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Recovery too hard? Methadone for life!

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Sexual Dysfunction on ORT

ResearchBlogging.orgBerlin, like many big cities, has a heroin problem. People presenting for help are being prescribed opioid replacement therapy (ORT) in greater numbers. That’s a good thing isn’t it? Well it depends on what you think is the end goal of treatment.

At the start of this interesting recent German paper  “Why do patients stay in opiod maintenance treatment?”, Dr Stefan Gutwinski and colleagues say that the scientific literature indicates the point of ORT is: “to increase survival and bring stabilization to patients, in order to enable them to reach abstinence of opioids.” The Scottish Government’s drugs policy and the UK policy agree.

Making it simple

We can simplify this into two aims:

  1. To make things better, then
  2. To move on to abstinence

The problem is that while the evidence is pretty solid that number one is generally achieved, there is less to convince us that the next bit is happening.

Not moving on

The paper outlines that retention in ORT is not great, with just over half of patients sticking with methadone and fewer with Suboxone. Despite this, in Berlin, as we have said, there are growing numbers of people on ORT. These are people who are not moving on; I suppose the ones the press call ‘parked’ on methadone. So the authors ask: “Why is this?”

The researchers speculated that it could be because:

  • fewer people are dying;
  • that people don’t want to move on because of the benefits they are getting;
  • that detox is generally unsuccessful, or
  • that what staff think patients want is not what patients actually want.

question markQuestionnaire

To test this out they sent out an anonymous questionnaire to treatment settings in Berlin.  Forty-six staff (more than half doctors and the rest nurses and admin) and 986 patients completed it. They focussed on whether ORT was of benefit, whether it was perceived as harder to detox from than heroin and how strongly patients wished to come off of ORT compared to how strongly staff thought their patients wanted to come off.

What did they find?

  1. Both patients and staff thought ORT helped physical and mental health.Beneficial effects of ORT on the ability to work and on crime were rated significantly higher by patients compared to staff.
  2. Staff and patients agreed that coming off ORT was hard. Patients thought it harder than coming off heroin.
  3. Patients wanted to eventually come off ORT at a significantly higher rate than staff estimated.

About half of the patients in the sample were over 40 years old and more than one in ten were over 50 with almost three quarters of patients struggling with opiate dependency for more than ten years. Only ten percent had never tried to detox, suggesting high failure rates which may have reinforced the belief that ORT was hard to more on from.

There was no differentiation made between methadone and Suboxone. Perhaps methadone is seen as more ’sticky’ to move on from. The study didn’t look at whether evidence based support and treatment was given at the time of the detox.

Striking

The thing that intrigues me the most is the:

“striking discrepancy between the patients’ and staff members’ assessment of the patients’ desire to end OMT on the long term. The large majority of patients report the desire to end OMT on the long term, whereas only a minority of staff members believe that their patients might really have such a desire.”

Service users seeking abstinence

David Best found much the same thing (in aspirational terms) in a sample of drugs workers in the UK. They believed only 7% of their clients would eventually recover. The DORIS study in Scotland angered some professionals when it reported that many patients entering treatment wanted only to become drug-free; something treatment was not delivering.

recent study in Leeds found that service users, their families and friends placed “considerable weight” on abstinence and “ways of maintaining abstinence”. It’s clear to me that where there is such a mismatch, when the bar is set so low and when there is little hope pervading treatment settings, then it’s no wonder that so few actually do move on.

methadone for lifeMethadone for life?

By the conclusion the authors find themselves at odds with the assertion at the start of the paper (that ORT has an aim of ‘abstinence from opioids’.) Here’s what they say (my emphasis):

Finally, detoxification of OMT is not the prime objective of treatment. The prime objective of treatment is continued physiological and social stabilization. As yet, there is no validated medical cure for opioid addiction. Until a curative medication or a safe curative procedure is developed, many of the patients may have to remain in treatment for the duration of their lives to avoid relapses, increased criminality, subsequent overdoses, and death during the post treatment period.”

Solution? Lower expectations!

So the solution to the mismatch between the low expectation of staff and the higher expectation of patients is to lower the expectation of patients to that of staff? Well that’s one way of looking at it.

We still have the problem that lifelong ORT, whatever its evidenced benefits, is not what people want and that, in fact, many do move out of opiate dependence into long term abstinent recovery. These people would no doubt agree that methadone did make things better, but for them it was not the final destination.

What if…?

What would it be like if the dearth of recovery-oriented research in the UK was addressed, if we focused on what works rather than what doesn’t? If all we do is compare ORT with stand-alone detox, then we are always going to see poor outcomes leading to recommendations to prescribe methadone for life.

Another more enlightened and rewarding approach might be to move away from thinking about a drug or a medical ‘cure’ as being the solution to addiction and looking to introduce recovery-oriented systems of care using strongly evidence-based psychosocial interventions and treatment where those interventions are of adequate intensity and duration. Linking people to recovery communities is protective with regards to relapse, but there is little evidence that it is happening.

ORT as a bridge

In the UK we have recovery-oriented drugs policies which aim for rapid access to treatment with a variety of approaches on offer. The answer is not to lay out the choice as ‘methadone or abstinence’ but to see how we use ORT as a tool and to find ways of bridging people out of treatment and reliance on services into recovery. Some may have to remain in treatment in the long term, but we need to set the bar high and be positive about patients’ ability to move on.

Professionals should spend time with people in recovery to engender hope in themselves. The ethos and structure of systems of care need to change so that recovery becomes the norm instead of a wild aspirational status that we actually believe most people will never achieve.

Now how do we make that happen?

Gutwinski, S., Bald, L., Gallinat, J., Heinz, A., & Bermpohl, F. (2014). Why do Patients Stay in Opioid Maintenance Treatment? Substance Use & Misuse, 49 (6), 694-699 DOI: 10.3109/10826084.2013.863344

A review of this paper was published on Recovery Review in April 2014.

 

    18 Responses to "Recovery too hard? Methadone for life!"
    1. Innocent Abroad says:

      Frankly, the longer I survive in recovery the more astonished I am that anyone stays abstinent.

      A.A, (and its siblings) do an excellent job in many different ways, but – and no one need be surprised by this – they also oversell themselves.

      At the time Bill Wilson described his now famous 12-step programme as “a bridge to normal living” he was speaking from faith, not experience let alone evidence. What was forgivable in 1934/5 is hardly so eighty years later. Almost all those attending 12-step programme meetings are still suffering from “grave mental and emotional illness”. They’re just no longer abusing alcohol and other substances.

      Recovery professionals are faced with a vicious dilemma. Honesty is a key principle of any form of recovery, yet if they are honest with their clients about their prospects, more would relapse and more would die sooner.

      • djmac says:

        Almost all those attending 12-step programme meetings are still suffering from “grave mental and emotional illness”

        Your citation for evidence? AA membership (in the research evidence) has been consistently associated with improvements in mental health. This blog was not about AA by the way.

        • susie says:

          “yet if they are honest with their clients about their prospects, more would relapse and more would die sooner”
          I’m not sure what you are trying to say? Are you saying that professionals lie to people about what is achievable? This year, I have seen so many peer mentors and volunteers in recovery get jobs and thrive. They remain part of fellowship networks and peer support groups and they come back to our service to inspire others. They constantly tell people “if I can do it, so can you”. Our “recovery professionals” talk about them to people in the service all the time. I can only see that as being a good thing. Yes “recovery professionals” should be realistic with the people that they are supporting, but when you and the people around you believe that you will never get anywhere, often you won’t.

          Great blog by the way djmac.

          • djmac says:

            when you and the people around you believe that you will never get anywhere, often you won’t

            Couldn’t agree more. We can transmit hope or we can transmit ‘pragmatic gloom’. I know which I prefer.

            • Innocent Abroad says:

              There’s no contradiction between what I’m saying and what others here are saying. Mental health is improved by abstinence, at least to the extent that abstinence is a precondition for an individual’s having the ability to set up and sustain programmes and practices that will enable them to address the causes of their abusive behaviour, to size the extent of it (e.g. continuing to self-harm in sobriety) and to contextualise it – for example, by learning that they were to a greater or lesser degree the victims of some form of abuse in childhood and very likely abusive in their turn. The obvious way to do this is psychoanalysis, and one measure I have of the continuing sickness of the “clean and sober” is their hostility to psychoanalysis; another measure is that analysts report that people in their first few years of recovery are still too damaged to accept anything more than counselling.

              In his writing, Wilson constantly hovered on the edge of suggesting that recovery consists of hiding under the skirts of religious practice – and he had to, because some people are so damaged that they probably are, although clean and sober, only capable of surviving in a sheltered environment. But that sort of environment may itself be damaging to others. And if Wilson was right to insist that the acceptance of problematic addiction has to be made by the individuals themselves, then it follows that the decision as to what constitutes help must also be made by each of us for ourselves.

              One decision I made very soon after getting sober was that I would never become a recovery professional: I have never had any cause to revisit that – entering that field means that there is a grace danger that your own recovery is put on hold. Any outfit that hires recovery professionals without insisting that they are undergoing a comprehensive course of psychoanalysis is utterly irresponsible and should have any public funding it receives withdrawn immediately. Every recovery professional should ask themselves periodically whether it is still appropriate for them to practise in the field.

    2. Detox Nurse says:

      I’ve said it before – and I’ll say it again – there’s often a discrepancy between what people what and what they’re willing to do about it. A very human trait. I know your answer to this is the implementation of recovery oriented treatment system. I’m all in favourite of this, but I don’t see it as the answer. I’ve previously alluded to the poor uptake of our AA Myth Busting sessions that we run tandem AA members.

      By definition, a ‘treatment system’ is a closed environment, almost separate from the rest of society. Recovery from dependence needs to be seen as the norm in the by the wider public, not just by those working in treatment serviceS. The government, health services, education system, and most importantly the media, must be on board with the recovery message so that when I meet a treatment naive client for the first time, they’re already primed to want explore their recovery options. As it stands now, many ready to walk out the room when I mention mutual aid.

      Your point about workers seeing people who have achieved recovery is an important one. This is a two way process though. People in recovery need to spend time with workers to let them know they exist. That being said, within the service I work for, a significant proportion of the workforce (including senior management) are in recovery, which is encouraging.

      • djmac says:

        ’ve said it before – and I’ll say it again – there’s often a discrepancy between what people what and what they’re willing to do about it

        You are completely right, but there are two things that can encourage us. One is that motivation and readiness for change vary naturally and what is not possible at any moment may become possible. The second is that there are ways we can influence those factors (motivational interviewing for instance, or introducing clients to other recovering people). I don’t think ROSC is the answer, but if we had consistent implementation across the country we would surely get better outcomes for clients.

        I think you make a valid and powerful point about recovery being seen as the norm in wider society. I think that is changing with the rise of the recovery movement.

        Mutual aid mentioned to clients by other recovering people may get a higher ‘hit rate’ than when professionals mention it. Peer support could play a powerful role here.

    3. Frazer Hill says:

      Having worked in the field for 19 years now I have lost count of the amount of times professionals have said “Oh he is not ready to come off methadone yet” etc. or “I dont want to set her up to fail.”

      It is a very complicated issue. Firstly I dont always trust statistics that say x many people want to be abstinent. Lets use a legal drug as an example – 80% of smokers want to give up apparently – I take issue with that, perhaps 80% of smokers know they should give up but do they want to? Probably not. SO when people are asked do they wish to be abstinent then some will reply “yes” and mean it and some will reply “yes” and either not really mean it or say it because that is what they think the researcher wants them to say. None of this is about belief ( a very important aspect of recovery), it is simply about human nature and the response to questionnaires.

      I competely agree that staff need to see recovery as well as service users, one group so that they can see that it is possible and encourage the other group to achieve it, the other group to see it is possible so they can aspire to it.

      WE must take note of what people say and how they act. It is not up to professionals to ‘decide’ if someone is ready to come off methadone, we should listen and support the service users in their aims and wishes. By “not setting them up to fail” we are also suppressing their ability to suceed. If they do not achieve their goal at the first attempt then we are there, as services, as a safety net to help support them until they are in a position to move forwards again.

      It is important to remember what Prof Strang said – OST is a “part” of treatment – it is not treatment on its own. The sooner that this philosophy is accepted by all staff then more service users will be able to move forward in the direction that is beneficial to them, their families and society.

      • djmac says:

        It’s a fascinating area, the ambivalence that folk have about quitting smoking or other drugs and how ‘failure’ affects subsequent motivation. I absolutely avoid that word.

        In terms of motivation, it helps me to think of it as ‘a bit of them wants to stop’ and then I try to work with that bit. How do you help it grow stronger, have hope, be in the driving seat?

    4. Detox Nurse says:

      Yes, motivation (the biggest predicter of a successful outcome in my view) is fluid and ever changing. This certainly gives us hope and tools like motivational interviewing are useful in helping people to move themselves in the right direction. The purpose of a recovery orientated treatment system is to provide a rapid response to an individuals recovery needs when motivation and a willingness to explore options is high.

      • Frazer Hill says:

        Surely a recovery oriented system is there to respond rapidly to the service user regardless of motivation. As it has been stated motivation is fluid (look how many people state they are going to the gym when they finish work then turn round and say they cant be bothered to go at the end of the day). A true recovery oriented system should respond rapidly, to support people achieve their recovery goals when their motivation is high AND support people to realise that recovery is possible when their motivation is low, in order to increase their desire for recovery.

        If we only work with people who have high motivation then we are doing a disservice to those who are struggling and who are wondering if they can achieve their goals. Those people with high motivation already have a greater element of recovery capital than those with low motivation, so working with the hardest to reach, with the hardest to engage, with the most ambivalent should be the aim of a true recovery system.

        Too many people have been written off because their lack of motivation. Is it lack of motivation or is that services are not offering what the individual wants? Again, a true recovery oriented service listens to people in their care and works WITH them to address their substance misuse. When people are listened to and treated like people then their motivation increases

        • Detox Nurse says:

          Frazer, I think you make some very interesting points. How does your service ‘rapidly respond’ to clients with low motivation and willingness to explore recovery options?

          • Frazer Hill says:

            Rapid response – drop in assessments, no prebooked assessments – people come in and get seen immediately (if the duty worker is busy doing an assessment and someone else walks in then either another member of staff is asked to do the assessment or the person is asked to wait until the duty worker is free) the longest someone really has to wait is about an hour.

            We operate a DNA process so if a person misses their appointment and looks to be in danger of dropping out of treatment (regardless of how long they have been in treatment) we will go out and knock on their doors asking them what support they need to attend their appointments, – phone call reminders, lifts to appointments, appointments closer to home through satellite clinics etc. we work in a very rural county – 2 towns 6 miles apart costs £13 return on the bus.

            We also work with people in their own homes, outside of office hours – up until about 7.30pm, utilisation of trained peer mentors who are drug and crime free to illustrate recovery is possible, referral to either SMART or 12 step and utilising mutual aid workers to explain and take people to meetings (all staff have a target of attending mutual aid meetings as well to see that recovery is a large community).

            Having a Recovery Hub – away from the treatment centre – where the social aspects of recovery are addressed, ranging from PSI 1-2-1s, group sessions, recovery radio (not up and running yet) complementary therapies, activities such as weekend walking groups, discussion groups.

            Working with the prescribers as part of the overall service, as opposed to being a seperate commissioned service, does help, utilsing the expertise of workers with a variety of backgrounds, from nurses, social workers, counsellors and drug workers – and working as partners rather than as competitors.

            Hope this is of some use.

            • Detox Nurse says:

              Sounds like a great service. You’re not in Cumbria by any chance?

            • djmac says:

              This sounds like an exceptional and very client-focused service.

            • Detox Nurse says:

              It does sound like a wonderful service and, although quite a bleak picture of services provision is often painted, I don’t think it’s the only one. Our service, and the wider ‘partnership’ in the area, has a very similar approach: a Recovery cafe, late clinics, ‘neighbourhood’ clinics, carers support group, S.U. forum, acupuncture, etc, are all on offer. Indeed, all workers have to attend a mutual aid meeting as part of their personal professional development which, getting back to DJ Mac’s point, is a great way workers seeing people in active recovery.

              That being said, your rapid response ‘bit’ is just another way of saying that it’s easy to access treatment which, if we’re honest, is something that’s been offered by most services for many years (even if they offer very little else). I’m just not sure exactly how this helps people with low motivation and willingness to explore recovery options. Having all those other things on offer is brilliant, but you can’t force individuals to access it.

              I recall a lovely client who I saw around Christmas time. I saw him as a favour for a colleague as he’d missed numerous appointments and needed to collect his prescription. When I explained to him that I couldn’t issue his prescription because he’d blown over his breath alcohol limit, he said he would “slit my throat” if I didn’t give it to him.

              An extreme case, obviously, but at that time, I’m not sure he was ready to take up the offer of acupuncture or a peer navigator.

              I’ve mentioned before that our service is really fortunate to have a clinical psychologist who’s able to deliver a range of interventions from CBT to behavioural couples therapy, and can usually see clients within a week. The current waiting time for IAPT services in our area is around 52 weeks, yet the DNA rate for psychology appointments is frustratingly high.

              Recovery isn’t something that is ‘done’ to a person. The individual has to play a very active part in their own recovery. And this was my original point: a recovery system should be able to respond rapidly (and have things to offer) when an individual is at the stage where what to explore their recovery options.

              Furthermore, I think it’s the responsibility of society at large (and in particular the media) to be promoting the possibility of, and routes to, recovery, so that when an individual access treatment for the first time, there’s already an expectation that we’ll be discussing mutual aid, volunteering, etc, and with it, a willingness to try out such options.

    5. anonymous says:

      I feel very privileged to work for an integrated service. Our assessment is a group assessment which gives information relating to how to maximise your chances of recovery, discusses mutual aid, abstinence and abstinence from harmful behaviours. At the begining of “treatment” clients are spoken to about recovery, the multitude of differing community groups, and how we can support them to achieve their aims.

      Care planning is done using itep maps during the assessment. ORT is used and rightfully so, but is a part of a recovery-focused package. Motivation. . . . As a professional I strongly believe my responsibility lays with believing in my client’s ability to recover and my client’s ability to integrate into society within and external to mutual aid.

      Thanks to the research of David Best and John Strang we know that 80% of those who Ientify as being in long term recovery, either attend or have attended mutual aid. Substitute prescribing keeps people alive. You know the evidence. A dependant heroin/crack user outside of treatment is 14 times more likely to die than a non dependant peer. However substitute prescribing should begin with a treatment discharge care plan and how to achieve it.

      • djmac says:

        I strongly believe my responsibility lays with believing in my client’s ability to recover and my client’s ability to integrate into society within and external to mutual aid.

        I think this is fundamental to the process of recovery. Couldn’t agree more.

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