Methadone and the Hall of Mirrors

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The International Journal of Drug Policy takes an editorial wander through the ‘hall of mirrors’ that is opioid replacement therapy pointing out that, depending on viewpoint, ORT can be seen as “a medical treatment; a method of harm reduction; an overdose prevention tactic; a crime reduction strategy; a public health measure; a social welfare intervention; an administrative system; a mode of social control; a dangerous drug of dependence; or some combination of all of the above… It is ambivalent and has no stable essence, being simultaneously cure and poison.”

Methadone in particular is pretty much loathed by the press. One of the catalysts for the recent Expert Review on ORT, commissioned by the Chief Medical Officer in Scotland was the negative press around methadone a year or two back. In the Expert Review, patients actually report pretty positive experiences, but complain that too often it is the only dish on the menu.

Black and white thinking around ORT is unhelpful. Says the editorial: “writings and debates routinely reduce OPT to a series of overly simplistic binary oppositions. Thus… we encounter abstinence contrasted with maintenance; prohibition with harm reduction; health with law enforcement; social problem with medical problem; criminal justice policy with health policy; analgesic with therapy; and normal with abnormal etc.”

Stigma is addressed with methadone clients described as inhabiting a kind of limbo between worlds, labelled drug users and bound to services making normality difficult. The article acknowledges that there are advantages and disadvantages to methadone. Then there is the question ‘who benefits most?’ Crime reduction arguably benefits society more than the person on the prescription.

The editorial although impressively referenced is rather short on recovery. In fact, recovery is only mentioned in one paragraph, yet one of the functions of ORT, says the editorial, is an aid to abstinence.

Not everyone agrees. Dawn Farm recently posted on the lack of evidence for ORT being an aid to recovery. With regard to methadone and Suboxone they say: “The problem is that this isn’t what patients are looking for. They want their lives back. They want recovery. The evidence-base for these drugs is for reducing overdose, reducing drug use, reducing criminal activity and reducing disease transmission. They are not an evidence-based treatment for promoting recovery.”

Dawn Farm goes on: “If what you want is an evidence-based treatment that’s associated with complete abstinence, low relapse rates and returning to employment, they exist and have a robust evidence-base. Health professionals and pilots have programs with outstanding outcomes.”

I’m left with questions. Do we have a mismatch between what patients want and what is offered? Is methadone currently a conduit or a barrier to recovery? Who can move on and how should they do it? Where is the evidence base for recovery in patients maintained on methadone? Can we do better and if so how?

[This post was first published on Recovery Review in April 2014]

    3 Responses to "Methadone and the Hall of Mirrors"
    1. Anon says:

      I agree whole heartedly with the suggestion that methadone is regarded as “evidence based” with too little consideration of what the evidence shows it enables but…………………although Dawn Farm is no doubt right that pilots and medics get excellent care, it is a specious analogy in some ways, most conspicuously cost; we can change approaches and attitudes but one would have to suspect that the low cost of methadone treatment plays a part in its popularity? the uk governments changed their policy positions on addction but not the budget allocations.

      • djmac says:

        I think the contrast is well made and ought to make us uncomfortable. Why should social standing or bank balance determine the sort of care that can be accessed? We don’t do that with cancer care. In any case I wonder if cost effectiveness should come into our considerations rather than just cost.

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