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.
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.