Drug Abuse

METHADONE TREATMENT: THE THERAPEUTIC MIRAGE

Does the research on methadone treatment warrant the vast expansion in treatment facilities since HIV and AIDs? Pat Shannon critically assesses the evidence for the new Australian orthodoxy

INTRODUCTION

Methadone is used as a medical intervention for persons dependent on various opioid drugs, usually heroin. It is used as a symptomatic approach for the treatment of opioid-dependence problems. The main reasons for the introduction of this form of treatment were that the drug could be administered and taken orally once in each 24-hour period in a manner that could control the illegal, short-acting, impure, injectable, expensive substance of unknown quality, with a drug that is free, legal, pure and of known dose.These factors were intended to free addicts from the need to commit crime, and thus enable them to become employed in activities other than procuring drugs and also to prevent the adverse health consequences of frequent drug injections (Baldwin, 1986; Prescott, 1988).

The American innovators of methadone treatment, Dole and Nyswander (1967), postulated that heroin addiction caused metabolic change within the central nervous system, inducing a narcotic hunger, and that the treatment turns heroin addicts into constructive law-abiding citizens. Dole et al. (1968) produced a study of 750 addicts which boasted a remarkable 94 percent success rate, as defined by nil recidivism. Politicians and policymakers rallied to promote a chemical solution to an extremely complex problem. Australia was soon to follow the American example with the pioneering work of Dr Stella Dalton in 1970. Dalton et al. (1976) undertook a retrospective self-report study of the first 50 opioid addicts to receive methadone treatment in Australia and found that 88 per cent were found to have incurred no new criminal convictions. Although a return to crime is only one possible indicator of a programme's effectiveness, this factor led to the initial expansion of methadone in Australia (as it had in the USA).

Foy et al. (1989), in their prospective study of clients to the Newcastle Programme, followed up 50 of 63 admissions, using urinanalysis to determine extraneous drug use. Of the 50 admissions, 35 were terminated because of drug abuse, absenteeism, violence or drug dealing. Only 8 patients achieved a stable state without drugs over a 3-month period. No improvements were noted in patients' relationships, social situations, health or criminal activities.

In another relatively recent study, Hume and Gorta (1989) found that, of a sample of 377 prisoners, 70 per cent of those on the prison methadone were re-convicted after release. Mandelberg (1988) has suggested that the communities' response to the drug problem is essentially reductionist in nature: a very complex problem is reduced to the most simplistic element. Mandelberg (1988) reasons that when the community is confronted by the urgent distress of addicts we sometimes feel like the beleaguered mother who can only calm the screaming baby by feeding. It seems that the need is so urgent that the infant cannot wait for the mother to work out what is troubling the child. An excessive reliance can be developed on the milk itself. Methadone can enable the addict to put their pain out of their minds and its use can enable us to put them out of ours. Mandelberg (1988) further suggests that the Government emphasises placing large numbers of clients on methadone, holding onto the hope that methadone will bring about rapid and significant change. Rarely, however, is funding sufficient to provide adequate support.

Heather et al. (1989) point out that methadone treatment remains the treatment of choice for opioid dependents, not because it is supported by a large body of evidence supporting its effectiveness, but because of its popularity with opiate users and the relatively high rates of retention in treatment which result from this.

Further, Heather et al. (1989, p.56) state that Despite a voluminous literature, there is little firm evidence of the superior effectiveness of methadone maintenance compared with other forms of treatment.

METHADONE TREATMENT AND SOCIAL POLICY

Blewett (1987) states that the current policy towards intravenous drug users (lVDUs) in Australia is one of harm reduction. The underlying,*. assumption held is that, by using methadone, at least heroin users are kept alive and the harm they do to themselves and others is  minimised. This has great public appeal in light of the current AIDS epidemic and needle-sharing behaviour.

The recent Policy and Procedures for the Treatment of Opioid Dependence in NSW (1989) points out that methadone is to be used as an important strategy, to reduce the spread of HIV and, likewise, the spread of the hepatitis B virus in the IVDU community, and from them to other members of society. It is also promoted strongly as a treatment to be used with pregnant IVDUs and to reduce drug-related crime. The general aims are to assist opioid addicts in improving their health and social functioning and to alleviate social consequences of their drug use by eliminating and reducing illicit opioid use. In achieving these aims, it is reasoned that there will be a reduction in mortality and morbidity rates. Drug-related crime will be reduced and there will be a reduction in unemployment. Social and family functioning will improve and also a person's home duties and student functioning would be expected to improve.

Krivanek (1988) points out that in 1985 there was an 'epidemic' of political concern with heroin problems. Since that time the number of people on methadone has increased threefold. However, this does not necessarily mean that there was an epidemic of heroin use. In 1985 the National Campaign Against Drug Abuse (NCADA) was launched. Saunders (1985) has described the flavour of that time as one having the impression of a steamroller careering madly downhill. The central issue was heroin addiction and the steamroller seemed to he spurting methadone in all directions. Table I details the escalation of methadone client numbers since February 1985.

The National Drug Abuse Data System Statistical~ Update (January 1989, p.2) provides data for the period from February 198 5 to June 1989. Figures for the period from January 1989 to December 1990 were obtained from personal communications with the National Drug Abuse Information Centre, Canberra on 3 January 1990 and 26 June 1991 (Figure 1).

The February 1985 figure has been included to demonstrate the significant rise in client numbers. The December 1990 figure has been included to demonstrate the continued escalation of client numbers.

As seen in Table I and Figure I in February 1985, there were 2203 clients receiving methadone in Australia and, in December 1990, the overall figure had risen to 9137. The author would contend that an increase in staffing levels has not been adequate to deal with the increase in client numbers. McPherson (1990) points out that between 1986 and 1989 patient nombets increased from 115 to 988 in private-based programmes in Victoria whilst the institution-based programmes remained relatively static at approximately 200. As he states (McPherson, 1990,p.2):

'Because of their rapid growth, enormous strain has been placed on resources and appears to have affected the reasonable quality of some resources considered essential to ensure safe and successful management of programmes.'

TABLE 1: AUSTRALIAN METHADONE CLIENTS, TYPE OF CLINIC, FEBRUARY, 1985-DECEMBER, 1990

Number in

Type of clinic
	February 1985	June 1986	June 1987	June 1988	June 1989	June 1990	Dec 1990
Public	1794	2761	2931	3679	3816	3824	4475
Private	409	1745	2301	2441	2781	4543	4662
TOTAL	2203	4506	5232	6120	6597	8367	9137

A further difficulty was identified by McPherson with regard to the shortage of Drug and Alcohol counsellors working in the programmes. Renner (1984) would support McPherson's assertions arguing that it has been consistently noted that success of methadone treatment is directly related to the availability and the quality of counselling and ancillary services. This relates well to Mandelberg's (1988) earlier point that funding is rarely sufficient to provide adequate support programmes.

McPherson (1990) has identified six main problems with GP-based programmes in Victoria: those inexperienced in assessment, inappropriate commencement doses of methadone, poor follow-up, lack of counselling facilities, lack of education and training, inexperienced locum doctors covering for the treating doctor.

It is suggested that private clinics in NSW have less structure and control than the public sector. It is the writer's experience that in some clinics urinalysis is not always conducted on a regular basis, assessment is poor and counselling not incorporated into treatment at all. Staff turnover is high in some methadone programmes. Batey (1987) stated that there are too many clients on programmes and that units and general facilities are overstretched.

METHADONE AND NARCOTIC DEATHS

In Australia, Liddy (1978) in a study of fatalities related to narcotic deaths in NSW and the ACT found that, in 121 deaths during 1974-1977 attributed to narcotic analgesic drugs, opiates, heroin, morphine, opium, alone were the most frequently encountered cases (65) followed by methadone alone (23).

In a study of opioid drug-related deaths in Western Australia between 1974 and 1984, Swenson (1988) found that 108 (18.7%) of the 578 drug deaths in the period of the study were found to be directly due to the use of opioid-type drugs. The second most common implicated drug was methadone accounting for 19 deaths (18%). Heroin/diacetyl morphine was the cause of death in 12 (11%) of cases.

More recently, McPherson (1990) has noted that a substantial number of heroin addicts die within a few days of starting a methadone prograinme and has particularly considered 10 deaths that occurred between June and November 1989.

All three of the above authors have identified the high risk of prescrihing methadone to clients, in both public and private clinics. O'Neill (1978) believes that it is possible that the increase in narcotic use in the 1970s could he related to the expension of methadone prograintrics at that time. With the expansion of methadone prograinmes that has occurred since 1985 and the high level of client extraneous drug use in such programmes, it would appear likely that methadonerelated deaths will continue to increase.

'AUSTRALIAN STUDIES'

The study of Dalton et al. (1976) was instrumental in persuading social policy formulators to expand the Lise of methadone as a treatment option in Ausmilia in the early 1970s. The study traced 36 of the first 50 opioid addicts to receive methadone in Australia at Wisteria House. The follow-Lip period ranged from 6 to 27 months, with a mean of 12.5 rr~)nths. High-dose methadone blockade therapy was used. It was found that 89 per cent of clients cooperated with the treatment programme and that 88 per cent had no new criminal records. Further results indicated that 75 per cent were drug free, apart from methadone and that 5 of the 36 subject,,, were free of all addictions, 7 of these 35 had no previous criminal records and 3 had records for nondrug-related matters.

The sample size Used was not adequate; sample selection procedures were not described; the follow-up period was overly flexible, between 6 and 27 months; we are not told what other drugs, if any, clients were meant to abstain from, multiple drug use being ignored; urinanalysis was not used as an instrument to verify abstinence; we do not know if clients continued to commit undetected crime. The study cannot answer the question: 'Was the treatment responsible for success?'.

A further study conducted by Dalton and Dunkin (1979) used 43 patients from the same sample of 50 clients, followed up over a period of 8 years. The same flaws as those previously stated were present. The second study found that overa mean period of 6.7 years, 28 per cent of clients were judged to be a complete success.
The study does not qualify what the criterion for a successful outcome was.
There were conflicting reports between the 8-y ] and the earlier study. Neither study used a control group and both studies were undertaken by clinicians working within the programme under study. Therefore, the study was possibly biased to a large degree. Renner (1984), Epstein (1974) and K. Powell (unpublished data) have criticised the Dole et al. (1968) study results as being artefactual: the study excluded clients from the courts, clients with a psychiatric history and those who' were poorly motivated. Patients who were re-convicted while on the programme were dropped from the sample.
More recently, Bell et at. (1990) conducted a study of the characteristics of 767 patients who applied to enter public methadone programmes in the western suburbs of Sydney between 1986 and 1988.
It was found that 87 per cent of clients had been exposed to the hepatitis B virus; however, the HIV seropositivity rate was low, only 6 of 767 being found to, be HIV positive. Five of those were homosexual men and clinic staff held a strong impression that the sixth was homosexual. Needle sharing was found to he apparent in most subjects. Only two of the studiesl Hume and Gorta (1989) and Webster et al. (1977), have used a control group. No double-blind procedures have ever been used in Australia. Only one study has been prospective: that of Foy et at. (1989) which involved a clinical audit. None has used pre-post test designs.

Policy to date has been developed largely on the basis of such studies and generalisation of overseas results. There has only ever been one double-blind study conducted in the world which has compared methadone treatment with placebo. Newman and Whitehall (1979) conducted this study in Hong Kong. The study found that, over a 32 week period, 10 per cent of the controls were still in treatment, compared with 76 per cent who received methadone.

This study is cited religiously by the proponents of methadone treatment as strong evidence for the effectiveness of methadone programmes. Newman and Whitehall (1979, p. 486) described the exclusion criteria of the study as follows: 'Subjects were removed from the study when they failed to attend the clinic for six consecutive weeks, or if they had six consecutive positive urine tests for morphine.'

In effect then, subjects who did not attend the clinic for a period of 5 weeks and 6 days, and then attended on the appropriate day would be allowed to stay on the programme. They could continue use of heroin or other opioid drugs during that time.

In citing the above study Wodak (1989, p.11) has stated that: 'If something is attractive to people and retains them in the programme you are half way there.' The writer would ask the question 'where are we heading half way to?'.

Seow et al. (1980) examined urinalysis results of 231 patients, who were on the Western Australian methadone programme overan 8-week period, between February 1978 and April 1978. Of the 1160 specimens analysed over this period, it was found that 21.89 per cent contained an extraneous drug; opiates were found in 13.91 per cent of samples taken.

In terms of total abstinence as a criterion for success, Australian results have not been encouraging. In the Reynolds and Magro (1975) Brisbane Street study, it was found that only 3.2 per cent of clients had not used narcotics for longer than 6 months, the sample size being 94 clients.

Powell et al. ( 1984) found, in the Canberra study of 35 methadone admissions, that 5 of the clients graduated opioid drug free after a period of 20-42 months, I I patients clearly failed and the results for the other clients were unclear. Powell et al. (1984) boasted a high 31 per cent success rate in terms of client opioid abstinence. These authors were classified as having a serious alcohol problem and that consequently a figure of Z5 per cent abstinence would possibly he more appropri~te. The Powell et al. ( 1984) study failed to describe the research methods incorporated and there was no indication as to how abstinence was confirmed. The sample size was also inadequate.

A study conducted by Walby (1988), which examined methadone use in pregnancy, using a sample of 96 respondents, found that approximately 50 per cent of women used extraneous drugs in the period of 1-2 months just before the birth of their babies. The use of minor tranquillisers was found to be very common among pregnant women on methadone programmes.

Few clients reduced their methadone dose prior to the birth of their babies. Only two women achieved a smooth reduction, and both admitted to use of heroin during this time. Reilly et al. (1987a,b) conducted a descriptive study of 100 clients on the Sydney Rankin Court Programme. Clients' files, self-reports and urinanalysis results were used to collect and collate data.

The average length of time clients were in treatment was 15.7 months; the average dose of methadone was 46.3 mg.

In examining the Reilly et al. (1987a) study, the writer came across conflicting statements. For example, in the report published by the NSW Drug and Alcohol Authority (1987), Reilly et al. (1987a, PAO, state in their abstract: 'One third of all clients were abstinent from heroin for the duration of their treatment.' In the same report published by the Drug and Alcohol Directorate 1987, Reilly et al. (1987b, p.ii) state in the abstract that: 'One third of all clients were relatively abstinent from heroin for the duration of their treatment.' With regard to the same study, in his abstract presented at the International Symposium on Alcohol and the Brain, August 1987, Reilly (1987, p.9) stated that: 'Urinalysis results confirmed a decrease in heroin use, whilst one-third of clients remained totally abstinent from heroin.'

Is a result of 13-14 per cent sufficient justification for the huge expansion of methadone in Australia? What is the possible outcome for the 85 per cent of clients whose extraneous drug use does not cease, and who are then subsequently rendered physically dependent on methadone?

METHADONE TREATMENT AND OTHER FORMS OF THERAPEUTIC INTERVENTION

Simpson (1981), Simpson and Sells (1983), Joe et al. (1982/1983), Sells and Simpson (1980) and Simpson et al. (1982) have demonstrated in studies that~ methadone maintenance (MM), therapeutic communities (TC) and drug-free programmes (DF) are approximately equal in terms of successful outcome criteria, with no form of therapy demonstrating significantly superior results than another.

Bale etal. (1980) have also found that TC and MM are not significantly different in terms of outcome results. The Bale et al. ( 1980) study compared the effectiveness of an outpatient methadone programme with three residential therapeutic communities. Short-term (ST) and longterm (LT) communities were also compared, with a no-treatment (control group) (CG) also incorporated in the study. Bale et al. (1980) randomly assigned 585 clients to one modality or another to examine drug use, criminal behaviour, time in treatment, and work and school attendance. Overall, TC was found to be slightly superior in outcome if the client remained in treatment for more than 50 days.

The Simpson et al. studies showed equally beneficial results between TC and MM in terms of reduction in crime, drug use and increased employment. Detoxification programmes (DT) were also included in the above comparative studies. They demonstrated that outpatient drug-free programmes and control group 'no treatment' show the least successful outcome.

The database for the above studies, excluding Bale et al. (1980) was obtained from the Drug Abuse Reporting Programme (DARP). This is a large-scale evaluation project which focuses on the effectiveness of drug abuse treatment. The database includes 44000 clients admitted to 52 treatment agencies between June 1969 and March 1973 in the USA and Puerto Rico.

In another major American comparative study known as the Treatment Outcome Prospective Study (TOPS), methadone was found to be the most effective modality for treatment of heroin use. In this study, the prevalence rate of daily or weekly heroin use after treatment was found to be one-quarter of the pre-treatment rate for long-term methadone clients and one-third of the pre-treatment rate for long-term residential clients.

In terms of effectiveness of treatment for client use of prescription psychotherapeutic drugs, the post-treatment prevalence rate among all short-term clients and longterm methadone clients was approximately twothirds the pre-treatment rate. Long-term residential clients reported post-treatment prevalence rates of onethird of the pre-treatment rate (Hubbard et al., 1988)

Given the above, it is interesting tctnote the largest proportion of funding and resources is being allocated to methadone treatment programmes and not equally to other forms of intervention such as long- or short-term therapeutic communities.

METHADONE TREATMENT AND HIV/AIDS

The Albion Street Centre (1989) points out clearly that HIV will inevitably increase its spread in the VDU community of Australia, and from them to other members of society. This is not doubted by the present author; what is doubted is how effective methadone treatment will be in minimising the spread of the virus.

Batey (1987) argues that there is no strong evidence to indicate that, by increasing methadone availability, we will decrease the spread of AIDS. He states that: '50% of people on a methadone programme do continue to use intravenously albeit much less frequently.'

The Commonwealth Department of Community Services and Health (1989, p.9) point out that: 'people on oral methadone programmes continue to use injectable drugs and may expose themselves to a higher chance of HIV infection because concurrent IVDU is unplanned.' Smith (1988) has discussed the_i_ssu_eofff1 methadone use producing an immunosuppressant effect which decreases host resistance to the AIDS virus, particularly when there is a pattern of multiple drug abuse involving alcohol. Joseph and Appel (1985) have described the widespread nature of alcohol abuse in methadone programmes in detail. If maintenance programmes are associated with a high incidence of multiple drug abuse, and if these drugs are immunosuppressants, then it is possible, and even likely, that the expansion of programmes will not reduce morbidity and mortality associated with AIDS (Smith, 1988).

Casriel and Bratter (1974) ask the following questions: Is the heroin user a criminal and an addict who uses methadone a patient? Is a person who sells heroin a criminal pusher and a person who sells methadone a businessman or physician?

CONCLUSION

The current expansion of methadone treatment is not based on a solid foundation of empirical evidence. Australian programmes are being expanded for emotional rather than logical reasons and the current AIDS issue is effectively being promoted as a rationale for this expansion. It would appear that there is no conclusive evidence at present to suggest that methadone is uniquely useful in reducing the spread of HIV to any significant degree.

Methadone is a highly visible form of treatment which attracts large numbers of clients. Its use therefore can be seen to be doing something constructive about the illicit drug problem. Given the dramatic increase of the number of clients on methadone in the last 5 years, we ask whether opioid addicts may not be regarded as losers in this social control experiment?

The staff to client ratios, particularly in terms of counselling provision, have not seen a comparative increase. It is not unusual for clinicians working in such programmes to have caseloads in excess of 45 clients. The continued expansion and promotion of this model of therapy without adequate increases in resources and staffing levels also raises the question of whether we may just be giving out medication as a social panacea and as a sop to our collective consciences.

ACKNOWLEDGEMENTS

A special debt of thanks is due to Margarita Parrish for advice and constructive criticism in preparing the final manuscript. Thanks are also due to Dr Ben Gellan and the comments of reviewers are also gratefully acknowledged.

Pat Shannon, Caringbah Community Health Centre Miranda, Sydney, Australia, is manager for Community Drug and Alcohol Services in the Sutherland District Health Service and has worked in the Drug and Alcohol field for 14 years. The views expressed in this paper are entirely those of the author and do not necessarily reflect those held by the Health Department of NSW, Australia.

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