METHADON SCREWS YOU UP

Exploring the Limitation of Opiate Substitute Prescribing

Michael George, Principal Clinical Psychologist and Director of the Options Project, Worthing, East Sussex

The literature describing the use of methadone (Physeptone) in the treatment of opiate dependence now spans a quarter of a century (Newman, R G. 1977). Although policies on the prescribing of methadone vary considerably dependent on time and location (Senay I988), and while there has been considerable fluctuation in dosage (Griffiths et al, 1988) a broad and important distinction has been made between maintenance and withdrawal prescribing. The former implies therapeutic goals of stabilisation and risk reduction while the latter has abstinence as its objective. This paper attempts to identify some of the practical and ethical problems which are associated with the most widely practised chemo-therapeutic intervention in the contemporary treatment of opiate dependency.

Maintenance prescribing

Maintenance prescribing of opiate substitutes has continued to attract debate since it was first described by Dole and Nyswander (1976), both by prescribers and recipients. A frequent criticism is that the socialisation of opiate use by providing safe and legal supplies for the dependent individual does not constitute treatment any more than the long term prescription of Lorazepam for anxiety. Others (Edwards 1969), have pointed out that maintenance prescribing may in fact encourage people to maintain their existing lifestyle and thus prevent them from having the compelling incentive to try to stop using opiates.

These criticisms arise out of the (not always explicit) assumption that abstinence is the only legitimate goal of treatment. The emereence of HIV and Aids has introduced the concept of harm reduction as a justifiable treatment goal. The practical implications of these two conflicting ideologies have given rise to disagreement and inconsistency in working practices. Whether an opiate user presenting for treatment is offered a non-prescribing, swift methadone reduction or maintenance methadone schedule may depend more on the accident of their address than their clinical assessment.

Peele (1981) observes, "the many mistaken and costly ideas about defeating addiction that have been propagated all stem from the same fundamental error. This is the failure to understand that a person is addicted to an experience. If a cure for addiction fails to take into account a person's need for the addictive experience, he or she will simply be set loose to seek a comparable experience elsewhere."

This observation may give us a clue to the alarming growth in the use and distribution of other powerful psychoactive drugs such as Cocaine and "Crack" in places such as New York and Amsterdam, where low threshold opiate substitute prescribing services exist. Simply stated, I am suggesting that when an individual's opiate habit is catered for in a way which causes minimal fuss, aggravation and cost that individual may be enabled to divert their energy and resources to the acquisition of alternative pleasurable stimulation. Senay (1988), for example, notes that "a significant number of methadone maintenance patients increase alcohol consumption to the point, in some cases, where it becomes "alcoholic" drinking..".

A variety of sources (ACMD 1982, Stimson and Oppenheimer, 1982) have identified the low morale among staff in clinics where maintenance prescriptions a used. The feeling was prevalent that therapeutic contact was the price the client had to pay to obtain a prescription rather than a vehicle of behaviour change.

The effectiveness of methadone maintenance has also proved a contentious issue. Wilks (1989) reviews evidence that suggests no difference in death rates or criminal behaviour between maintenance and non-maintenance populations. Others (Dole 1989, Cooper, 1989) defend the normalising effect of maintenance methadone and suggest that failures are not due to maintenance itself but to inadequate daily doses. Confusion arises, therefore, as to whether the tool itself is at fault or the modus operandi.

Care or control?

A feeling of unease is generated by the Huxley-like "brave new world" which has been ushered in by the state financed and co-ordinated chemical distribution scheme methadone maintenance programmes) which control and monitor the behaviour of some of the most deprived and disadvantaged members of urbanised civilisation (Drucker 1989). Trebach (1982) peaks for many when he raises the ethical issue of the "social control" implied in methadone maintenance. Strang (1987), somewhat euphemistically, speaks of a social contract". Drug treatment agencies often attach stipulations to prescribing agreements which might include proof of employment, stable accommodation, provision of urine specimens and cessation f illicit drug use. Whose ends are being served? Is the drug worker an agent of social control, or a therapist helping a confused individual to sort out his or her chaotic lifestyle?

If behavioural control is the objective there is a good argument for reintroducing more favoured and short acting injectable reparations and considering the use of stimulants in maintenance programmes as well. Such ideas (Marjot 1987) have usually attracted fierce opposition. There is a ubiquitous methodological inconsistency in embracing maintenance programmes while resisting the very strategies which would make this form of intervention more widely effective. However, if the drug worker is a therapist helping the individual out of the trap of dependence, the use of methadone attract or retain clients is collusive and ultimately sabotages the main task of treatment.

Detoxification

Clients themselves complain that withdrawal from methadone is more difficult than from heroin (Stewart, 1987). Other reviews have found methadone withdrawal programmes less effective than -patient regimes and no more effective than the spontaneous remission rate. My observations about the use of methadone in withdrawal regimes go further. I suggest at methadone in this context has demotivating properties which are glossed over, both because the use of methadone has undeniable benefits and because treatment alternatives are scarce and of proven validity (such as the use of NET, Clonidine, opiate antagonists, etc.).

Most importantly, the addition of a methadone prescription to the climate and context of an individual's decision making n radically alter the process of change d the sustained motivation which powers progress. The urgency of the sire for active change which marks the client's initial presentation, can be weakened by the prescribing of methadone and at worst can lead to premature exit (Prochaska and Di Clemente 1984) and return to a precontemplative stage in the cycle of change.

Stimson and Oppenheimer (1982) report on the observations of one drug dependency unit in which staff felt that while the use of methadone "..alleviates the immediate problem of obtaining drugs, it reduces that motivation and energy needed to change the individual's situation and he frequently resumes illegal drug use in addition to his prescription after a period a some months..".

Concurrent strategies

The situation is made even more complicated when the different and conflicting strategies of maintenance and detoxification are combined in one treatment service. Henk Ten Have and Pal Sporken (1985) in a paper which deals wit] the ethics and philosophy of medical approaches to heroin addiction write, "The aim of treatment may be defined as either to achieve abstinence from heroin use or to neutralise the social consequences of such use. In fact, treatment tries to achieve both." Strang, (1987) attempts to make a distinction between flexibility of treatment services and liability to manipulation. He attempts to side-step the all important question of the power struggle which can ensue between client and therapist. He writes, "It is not just a matter of handing the patient a shopping list of all the available treatments: rather it is a matter of advising them on the much smaller list of potentially appropriate options...". Just how coercive is the a&vicwe? Who chooses which options are eliminated from the supermarket shelf and which remain available? ' I believe that while it may be necessary for drug treatment centres to operate both a maintenance (harm reduction) mode of responding to drug problems and a detoxification (abstinence) mode this can, and does, give rise to a confusion of mixed messages. The staff have to get used to the cacophony of a band playing two tunes simultaneously.

Local opiate-using communities have swift and effective channels of communication (Fraser and George 1988). It would be naive to expect that the treatment contract negotiated with John Smith on Tuesday morning has no bearing on the expectations of Mary Jones presenting on Wednesday afternoon. The problem with the shop window approach, stated bluntly, lies in the expectations and assumptions that it generates. The laudable intent of harm minimisation has implications which are antagonistic to the therapeutic goal of abstinence for therapist and client alike.

Conclusions

The use of methadone in combating opiate dependence is complicated by both ideological and practical conflicts. There is confusion between the treatment model and the social control model, which is further complicated by the antagonistic implications of abstinence and harm reduction as treatment goals. In the UK, where it is not unusual for a health district to have one identified treatment centre, problems can arise out of the concurrent availability of different treatment models, while adherence to a single model provokes accusations of unfairness and rigidity.

It would be naive, punitive and possibly dangerous to advocate abandoning the use of methadone on the basis of the diffficulties which this paper attempts to clarify. However, all treatment modalities achieve their maximum effectiveness only when their limitations are fully examined and understood. For that reason this author would welcome further debate surrounding the issues and implications of the use of opiate substitute prescribing both in maintenance and reducing doses.

References

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