(This week’s blog is the basis of an article which was printed in the Sunday Herald Scotland on 25th April 2010.)
Methadone, the substitute drug for heroin, has come in for some severe criticism of late here in Scotland. The main brunt of that criticism is that we are simply substituting one addiction (to heroin) with that of another (to methadone). Studies which suggest that 97% of people prescribed methadone in Scotland are still on it several years later combined with the latest figures showing that nearly half-a-million prescriptions were issued for it in 2008/09 at a cost of £16 million per year appear to lend credence to the idea that people are simply being ‘parked’ on methadone indefinitely.
At a time when the public purse is being squeezed and resources are scarce the temptation will be to look at the ‘failures’ of the methadone programme and rein it back, even scrap it altogether. I would argue strongly this would be a costly and terrible mistake. The methadone programme has been instrumental in saving many drug user’s lives in Scotland. As someone who has worked in the drug treatment field for twenty years I can testify that it has been a crucial ingredient in many people’s recovery from heroin dependency.
I personally know of a social worker, an elderly care worker, a taxi driver, a care assistant and home support worker for people with mental health problems, a bar manager, a foreman on construction sites, an actor and a number of individuals working with people who have addiction problems who, up to 10 years ago, were all former injecting heroin users with all the multitude of social problems: health, criminal, psychological, behavioural that comes with that title. I got to know them as they entered treatment for their drug use and was able to monitor their progress.
Now they are flourishing in their respective occupations, back to full health and being productive citizens: A good outcome by any standard. The point is that a decade ago if you had seen any of these individuals on the streets you would have probably written them off as destitute ‘junkies’ with no prospects and no hope; never say never. Resilience combined with tenacity and a determination to overcome their addiction to heroin played no small part in their recovery. But methadone was also an important contribution to their ‘success’ stories and played a vital role in reinforcing their determination to stay off heroin..
Heroin addiction incurs a chaotic, volatile lifestyle which is dangerous and often fatal. Keeping up an injecting heroin habit on little or no income usually brings in its train shoplifting, prostitution, low-level dealing, atrocious health risks, HIV/AIDs, overdose and many other risks..
As something which blocks the effects of heroin, particularly its narcotising, ‘euphoric’ properties, methadone can have an immediate impact in reducing and stopping all the madness and pain caused by a heroin dependency lifestyle for the individual, their families and the wider community. This puts the figure of £16 million for prescribing methadone in Scotland in perspective; this is a fraction of the hundreds of millions of pounds annually that is spent in treating the effects of heroin use. This includes health care, social work and social care intervention or all the massive costs incurred in arresting people, processing them through the courts and keeping them in prison only for them to invariably end up back on the streets on release to resume scoring and using heroin, leading to inevitable arrest again and so on, repeating the cycle. Methadone is good at putting a stop to all of this and is, therefore, very much a cost-effective form of treatment.
None of this is to even mention the misery, pain and heartache heroin dependency brings to families, above all its impact on children. The stability methadone brings can allow for structure and routine to be brought back into previously chaotic lives, in turn allowing family life to be rebuilt.
Virtually all heroin users want to come off. But only a small number will be able to do so right away. For most methadone is the tool which will allows them to rapidly withdraw from heroin and avoid the unpleasant effects of sudden withdrawal (the much dreaded and feared “cold turkey”) and use the stability afforded to resume a normal lifestyle and reintegrate back into society.
Yes, there are problems with the methadone programme: For one, the dosage of methadone prescribed as a substitute must be enough to counter the effects of the previous amount of heroin that was being taken. Prescribing a piffling amount of methadone to combat a large daily heroin habit is guaranteed to fail; the desire for heroin is still there and you stand the danger of fostering a double-whammy effect of dependency on heroin and methadone. As such, it is absolutely imperative that prescribers get the initial dosage of methadone right.
Equally if the individual has made the effort to withdraw and sustained that withdrawal, there must be good support services in the form of counselling, advice and encouragement allied to robust and honest monitoring of progress in order to maintain stability. Finally, there must be clear aims and goals for aftercare to capitalise on that stability, including signposting to other services in order to seize opportunities for continuing personal development, including training, further education and employment.
Essentially methadone is part of a package the constituent parts of which are mutually reinforcing and supportive. Take away any one part and the package will fail. Methadone can be prescribed for some considerable way into the journey of recovery, so there is nothing to be gained and a lot to be lost by setting artificial time bars on how long people can stay on the programme as long as it continues to play its vital role of countering cravings for heroin and maintaining stability. But it cannot be prescribed in isolation and with the minimum of, or no, support services.
Regrettably, this is clearly not always the case and the disrepute the programme is increasingly held in is largely due to the fact the important conditions for methadone to work towards successful recovery and a drug-free lifestyle are not being adhered to. In many parts of Scotland an almost industrial scale programme of methadone prescribing means that virtually every (particularly injecting) heroin user is put onto methadone with no real comprehensive assessment, beyond the minimum, of whether they are really willing to engage with the programme. Allied to this are many instances of prescribing inadequate dosages of the drug, ensuring that heroin will still produce its addictive properties if taken.
Caseloads, in some instances of up to 50 or 60 clients per addiction worker, means that the importance of intensive 1:1work around supporting stability and providing advice and encouragement simply cannot be met beyond a weekly or sometimes fortnightly 30 minute appointment. Aftercare services are either few or far between or where they do exist, they too are subjected to pressures to take as many people as possible including those who clearly are not stable enough to participate with their programmes, resulting in them having to leave.
In such a situation, people do become parked on methadone for indefinite periods and the role of methadone as an essential prompt for a full package of recovery becomes dissipated. Essentially, in these cases, the drug is now being prescribed in isolation with minimum or no support services. A situation where methadone is one tool among an armoury of props to overcome drug dependency and aid recovery is replaced by one where methadone is the only game in town.
Consequently, criticism of methadone per se is misplaced; to repeat it was only ever intended to be a short-to-medium term counter-weight to heroin use in order to allow a breathing space to build stability as a vehicle for recovery from drug dependency. The real question is how such a useful tool or prop aiding stability and aftercare, as attested by numerous former heroin users who are now alive, thriving and in full recovery, became the most important or only tool available in many situations. And, because it can only function effectively as a support aid for other inputs to recovery from heroin use and not in isolation, the absence of those other support aids means it will be largely ineffective or at worst exacerbate dependency.
Critics of methadone have yet to come up with an effective alternative for dealing with withdrawal from heroin addiction and promoting stability. Methadone has saved many people’s lives and played a (largely unsung) part in denting Scotland’s appalling record of heroin dependency. The real issue is how we effectively integrate the methadone programme into a package of effective care for recovery from drug misuse within scarce resources (and in all likelihood about to get scarcer). Cutting back the methadone programme or stopping it altogether could make a bad situation a whole lot worse.