A holiday from methadone?

This weeks guest blog is from Russell Webster. Russell blogs on the rapid changes in the way we deliver public services especially in the arena of crime and substance misuse treatment at: www.russellwebster.com/Blog

Mark Gilman has a long history in the drugs field as a practitioner and manager for Lifeline and a regional manager for the National Treatment Agency in the North-East and, currently, the North-West. Despite years at a government quango, he has hung on to his ability to speak plain English. Mark has been an advocate for improved drug treatment for over 20 years now. Unlike many in the drugs field, he sees no contradiction in being a passionate advocate for recovery while still ensuring easy access to the whole range of harm reduction interventions including methadone prescribing.

At his many conference presentations, Mark regularly uses a metaphor comparing providing drug treatment to long-term heroin users with operating a good local travel agency. When the travel agent sees a regular customer come back to book his yearly holiday, he is keen to keep his customer happy but also to suggest other destinations – particularly if they might bring him in a bit more commission:

"Benidorm again this year? Or I’ve got this lovely new resort in Ayia Napa. I think it might suit you even better.”

Similarly, the good drugs worker should welcome back the recently returned drug user and enquire if he wants to go back on his methadone prescription or had he thought about getting off? - especially with all these new recovery-focused services. The drugs worker doesn’t get any more commission (although that might change depending on how far the drugs field adopts payment by results) but, possibly, more job satisfaction.

While Mark Gilman sees methadone as a valid treatment option, the green juice itself provokes strong emotions in active drug users, people in recovery, drug treatment workers, researchers and policymakers.

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For some it is liquid gold – methadone has allowed them some level of control over their life, gives them stability, the chance to make or mend some meaningful relationships and get or hold down a job. Without methadone, we would have a bigger crime problem and, quite possibly, a lot more people with HIV/AIDS.

Others describe it as a poison, they say that methadone is more addictive than heroin and keeps you trapped in a gilded cage for years. They say it keeps people dependent and denies them the opportunity to change and move on with their lives.

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Interestingly, although most drug users and people working in the field have an opinion, there has been little informed debate. Drug and Alcohol Findings recently brought to my attention two research studies which looked at the quality of life for people taking methadone.

The first study, conducted by J. De Maeyer ,W. Vanderplasschen and colleagues, is a systematic review of research on the quality-of-life of opiate users. The review tackles head-on the difficulty in defining what "quality-of-life" is and distinguishes between health-related quality of life and a more subjective appraisal. The paper looked at 38 studies published between 1993 and 2008. Nine of these studies compared the quality of life of drug users taking methadone versus other kinds of substitute prescribing programmes. Measures of health-related quality of life were no different but there were differences in subjective perceptions of the quality of life. Perhaps one of the key findings of the review was that one of the most important reasons given by methadone clients for entering treatment was the desire to improve their satisfaction with life. The motivation to seek help is often not the desire to stop using drugs but to tackle other problems or dissatisfactions in life.

The second study, by the same lead authors, looked at quality-of-life under the influence of methadone via a series of in-depth interviews with 25 individuals who started methadone treatment in the Ghent region of Belgium between 1997 and 2002. The study focused on people who were in and out of treatment with different levels of heroin use. The aim of the study was to identify what constitutes a good quality of life for people who are dependent on opiates and how methadone impacts on this. The interviewees reported that methadone had a powerful positive influence in many areas and an equally strong negative effect in others.

Being on methadone enabled many individuals to maintain relationships and, critically, to continue to care for their children. It also meant that they were able to do something constructive with their time – work, study, hobbies, sport, etc. This in turn helped them to develop higher self-esteem and a more positive self-image. Perhaps most importantly, it enabled them to have a much more meaningful life because there were no longer dominated by the direct consequences of their illegal drug use – such as money problems, spending most of their time getting money for drugs and waiting for dealers or feeling "sick" due to withdrawal symptoms.

On the other hand, there was a clear stigma attached to being on methadone which made it difficult to form some relationships and to integrate into broader society. Methadone dampened down interviewees' emotions and stopped them fully enjoying life (or, of course, experiencing the full extent of negative emotions). Several interviewees regretted that they had substituted one dependency for another; not only was methadone withdrawal a more lengthy process than coming off heroin but they resented being constrained by the requirements of prescribing agencies – especially when these required public daily pick-ups from pharmacies.

For most interviewees a meaningful life involved being free from heroin and substitute drugs, but methadone was seen as a vital first stepping stone. I welcome the way that substance misuse interventions are increasingly based on a proper evidence base.

Nevertheless, I've always thought that effective drug treatment is more art than science – using personality and humanity as well as learnt skills. One of the key attributes of a good drugs worker is surely to work with service users to meet their own goals; to provide the safety and stability that methadone brings whilst encouraging people to consider recovery and to know that there is a lot of help available along the way.

For those who are interested in combining the methadone maintenance and 12-step approaches, there is a new study by Natti Ronel and others: “Can a 12-Step Program working methadone maintenance treatment?" Which describes a combined approach – delivering a 30 session 12-step programme to 32 heroin-addicted individuals in Israel. Beware though, it is behind the Sage Publishing paywall.

The views here are those of the author and not necessarily those of the RSA