilized countries in the world, national healthcare systems, where it's a human right and that it has been separate and siloed has had so many terrible consequences for the health of people who use opioids.

[Emily Dufton]

Totally. Totally. Well, from your lips to God's ears, Helen. I hope for the same thing. Fingers crossed. But in the meantime, the methadone industry privatized and it professionalized. You know, as soon as that federal honey pot kind of dries up, the system continued. It still had daily customers. So it continued and it built itself up into a private industry. And today it's actually quite thriving. Can you tell us about the interest private equity firms have recently shown in methadone and why such an interest exists?

[Helen Redmond]

Well, yeah. Capitalism. Healthcare. Oh, is that the reason there's A commodity. Everything in healthcare is a commodity. And methadone, I think is maybe one of the latest that private equity, the capitalists have eyed it and said, we can make some profits here. I mean, they've done it with dialysis, right? They look at dialysis patients and you're going to be on dialysis for years until you get a transplant and we're going to make money off of you. And so they looked around and everybody's heard about the opioid overdose crisis and that more and more people became addicted, right? That's a whole new patient base, right? Prescription opioids at three waves of the opioid overdose crisis, starting with prescription medications like OxyContin and then heroin and now fentanyl. And so the capitalists are very good at looking at markets and how many are in that market. And so unfortunately, because of the opioid crisis, more, more people have become addicted. And that, that's a market for them. You know, they want a big market, don't want a, a small market. And I think the, the private equity equity firms, they actually like that. They're highly regulated because it allows them to have a monopoly. And you have patience. If they can stay in the system essentially for life, right? You can't, you can never get out of the system. So they've always got you, they've always got that, that revenue source. But we know that their, their motto is, you know, you buy low, you grow fast, you sell high, you try to make quick profits and then you get out, right? Before you get out, you cut costs, you overload the staff, high caseloads, you're trying to see hundreds more people because that's how you make profits. So you see more patients, you cut staff. That leads to high turnover, low pay and really chaos in clinics.

[Emily Dufton]

It does nothing good for them. But methadone is such a perfect target for private equity's investment in healthcare, right? Because private equity really seeks out fragmented, really high margin sectors with predictable cash flow. And that's precisely what methadone is, a fragmented, high margin sector with predictable cash flow. You have a very consistent patient base. But this privatization has had some real effects, right? What has that done for treatment, service and quality over the past couple of years and decades since the industry privatized, right?

[Helen Redmond]

I mean, some of the private equity firms that have gotten involved in methadone are Revelstroke Wad, Warwick Capital Partners. These are some of the big ones that have, that are in the business now have bought up megamethrone change chains like Baymark and I think, I think hasn't. It hasn't improved quality of care. We, we haven't seen that. From the stuff that I've read, it hasn't improved quality. And I mean, not that they haven't tried some innovations. And you know, this is such a fossilized system. I often refer to it as just coated in amber. It hasn't changed in 50 years. So private equity could come in and say, hey, we need to be open more hours, for example. So in Arizona they have a clinic that's open 24 hours. I mean, why didn't anybody think of that before? Or we're open for 10 hours. Right. I mean there's reasons why they didn't. But that's an innovation that helps people. Right. But it's also all profit because if you're open longer, you can see more patient, you can bill more. And the source that they're billing the most is Medicaid. Medicaid is the biggest payer for methadone in the United States. And Medicare also reimburses.

[Emily Dufton]

So I don't believe that's a recent change. Right. I think it speaks to our aging opioid using population that Medicare now covers methadone treatment. Right. So there's obviously a really pronounced commercial interest in methadone, but there's also the legal interest in methadone. As you talked about, there's a lot of federal regulations on this drug. The DEA plays a role, but there's also SAMHSA and then there's these additional layers of oversight from the state and local levels. Right. Like you mentioned how some states outlaw methadone entirely or local regulations can make the drug even harder to get. Liquid Handcuffs discusses the confusion that this can cause when these multiple levels of regulation exist and clinics have to navigate this like multi layered red tape. I heard it once referred to as a regulatory fog, and I really liked that phrase. And I was wondering if you could discuss this regulatory fog that clinics live under and how it kind of came to exist.

[Helen Redmond]

That is a massively complicated question which I don't think anybody has the answer to. I was a couple years ago, there was a really great two day methadone reform workshop put on by the National Academies of Science, Engineering and Medicine. And they had a number of people who tried to address this what, what I call a regulatory hellscape. And we couldn't even understand what this guy was saying because as I say in the book, there's too many methadone cooks in the kitchen. So you've got the DEA Right. And they have a whole set of priorities that they want to see happen in clinics. They're mostly concerned about diversion, which is not even a problem. You've got samhsa, the Substance Abuse and Mental Health Services Administration. And they create, whenever they, whenever they feel like it, rules and regulations for opioid treatment programs, which is another way of saying methadone clinics. So they create rules and regulations, which, by the way, are recommendations. They're not. They cannot enforce them. They do not enforce them. They're recommendations to clinics. So SAMHSA is involved. And then you've got the state Opioid Treatment Authority, and they're the state, and they weigh in on the SAMHSA regs. They can't, as far as I know, they can't say anything about the DEA regs. Those are in place. And then as you said there. Could it be even local? I mean, New York City could have some local regulation that you can't build a methadone clinic within so many feet of a childcare center.

[Emily Dufton]

Right.

[Helen Redmond]

And it's all absurd. I mean, it's just this morass of rules and regulations, some that contradict. People are always asking for clarification. You know, I've been on a lot of webinars about the regulations. Clinics are always asking, are we in regulatory compliance? So this is why I truly believe that reform is impossible. I mean, you could spend a hundred years trying to figure out how to reform all of this. The DEA might agree with this, but SAMHSA doesn't agree with that. And then the state Opioid Treatment Authority, they don't want that. And so again, because it's such a regulatory morass, I don't think that you can reform it.

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[Emily Dufton]

Well, you might not be able to reform it, but certain people and organizations are trying to improve its technology. You had a chapter in your book about the new technologies that are making methadone surveillance more tech forward. Can you talk a bit about some of the things you profile like video dosing and GPS equipped lockboxes? Because that stuff seemed very dystopian, Orwellian as well.

[Helen Redmond]

Again, because the methadone clinic system has been in a Snow globe for 50 years, right? They're siloed. They're outside of a lot of tech innovations, which not all are dystopian and bad to be sure. I mean, telemedicine is really great, right? But what these, I call them the tech bros. The tech bros of the methadone surveillance state. And these companies that I profile in the book, the doctors are involved in all of them. Doctors are heavily involved in the methadone surveillance state, which I find gross. I find it unethical. And these doctors who looked at the system and were kind of appalled, it's like, why are there no innovations at all? And unfortunately, they developed tech that just continues the surveillance that continues that power dynamic that is foundational to methadone clinics. And that is the staff control access to the patient's medication. And patients have to prove on a daily basis that they deserve to take their medicine. Patients are never 100% in control of their medication, even if they get take homes. And so a couple of like Sonara, which I feature in the book, founded by Dr. Michael Giles, he looked at how take homes work and he understood all of the mistrust of people. And you had to basically, for two years you had to follow all the rules and regs and then you could start to get a Lot more take homes. And he looked at this instead of saying, this is oppressive, we need to end the system. He thought about how can I cash in on creating an app that could surveil people in their home while they take the medication, which then means they don't have to come to the clinic six or seven days a week. So it's moving their surveillance into the home, which.

[Emily Dufton]

Right, right again, on its surface it's like, oh, you get to stay home, but you get to bring the surveillance home with you. Which is not something that happens when people take most other prescribed medications. Right. That's what makes this really unique. That's what makes. Yeah, sorry, continue.

[Helen Redmond]

They call it remote supervision. So the way it's worked forever is the supervision is inside the clinic. Right. So how can we give people more take homes? Which is a good thing. Right. But we're still going to surveil you and we are going to make money. So Sanara is backed by private equity. Mark Cuban gave money to it. And they have what they call a virtual dosing window and that is your cell phone camera. So you video yourself swallowing the medication, you upload it to a platform and then staff can review it and see if you, if you've taken it correctly. But I want people to know, even though, you know it's double edged, it's almost like a Faustian bargain. I mean, who wouldn't be part of this if it meant they didn't have to schlep to a clinic seven days a week? If you're driving in an hour and a half each way you're going to do this. It's very much like the ankle bracelet. I can get out of jail, but I'm going to be monitored by this ankle bracelet. But I've got to get out of jail because jails are violent places. Right. It's a Faust bargain. And it just, it makes me so angry because there's this facade, oh, we're trusting you and this is some modicum of freedom, but it's really not. It's moving the surveillance into people's homes and people shouldn't be watched. Adults should not be watched while they take their medication. That's for children. You have to make sure a child, whatever they drink that medication or they swallow that pill, you've got to make sure. But not for adults.

[Emily Dufton]

Right. What did we grow up for if not the ability to be trusted to take our own medications? Right.

[Helen Redmond]

The other company was Veronetics and they created the lockbox with the gps.

[Emily Dufton]

Right.

[Helen Redmond]

So if you get take Home medication. You get a lockbox. And the ones that don't have the gps, they're just like a regular lockbox. But Veronetics created this. It has gps. It knows where the box is at every, every moment. It knows when you've taken a dose. They know when you haven't taken a dose. And they can lock the box down at any time. If they think you're, quote, tampering with it, trying to get out another bottle, they can lock it down. So you cannot access your medication.

[Emily Dufton]

It's terrifying.

[Helen Redmond]

It's terrifying. And you. And you get a message on the box to call the clinic. So this is not liberation. This is not freedom. This is the methadone surveillance state in your home.

[Emily Dufton]

A Faustian bargain indeed. There is one kind of lone bright spot in the history of methadone. How did the COVID pandemic transform methadone treatment in America?

[Helen Redmond]

It didn't. What the, what Covid did was it finally, finally just shone a light on the clinic system in a way it had never been before. You know, one of the things I say in the book is that methadone clinics are they hide in plain sight. You're not supposed to see methadone clinics, right? Because can trigger the not in my backyard stuff. They really, at least in urban centers, they, they. There's no, there's no signs, right? There's no signs. It says methadone clinic. So they're hiding really in. In plain sight. And what Covid did is it ripped the mask off that, you know, the curtain, right? Who is that man behind the curtain? And it was inevitable because it was a pandemic and people could have died, right? Staff working clinics, patients. Something had to be done. And the thing that is so enraging is that it took a global pandemic to make clinics. Finally, they had to look at take home medication. And SAMHSA got together with the DEA and said everybody can now be screened for 14 or 28 day take homes.

[Emily Dufton]

And then that's a huge change, right?

[Helen Redmond]

That's a huge change. But the vast majority of people did not get 12. I'm sorry, the vast majority did not get 14 or 28 day take homes. A tiny word did most people got maybe three or four. Some clinics, you were still daily dosing. There was one study out of Arizona said nothing changed. People still daily dosing, but, you know, they're waiting longer, their mask, et cetera. So there was a moment there when some people got more take homes and it changed their lives. They were able to live an almost, quote, normal life. If you get 14, that means you don't have to go back for two weeks. If you get a month, you. You have to only have to go back once. So for some people, they got a taste of freedom, but very quickly they went back to daily dosing. So there was a glimmer of change, but it didn't last.

[Emily Dufton]

Right? Right. Your last chapter focuses on methadone patient advocacy groups that have formed over the past few decades. And you close your book with a really forceful defense of methadone patients whom you argue have suffered long enough. So I have two questions here. First, what roles have activists played in methadone's history and why are they important? And second, what makes you such a fierce advocate for these patients? Like, what is it about methadone that motivates you so much that you've created two documentaries, articles, and now a book?

[Helen Redmond]

Well, I'll tell you my documentaries. I'm on the side of people who are oppressed. I'm on the side of the underdog. And when I was making those two documentaries, I thought about something Spike Lee said about his work, and he said, I think it is very important that films make people look at what they have forgotten. And methadone clinics, that system, that institution of dispensing medication had been forgotten until Covid. It's been forgotten. No corporate mainstream media was doing stories about methadone until Covid. And it really just. It. It's just. It was stuck. It's stuck in time. And my documentaries, I want people to see this system for what it is. Carceral, abusive, violent, ineffective. Right. We talk about how many people are still dying of opioid overdoses when methadone's gold standard cuts the. The. The death rate by over 59%. They're an epic fail as a. As a way of dispensing medication. So there's that. And then the chapter that was really difficult for me to write was the chapter about methadone advocacy organizations. And I had met some of the people who are part of these organizations over the years and talked to them about my films. And their. Their activism is very strange, actually. And it's not the kind of activism that I think is needed. Just the opposite. They, in fact, collaborate with the clinics. They believe in the clinic system. They want a few changes, but they believe that there are some people who need the clinic structure. And what they're saying, I believe, is they need that punishment. They need that control. And they have collaborated with the clinics, and they have collaborated with The American association for the Treatment of Opioid Dependence, atod. And ATOD is the trade group for clinics. So in my estimation, they are the enemy. But the organizations, it's the National Advocates for Medication Assisted Recovery, NAMA R is one of them. And stop stigma now. So in namh, the former president is a man named Zachary Talbot and he is a person who takes methadone. So he has lived experience, but he's also a person who owns a methadone clinic and he was the president of NAMA for several years. So that is a massive conflict of interest. So how do you advocate for patients rights, right, against ending the culture of cruelty when you are a clinic owner? So there's these conflicts of interest that are just crazy. The current president, Anita Kennedy, she is a peer specialist at a methadone clinic that's part of Mount Sinai. So president of NAMA works in a methadone clinic, conflict of interest. So I kind of unpack some of the problems with this approach of collaborating which with what I consider to be the institutions and the people who are oppressing people who take methadone. You know, they don't talk, NAMA doesn't talk about this and needed to stop stigma. Now they don't talk about the culture of cruelty. They're always looking outside the clinic system. They don't see the clinic system as the source, the foundational source of stigma and they're always looking outside of that system. And they also believe in this notion of a model methadone patient. So I don't want to say these organizations, NAMA in particular, don't want reform. They do, but they don't want reform for everybody. They want reforms for the model methadone patient, the person who follows all the rules. They have a good job, they're upstanding, tax paying citizens and they want them to get out of the clinic system. But for the rest of them, they believe they need that carceral structure. And that's where I have a lot of differences with naama.

[Emily Dufton]

Right, right. Well, let's talk about the future. You mentioned systems in other countries, including Canada, Australia and Britain. Excuse me, but what would real change look like in the U.S. what do you think reform looks like and is it possible?

[Helen Redmond]

Real reform is what Peter Van der Cleugh said in this wonderful article that he wrote 22 years ago, and that is prescription parity. Any healthcare provider should be able to write a prescription for methadone to treat addiction. Currently, they can write a prescription for methadone to treat pain, but they can't because methadone is locked inside opioid treatment prisons, and only physicians who work in those OTPs can write a prescription. So the future is any healthcare provider can write a prescription for methadone to treat addiction, and patients pick it up in a pharmacy like every other medication that we all pick up. That is the future. The clinic system is obsolete. It's outdated. It is violent, it is abusive. It's a relic of, of an area of the Nixonian era. It's, it's the Anslinger, the Harry Anslinger era. And it's long overdue that, that we shut this system down. I mean, the original sin was the creation of the clinic system in the first place. It never should have been created. Methadone to treat addiction should always have been part of, of, of the healthcare system. And then you wouldn't have communities up in arms about, you know, a thousand people coming into the neighborhood and drug dealers setting up shop. Right? You wouldn't have the stigma. Right. The clinic, the physical manifestation of a clinic, a brick and mortar clinic, is the embodiment of stigma. Right? And once it's integrated into the healthcare system, that stigma will go away. So that, for me, is the future. Now, that is going to entail a huge fight. But everything that means anything to vulnerable populations, to people of color, has had to be fought for.

[Emily Dufton]

Right? And now perhaps it's time for methadone. Well, I really want to thank you for taking the time to come back to the show, Helen. And I think that Liquid Handcuffs is going to do a lot to push forward the conversation about the role methadone plays in the US and if it is time to perhaps challenge this mosquito trapped in amber that methadone is, perhaps it will unleash an island full of dinosaurs somehow, who knows, Like Jurassic Park. But now I'm going to ask you our traditional last question, which is, what are you working on now? And what can we expect to talk about with you next?

[Helen Redmond]

Well, what I'm. What I'm thinking about and I want to work on, but this won't surprise you. I need funding.

[Emily Dufton]

Oh, that old thing?

[Helen Redmond]

I want to. Having done this work for almost 10 years and interviewed so many wonderful people who take methadone and some wonderful folks who work in methadone clinics and they understand there's problems. I want to do an oral history of people who take methadone.

[Emily Dufton]

That's cool. That's super cool.

[Helen Redmond]

And interview people, and it would be audio and maybe video. And I want to hire people who have lived, experience to collaborate on this project, but it will. It takes money. And so I'm looking around at grants to find a way, because David Courtright and Don Desjarolais, they did. They did an oral history of people who take drugs. It was published a couple decades ago. Right.

[Emily Dufton]

Addicts who survived. A seminal oral history. Yes. I believe it was published in, like, the 1980s. Yeah, yeah.

[Helen Redmond]

And I read that book and I loved it. I cried, I laughed. And that gave me the idea of, of, let's do a project just around people who take methadone. In their book, they do interview folks on methadone and very instructive. But I want to do one that is just people who are taking methadone and their clinic experience, good, bad and ugly. So if anybody who's listening has a grant, please get in touch with me.

[Emily Dufton]

Right. Any potential funders out there, we'll put Helen's contact information in the show notes. All right. Well, thank you so much for coming back to New Books Network. And I highly recommend Liquid Handcuffs to anyone listening who's interested in understanding more about methadone and its role in the United States. Thank you so much, Helen.

[Helen Redmond]

Thank you.

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