Methadone’s bad press

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Sexual Dysfunction on ORT

There’s something odd about methadone. Well, maybe not so much about methadone, but about the way it’s seen. It gets bad press. Think back to lurid headlines in the Scottish tabloids a couple of years ago – the ones partially responsible for the Chief Medical Officer’s Expert Review on ORT. This is a paradox, for opioid replacement therapy is one of the most evidence-based treatments around.

The evidence is around reducing harms, of course, rather than for abstinent recovery – despite the latter being something a significant proportion of treatment seekers have as a goal. This juxtaposition of reduction of harm versus accrual of positives may be partly responsible for the negativity that can be generated by methadone.


Families and methadone

It’s not just the press that don’t like methadone. Families don’t much like it either. The Expert Review found that while service users were actually pretty satisfied with their treatment on methadone programmes, they complained that it was the only show in town. Families however were much more vociferous. Here’s what the report found:

“Most concerned family members felt that ORT reflected a process which simply replaced one addiction with another – often perceived (by the families) to be worse – and harder to move on from. Methadone was at times seen as abhorrent…Many expressed overt hostility to the use of methadone as a treatment”

Why would families have such extreme views? I think for two reasons. The first is that they are generally excluded from treatment, so they don’t get to hear the rationale and evidence behind prescribing. They are not involved in decision making and may feel they have no agency; this may distance them from buy-in to this type of treatment.

Secondly families have high aspirations for their loved ones. They will welcome reduction of harm, but they want more. They want to see a move to abstinent recovery. Part of the problem is that families often have higher aspirations than treatment providers.

Clash of expectations

It’s this clash of expectations that causes much of the problem. We expect too much of a prescription. Our energy and time as treatment providers can be absorbed by the technical aspects of the appointment – filling in assessment and outcome measures, drug testing, sorting out the prescription and next appointment – and the content and quality of the stuff that goes around the prescription has to take a back seat.

If time after time I, as a professional, do the same things in appointments as I’ve done for the last five years, and my client does the same things that he or she has done for the last five years, then why should I be disappointed that there is no movement? Hostile observers can easily shout about patients ‘parked on methadone’ and it stings because we  actually would like a lot more time to do meaningful therapeutic work with our clients.

Methadone as a bridge or methadone for life?

Scott McMillin touches on this in a thoughtful blog On Recovery SI. He points out that discharge planning starts early on in abstinence focussed treatment, though hints at the dangers inherent in ‘acute care’ models of addiction. The point though is that a point of leaving treatment is anticipated. It can be rare for such planning with clients on replacement prescriptions:

“the client can stay until he feels like terminating, and if that day never comes, so be it. He’s still considered a success. I can see the reasoning there –leaving OMT prematurely is apparently a predictor of relapse.”

And if retention in treatment is the safest and most evidenced path, but clients and their families don’t want treatment over decades, then we have a tension which can lead to methadone hostility. McMillin writes:

“it seems to be about engaging the client and holding on to him for as long as humanly possible. Success, presumably, would be 100% retention in the program, indefinitely.”

Although there are still plenty of folk around who still think that way, recovery-oriented drugs policies in the UK and a growing recovery movement have helped  us move on a bit from thinking of retention as our main goal and that methadone ought to be for life. This doesn’t leave abstinence-focussed recovery programmes off the hook though. Treating addiction like a broken bone (the acute care model) is not appropriate:

Somehow we’ve gotten the idea that abstinence-based treatment should produce powerful benefits that should last months or years, after treatment stops. By contrast, the benefits of OMT aren’t expected to last beyond involvement in OMT — which is why clients aren’t encouraged to leave.

Methadone plus

So tensions persist. The mismatch between client expectations and what treatment with methadone can offer needs to be resolved. We really do need to put into action ‘methadone plus’ – the ‘plus’ being all of the things recommended in Essential Care and then again more recently in the Expert Review. Getting Recovery Oriented Systems of Care up and running in every ADP area in Scotland is a priority for Government and their development will help us move on, though I suspect that methadone’s bad press is here to stay.

    3 Responses to "Methadone’s bad press"
    1. Detox Nurse says:

      People wanting to give up smoking are offered (and encouraged) to utilise nicotine replacement therapy. The model – one of a replacement therapy – is the same as ORT, yet it is not (much) vilified by the public or the press. I wonder how many people are “parked” on NRT? Probably not many and I guess this is partly due to ‘discharge planning’ of sorts that takes places when people see one of my colleagues in smoking cessation services.

      That being said, with the rise of e-cigarettes, I’m sure there are a many who have ‘self-parked’ on a non-government sanction version of a nicotine replacement therapy. I recall a recent BBC R4 documentary interviewed an e-cig shop owner who successfully stopped smoking using an e-cig and sounded like he had no intention of ever giving up.

      There’s obviously an ‘all good’ or ‘all bad’ view of methadone that’s out there. This article alludes to the fact the things are far more nuanced and that maybe it’s case of how the treatment is implemented and in what context. I have only worked in drug and alcohol services in the recovery era, and from my point of view, I just don’t see people being encouraged to stay on methadone ad infinitum – quite the opposite. I’ve had a number of conversations with some clients who felt they were being pushed to come off or reduce methadone, when – for the time being – they didn’t want to come off or reduce.

      On a personal note, having had a brother who was on methadone, I can see the pressure service users come under from family to get off ORT. He died of a heroin overdose in 2011. Without question, I firmly believe he’d still be around if he had stayed on methadone.

      • djmac says:

        Thanks for your thoughtful comment. I am so sorry to hear about your own experience, but I’m glad you were able to share it.

        You make a powerful point in comparing NRT with ORT. Methadone stigma is part of this. I am so in tune with you over the ‘all good’ or ‘all bad’ problem. Shades of grey are harder to live with and deal with than black and white thinking.

        I also wonder if there is regional variation in practice. I can honestly say I have never heard of anyone in our area having pressure from professionals to come off methadone. I would be very concerned if it was happening. On the other hand I have had many folk tell me that their request to reduce or detox was rebuffed.

        Leaving ORT needs to be an informed choice, driven by the client and it needs to be planned and backed up with support, harm reduction education (relapse prevention, education on loss of tolerance and O/D risk, and how to avoid it, etc.) and is best done in an structured treatment setting.

    2. Anon says:

      Thanks for this. I thkn that the point about families’ exclusion is very well made and very important.

      in terms of the range of approaches from “pressurising people to come off” and resisting people’s active desire to come off methadone, there is surely a territory of “actively planning care with people”? I would agree with DEtox nurse that context is essential: IMHO, far too many patients in primary care, GP’s themselves and even the people who train GP’s are unable to make the distinction between promoting recovery and withdrawing essential “evidence based” prescribing and so leave people parked without considering the alternatives.

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