Is It Time We Learnt to Love Methadone?

“I’d be dead, if it wasn’t for the methadone programme,” Peter says. “A hundred percent dead.”

As of July, there were 9,947 people being prescribed methadone by the state. Peter is one of 3,500 of these who have been on a methadone programme for more than 10 years – he’s been on one for 15.

(Peter’s not his real name. He asked us to hide that because so many people around him don’t know he’s on methadone and he wants to keep it that way.)

“If you knew me before . . . ” he says. “The turnaround is just amazing.”

Growing up in a deprived area in south Dublin, Peter says he was hanging around with the wrong crowd. He was taking morphine pills in his twenties before he moved on to heroin in his early thirties.

In eighteen months, he dropped to seven and a half stone. For his height, he should have been 14. His habit grew to between IR£50 and IR£80 a day.

To feed it, “I was taking stuff from me parent’s house and selling it,” he says. “In the end they knew. That’s when I got the ultimatum.”

“It was put on the table: me older brother said, ‘Lookit, come here, we know; we’re not fucking stupid.’”

He started on the methadone programme and hasn’t looked back.

It was hard at first, he says, going to the clinics, because it was new. But after a couple of months, people could see he was starting to put on a little bit of weight and get back to himself.

“Towards the end of the second year, I really started to pace meself, and began making plans for employment,” Peter says.

He began learning how to drive heavy machinery used in construction.

“I started going for the excavator, anything up to 100 tonne; then after that it was the JCB; then after that, the 10-tonne dumper; after that it would be the articulated dumper,” he says.

He is flat-out with work, he says. Whenever there’s digging to be done in a high-risk area, around ESB cables or expensive fibre-optic cables, Peter is your man.

“I hadn’t even got a car licence,” he says. “Now I’ve every licence that you can think of.”

He has never tried abstinence or detox and says he has no desire to come off of methadone, which he collects weekly from his GP.

As he sees it, his methadone prescription is medicine for an illness. He likens himself to a person with diabetes, or to a friend of his who takes heart tablets every day. “It’s the same,” he says.

The prevailing consensus in Ireland is that the methadone programme is a short-term solution to addiction, part of a progression towards abstinence. It’s a gateway to a drug-free life, and long-term maintenance is pernicious, a substitution of one drug for another, green or liquid handcuffs.

But is it? Or is it just a medicine like any other, used to treat a chronic medical condition, an aid to a normal life?

What Does It Mean To Move On?

Tony Geoghegan, CEO of Merchants Quay drug services, says he wouldn’t be as disparaging as to call them liquid handcuffs. He and Merchants Quay have always been advocates of methadone, but he feels there hasn’t been sufficient emphasis on people moving through treatment.

When methadone was first introduced into Ireland in the 1980s to tackle the heroin crisis and the rise in HIV cases associated with it, he says, “it was posited as a mechanism whereby drug users could get out of the rat race, the whole treadmill of having to look for money, looking for drugs, taking drugs, back looking for money”.

Once stabilised, he says, they could begin to address the issues that underpinned their addiction in the first place. They could then start to develop new coping strategies and skills “that would support them to move towards a more independent life, free from methadone”.

“Unfortunately, that hasn’t happened,” he says.

For a variety of reasons, some people may need to stay on methadone for a long time, maybe even indefinitely, he says. But that shouldn’t be the norm. “It wasn’t how it was envisaged,” Geoghegan says.

At the Rutland Centre, Senior Counsellor Gerry Cooney is inclined to agree.

“Methadone maintenance seems to be the national response to heroin use,” he says. “That’s the first option offered to most. There doesn’t seem to be a lot of thought into helping people come off methadone.”

The Rutland Centre’s approach to addiction is total abstinence; there is no prescribing methadone. Cooney’s view is that methadone can work for some, but that there should be more options for addicts wanting to get off drugs completely.

What of the medical argument, that opioid dependency is a medical condition and methadone is a medicine that can treat it? “Like any addiction, it depends what your philosophy is, but I think it’s something that people can choose to change.”

“The Short-Term Thing Is Rubbish”

Dr Garrett McGovern, a GP and expert on addiction, looks at methadone maintenance in an entirely different light.

McGovern has been working in the area of methadone treatment since 1998, the same year the first legislative framework, the Methadone Protocol, was introduced. He has about 250 patients on the programme under his care throughout the city.

“If it’s done well, and if the patients have a good relationship with their doctor and good relationship with the person who’s looking after them, [methadone] really is a magnificent drug,” he says.

As he sees it, much of the problem lies in the public perception of methadone. “When you talk to people who don’t know very much about methadone, they nearly always immediately become philosophically judgmental about it, rather than taking the time to read the evidence.”

Worse still, he says, there are a lot of people, GPs included, providing treatment and prescribing for addiction who are ill-informed about methadone.

“The general public can be accepted. They think drug users are scumbags, it’s bad and it’s awful, but I can accept that part, but people who are providing treatment should know better but they don’t,” he says.

“Worse than that, you have people prescribing methadone who don’t know an awful lot about methadone.”

There is no structured training for drug treatment in Ireland, he says. “My training was basically sitting with a doctor who’d been doing this for years – the wrong way, I might add. Then I was given a script pad, a pen, and off I went to do a clinic.”

He started researching the evidence on opioid addiction, attending conferences, and then did a master’s degree in clinical addiction at King’s College, London, which led him to believe that the way methadone treatment was done in Ireland “was all wrong”.

The punitive approach of threatening to kick people off of a methadone programme has changed, he says. It still goes on, but it’s rare. “But I think there are a lot of doctors who still approach this as a sort of social-control type of drug, and see it as a policing role rather than a medical role.”

If methadone is prescribed in the right way, and coincides with supportive counselling, it can be a really good service, he says.

“I don’t see why we should treat methadone any differently than any other medicine for a chronic, relapsing condition. But for some reason, methadone has been demonised as a sub-normal kind of medication.”

But should it not be used as a short-term means to the eventual end of abstinence?

“That’s nonsense,” he says. “The short-term thing is rubbish.”

“If coming off medication means you don’t have to see a doctor anymore, you don’t have to come to a clinic and you’ll never take drugs again, well, then it’s the best idea in the world. But if the likelihood is that you’re going to do those things and possibly be at the risk of death, then it’s not such a great idea.”

“And, unfortunately, the research shows that the risk of relapse in heroin users who come off methadone is huge.”

The Risk of Relapse

A 2009 World Health Organisation report backs him up.

“Opioid withdrawal (rather than maintenance treatment) results in poor outcomes in the long term,” the report said. “In practice, most patients resume opioid use within six months of commencing opioid withdrawal.”

It goes on to say that if it is their informed choice to do so, patients should be helped to withdraw from opioids, “but most patients should be advised to use opioid agonist maintenance treatment”.

A 1994 study in the International Journal of the Addictions compared an abstinence-orientated approach to opioid dependency with methadone maintenance.

It found that subjects in abstinence programmes were significantly more likely to use heroin and amphetamines in the first two years. (It also found that those in methadone treatment were the more likely of the two to use benzodiazepines.)

Because of long-term changes in neuronal circuitry as a result of repeated opioid use, there is a high risk of relapse to opioids, even after a long period of abstinence, according to the WHO report. And then the risk of overdose is high, because the person’s tolerance will have fallen.

Historically, according to the report, opioid dependency was seen as a “disorder of willpower” and a character defect, but thanks to recent advances in understanding the biological mechanisms behind dependence, this has changed dramatically.

“It is widely accepted that, regardless of the reasons for opioid use, the neurological changes that occur with opioid dependence constitute a brain disorder,” the report WHO said. “Therefore, opioid dependence can be considered a medical condition.”

The report goes on to say: “In most cases, treatment will be required in the long term or even throughout life . . . Such long-term treatment, common for many medical conditions, should not be seen as a failure, but rather as a cost-effective way of prolonging life and improving quality of life.”

According to 2012 article in the British Medical Journal, there is “moderately strong evidence” of the efficacy of opioid agonists such as methadone and buprenorphine (another opioid commonly used in treatment outside of Ireland) in reducing heroin use, keeping people in treatment, and keeping them alive.

“The evidence for effectiveness and cost effectiveness is far stronger than for all other treatments for severe heroin dependence,” it said.

The estimated cost of methadone in community-based programmes in Ireland for 2015, including pharmacy fees, is €20 million. That’s an average of €2,000 per year per patient.

According to a study, quoted in the British Medical Journal article, undertaken by the National Institute for Health and Care Excellence in Britain, this money will save the state more money.

Compared to no treatment, methadone and burpenorphine are highly cost effective. For every £1 spent on them, £5 pound is saved in criminal justice, health, and social care costs, the study found.

Methadone and Deaths: A Complex Relationship

Compared to Europe, Ireland has a higher-than-average rate of overdose deaths and, as Tony Geoghegan of Merchants Quay points out, methadone is often implicated.

In 2012, methadone was involved in a quarter of all overdose deaths, according to the Health Research Board. However, in most of these, it was mixed with other drugs.

Take a step back to look at deaths and methadone, and the picture is more complex.

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) has found that: “Observational studies report the mortality rate for opioid users in methadone treatment to be approximately one third the rate of those out of treatment.”

Analysis by the UK General Practice Research Database (GPRD) published in the British Medical Journal claimed that the death rates for those in continuous opiate-substitute treatment was significantly lower (1.6 percent) than those in the year after patients stopped treatment (8.2 percent).

There was a greater than 85 percent chance of reducing overall mortality if patients remained in methadone treatment for 12 months or more, the GPRD found.

Why the Opposition?

So if methadone maintenance, according to the research, is the most effective treatment in reducing overdoses, HIV transmission, illicit drug use, crime, health problems and social issues – and it’s cost effective – why is there such opposition, particularly to longer-term maintenance?

For Irene Crawley, director of Hope, an inner-city drug-free rehabilitation centre, containing the cravings and preventing the illness of withdrawal from heroin does not get to the root of the problem: addiction.

The problem isn’t the substance, she says; it’s addiction.

“A person’s absolute best chance to recover in all areas of their life – that is, emotionally, spiritually, psychologically, socially, financial – is to actually get away from their addiction, to stop taking drugs,” she says.

Crawley is not 100 percent anti-methadone, but she feels it should be the last course of action, after all other possible avenues have been exhausted. Not the first.

If someone needs it for detox, if their drug use was particularly chaotic and they’re finding it difficult, methadone can be helpful, she says.

“But it’s the long-term methadone maintenance, where they go down to the clinic and it’s like quicksand: you never see them again.”

What’s meant to be six months of maintenance, she says, turns into five years. “Bottom line is that if someone is on a clinic that long, little by little by little, it erodes the human spirit.”

She’s aware that some people on methadone maintenance go to work and go to college, but she believes from what she sees in the community that most people aren’t working, aren’t in education and are just going to the clinic and hanging around all day.

“I don’t believe people coming forth for help with their addiction are getting the best help possible because the resources and the political will are just not in place for that,” she says.

There are just 25 detox beds in Dublin, which has the vast majority of the 10,000 people on methadone maintenance in the country. There’s also an estimated 10,000 heroin users not in methadone treatment.

Long-term maintenance treatment is inherently discriminatory towards the poor, Crawley says. Somebody who comes from an affluent background who has a drug problem, she argues, is not going to be sent to an inner-city methadone clinic; they’re going to be sent to a treatment centre.

The Rutland Centre costs €11,500 for a five-week residential treatment. “They’re going to be sent there, and they’re going to get the best possible help to get free of their addiction,” she says.

If the resources were there, that sort of choice could be open to many more addicts.

“I see people who get completely clean and get off everything and move on with their lives, and I see the same people walking by my window for the last ten years down to the clinic, and there is clearly a difference,” she says.

Dr Garrett McGovern doesn’t get excited about detoxing because of the relapse rates, which means people are at a higher risk of an overdose because their tolerance levels have dropped. It doesn’t mean detox is wrong, it just means they need to be aware of that risk, he says.

“People will say we don’t have enough detox beds and we’ve too many people on methadone,” he says. In fact, we’ve too few people on methadone, McGovern argues, particularly outside of Dublin, where treatment is patchy.

“At the end of the day, it is a harm-reduction service. It’s sort of, ‘Welcome to the real world,’ in terms of addiction and all sorts of addiction, and the idea the everyone is going to be abstinent and they never touch drugs again or alcohol again and we all live happily ever after is really nonsense.

“If they treat it just as a medication that’s going to help people get better, they should look no further than that,” he says.

Hush-Hush

Stigma. The structure of services. Those are the two major impediments that stop people from treating methadone as just another medication.

The former is why Peter could not tell his employers he is on methadone treatment.

“I’ve no intention of telling them,” he says.

Some of the digging he does is risky. And there’s a lot of money involved sometimes, like when he’s digging around a fibre-optic cable worth half a million euro, which, if ruptured, cannot be repaired.

He feels that, as a methadone patient, he would be seen as unfit for such work.

“In actual fact, I’d say they’d be shocked,” he says. “If only they knew the truth.”

It frightens him to think where he’d be now, he says, if he hadn’t started on the methadone programme.

But once on it, he says, “I really put my head down and got stuck into it. I said this is the life that I want. And this is the road that I’m staying on, because I know what the other road is.”