I was talking about methadone with a young man named Alex1 and he didn’t want to hear it. Alex was on my service because he had just overdosed. It wasn’t the first time; he’d overdosed in the past from fentanyl and Xanax and other substances. He’d tried suboxone, but it hadn’t worked for him. I thought methadone would be a great option but as soon as I brought it up, he bristled.Alex was adamant about not starting methadone because he didn’t want to be associated with “that system”: the daily dosing, the mandated counseling sessions, the long public lines outside methadone clinics, the urine screens that could get you kicked out of the program, the profound disruption to daily life, and, most importantly, the stigma. He didn’t want his life to be defined by yet another layer of baggage: treatment.He told me that counseling never worked for him, so why would he sign up for a treatment which requires it? Methadone would take too much time out of his day—he couldn’t afford to risk losing his construction job, or his girlfriend, who lived three hours away. Listening to him, I could see why patients on methadone referred to the system as “liquid handcuffs”: when you enroll in a methadone program, you sign your autonomy away.[1]From the moment you walk in the door, methadone clinics make you feel like you’ve done something wrong. As a medical student, I toured Connecticut’s largest methadone clinic in New Haven. There were security cameras everywhere, the chairs in the waiting room were bolted to the floor, and a sign that read “no firearms or weapons allowed” hung on an off-white wall in need of spackling. There were plexiglass barriers—there long before COVID-19—between patients and dosing nurses, who handed each patient their dose through a small opening, careful not to spill.I took a year off from medical school to get a Master’s in the history of medicine, where I focused on how methadone came to be widely available for the treatment of opioid use disorder in the U.S. History, I realized, created this encounter between Alex and me. The strict methadone regulations,[2] the narcotics agent audits, the unmarked facades of methadone clinics made me understand, and respect, Alex’s decision to forgo treatment, even if being on a medication like methadone might save his life. We found a middle ground: I talked to him about harm reduction, like using with other people, fentanyl test trips, and syringe service programs. He told me he wanted to eventually not use drugs at all, but he knew that goal was unrealistic at this point in his cycle of substance use.Having interfaced with hospitals, detox centers, and thirty-day rehabs for the last couple of years, Alex was an expert. I was not. I knew the history, but I hadn’t lived it. Rather than rehash the same lecture on the clinical benefits of methadone, I chose to do something different.I began to talk history. I told him about how the methadone clinic system was established based on fears of the street sale of methadone, not patients’ health or needs.[3] I told him how the early studies on methadone focused on crime reduction, solidifying the notion that patients on methadone were perceived as criminals.[4] That former President Richard Nixon championed this view. We talked about how people who took methadone not for addiction treatment, but for chronic pain, could pick it up at a pharmacy like any other medication. Only those taking methadone for the treatment of addiction had to restructure their lives and schedules around these carceral clinics.My intention was not to give Alex a history lesson. I wanted to use history to illuminate the systems and people that have produced this landscape of inequality. Alex knew from his own experience that people with addiction were treated as lesser, like criminals not patients. But I don’t think he had fully grasped how baked in, how intentional it all was.“What the hell?” he asked me. His blue-gray eyes narrowed, his voice sounded confused and angry. He shook his head. I played with my rings, taking them on and off my fingers. My knees and ankles—strained from being bent—were throbbing. I wanted to stand up, but I sank down further. All I could say was, “I know. I’m sorry.”Then I invited blame. I invited blame for the stigmatizing language medical providers use, blame for the fact that the laws governing methadone have changed little in the past fifty years, and, most of all, blame for devaluing the lives of people who use drugs. I wanted to validate that his feelings of stigma and shame had a definite source: they had been produced and codified by people in power who considered his life less worthy.I didn’t change his mind about starting methadone or trying suboxone again. That wasn’t my goal. Instead, I used my understanding of the past to make room for a new type of therapeutic alliance. I knew I didn’t have the power to “save” Alex. I wanted to create space for rage, for context, for questions. Perhaps if I could help him identify where his internalized stigma came from and why medications like methadone reinforced it, he might be able to reframe how he felt about himself. He could direct his anger towards systems and structures—things he couldn’t control—rather than turn inward.If Alex’s stigma lifted, if he stopped blaming himself, what might be possible?I don’t know if talking history with Alex made a difference. In realizing the system was meant to be this way by design—not because of his choices or actions—perhaps he felt more empowered. Politics and medicine are impossible to decouple. But too often physicians conveniently separate them out. Maybe it was the look in Alex’s eyes when we spoke about the past—a combination of rage and revelation—maybe it was that look that gave me hope.