Or does methadone stop addicts from tackling the causes of dependency. Experts and users are divided about the merits of this 'maintenance' approach compared to the more robust alternative of rehab. Elizabeth Day listens to arguments from both sides
Michelle Kerry does not want her eight-year-old son to see her taking drugs. Each morning, she gets up at 5.30 and quietly goes to the kitchen to drink 10ml of concentrated liquid methadone. She swallows the watery concoction as quickly as possible, chasing it down with a cup of coffee to blot out the bitter aftertaste. Then she goes back to bed. At 7.30, she gets Ashley up and makes his breakfast. He leaves for school, none the wiser.
Although Michelle, 30, has been taking methadone every day for the past four years, she would not consider herself a drug addict. On the contrary, she is what the National Treatment Agency, the government authority tasked with tackling drug misuse, would describe as a success story. Last year, it is estimated that around 170,000 people, like Michelle, were given regular, controlled doses of methadone as part of a community prescription plan. Central government funding for the NTA has risen from UKP 60m in 2001 to UKP 398m for 2008-09. And, in 2007, 2.4 million methadone prescriptions were written - a rise of 60 per cent since 2003, at an annual cost of more than UKP 27m.
By comparison, only 2-4 per cent of the 200,000 drug users in contact with treatment services each year are referred by their local Drug Action Teams to residential rehabilitation centres that have total abstinence as their goal. Rehab, say its critics, is both costly and ineffective, whereas methadone maintenance works better and promises more immediate results.
Peter McDermott, the press and policy officer for The Alliance, a user-led advocacy group, says: 'A fairly typical 12-week stay in rehab will cost between UKP 6,000-UKP 12,000, depending on how complex your needs are. When you multiply that by the 200,000 currently in treatment, it soon becomes clear that we're talking astronomical sums of money.
'Residential rehab doesn't actually work very well. Most people don't make it through the programme. Of those that do, a lot use immediately on discharge. After six months is up, only a small number of people are still drug-free.'
McDermott says that rehab works only if the addict in question has the necessary financial, emotional or familial support to help them through the gruelling process of detoxification and then, crucially, to provide a support network when they are discharged.
'If you're poor or homeless, or if you're the third generation of a family of heroin addicts and thieves, or if your father persistently sodomised you from the age of five, then you've got no marketable skills, and no family to help you while you get back on your feet,' he says. 'A lot of those people come out of rehab and, although they might not be using, the quality of their life is sometimes worse rather than better. You've got all of the pain, and none of the things that were promised. And drugs are very functional for such people.'
At a time when Michelle's life was shaped by a vicious cycle of shoplifting and scoring, rehab seemed a distant illusion. 'I could only just make the appointments to get my prescription,' she says. 'I wasn't capable of anything else. I didn't have the confidence, motivation nor strength to go to rehab. What would be the point, only to go straight back to a life where it was all the same?'
The abstention approach, whereby a user normally undergoes a 12-step detoxification process, with the goal of emerging drug-free, is criticised by those who claim that drug addiction is not a 'curable' disease. An addict will, they say, always be in danger of relapse. Rehab requires a degree of ambition and self-reliance that the majority of hardened drug users simply do not possess. It is thus a question of living with that addiction in the most harm-reductive way possible. And that is where methadone comes in.
Methadone is a synthetic opioid that has been shown to relieve the narcotic craving and block the euphoric feelings associated with heroin. It is, supposedly, safer than other opioids because even long-term use does not harm the body's vital organs and the National Institute for Clinical Excellence recommends its use for the treatment of people who are opioid-dependent. But it is by no means a miracle cure: side-effects can include drowsiness, stomach cramps, hallucinations, vomiting and constipation. Long-term users can sometimes experience a sense of creeping apathy, a lack of energy and a decreased sex drive.
The aim of a methadone maintenance programme is twofold: first, to stabilise the chaotic lifestyle of an addict and then, over a sustained period of time, gradually to decrease the dosage until the user is no longer dependent on illegal drugs. Treatment with methadone or buprenorphine also significantly reduces the chances of HIV infection and contributes to falling crime levels. Or that's the theory.
In practice, as Michelle has discovered, it can be a long and difficult journey. She became addicted to heroin at 18. Her boyfriend at the time was a regular user and she remembers the first time she snorted the drug, it made her feel 'fantastic. It made me, not forget, but feel nice and warm. I was unhappy, I had hassles with my stepmum, I'd left home and heroin was a good escape.'
Soon, she was injecting. She tried to stop when she discovered she was pregnant with Ashley, but resumed the habit after she'd given birth. Things spiralled out of control. Michelle started shoplifting to fund her addiction. Then, when her son started school four years ago, she finally decided she'd had enough. 'I didn't want him growing up and realising what I was.'
She left her partner, walked into a local drugs clinic and was put on a waiting list for methadone treatment. 'They start you off on a certain amount and, if you're not coping and still using [heroin], they increase your dose until you feel stable.' Once Michelle had reached the point of 'feeling normal', her heroin usage dropped off. 'For me, methadone has been a lifesaver,' she says. 'I wake up in the morning and I don't have to rush to the toilet because I have diarrhoea. I have a proper diet - I was eight stone on heroin and now I'm 14. I can do things all the other parents do, like going to parents' evening, without thinking, "I have to go and score so that I'll feel OK."'
Michelle now has a new partner with whom she lives in Sowerby Bridge, near Halifax. She holds down a part-time voluntary job. Perhaps, most importantly, she feels that methadone has given her the chance to be a better, more attentive mother. Ashley, she says, is 'so much happier. I'm just so proud of him.'
Is Michelle a success story? In one very obvious respect, she is: she is no longer committing crimes, she is able to live a normal life, to contribute positively to society, and to raise her child in a happy and stable environment.
But Michelle is not drug-free. Nor is there any evidence that she will become so. Astonishingly, the government sets no limits on the length of time a former user can be on methadone. Many stay on the drug for decades. The government's measure for achievement is how many people are in treatment and retained for 12 weeks - there is currently no target for getting people off drugs. Indeed, the NTA's own figures for last year show that only 3.6 per cent of those in treatment - 7,324 - were discharged free of drugs.
'The methadone programme is like doping up people in an old people's home,' says Deirdre Boyd, the chief executive of the Addiction Recovery Foundation. 'We know of people who are desperate to get off it but who feel demotivated because they're not being given the therapy and support that they need. The National Treatment Outcome Research Study [a five-year drugs survey] put the cost of methadone at UKP 55 a week. Over a year, that will cost UKP 2,860 per person.'
That, Boyd points out, is equivalent to around four weeks in residential rehab - 'the difference being that there are good success rates of patients leaving rehab drug-free after those four weeks. Also, that cost is for dispensing methadone alone, without psycho-social support services. Patients should be offered appropriate psycho-social support.'
Underpinning all of this, according to Professor Neil McKeganey of the Centre for Drug Misuse Research at the University of Glasgow, is the evolution of an increasingly tolerant attitude towards drug use over the past 20 to 30 years. 'Drug use in itself is no longer seen as a problem,' he says. 'The only problem is when the individual starts to experience difficulties with it and that's why the services on offer are not focused on getting people off drugs, but on harm reduction. You'd be surprised at how resistant the civil servants I've spoken to are to the idea of rehab - there's a feeling that they might as well stick with [methadone] because it's cheaper.'
Although it is notoriously difficult to carry out research into the long-term effectiveness of drug-treatment programmes, the brutal reality is that many addicts will relapse, slip under the radar and become almost impossible to monitor. The 2006 Drug Outcome Research in Scotland study found that drug users in contact with residential rehabilitation services were more likely to remain abstinent. The survey of 695 found that 29.4 per cent of those who went through rehab had had a 90-day drug-free period nearly three years after treatment. Only 3.4 per cent of those who underwent a methadone programme could claim the same.
Proponents of the rehabilitation model insist that it tackles the cause of addiction, rather than simply the symptoms. Drug users are offered counselling and peer group support so that, instead of drug addiction being treated purely as a criminal justice or a health issue, it is approached in a more contextualised way. The problem with methadone, it is claimed, is that it replaces one addiction with another. The National Treatment Outcome Research Study showed that 40 per cent of people on methadone programmes also became dependent on alcohol, presumably because the core issue of what was causing these addictive traits was not being addressed.
'For me, treatment has to be about really dealing with the roots of the problem,' says Carolyn Cowan, 48, a recovering alcoholic and drug addict who attended a rehab centre in Arizona, USA, where she underwent extensive therapy and group counselling. 'I honestly believe that rehab saved my life. I was a very angry person and I had to deal with a lot of stuff that had happened to me as a child, a lot of sexual abuse that I had processed in a dysfunctional way. It helped me to rearrange my thoughts. It gave me tools for life.'
A study to be published by the Addiction Research & Theory journal next year demonstrates that patients on methadone maintenance get an average of only four hours of 'meaningful therapeutic activity' a year. This despite the fact that the vast majority of addicts use drugs as self-medication because of troubled or abusive personal histories.
For some, it is a question of aspiration and ambition, of how society treats those at the bottom of the pile. 'It depends what your goals are,' says Kathy Gyngell, a research fellow at the Centre for Policy Studies, a right-wing think tank. 'If your goal is to reduce the rate of HIV infection and to deal with crime, then give people clean needles and put them on methadone so that they're not using street drugs. But if your goal is to do with people getting better, the evidence is that rehab is much more effective.'
Why, then, are so few committed drug users referred to rehab? Gyngell says it is partly to do with a complex commissioning procedure that is extraordinarily bureaucratic and costly. To run a successful rehab 'takes a huge amount of nous and commitment' and should ideally incorporate half-way houses and long-term support for former residents. A lack of patient referrals means that many rehabilitation centres have been forced to close - 12 in the UK in the past year alone. Often, they are seen as dispiriting places of last resort for only the most hardened addicts.
At the same time, the word 'rehab' has also become synonymous with a certain kind of celebrity excess. Amy Winehouse, Robbie Williams and Kate Moss have all checked themselves into ( and out of ) rehab in recent years, accompanied by the inevitable paparazzo snapshot of them looking suitably stricken and ashen-faced in dark glasses. Of course, none of them is on methadone - if you have the money, why would you choose to be?
At the top end, residential rehab is often perceived as a sort of luxury health spa, set amid the extensive grounds of a picturesque Victorian mansion in the countryside. The Priory in Roehampton, south-west London, costs up to UKP 15,000 a month and remains the preserve of the rich, the famous or those with understanding private health insurers. In the United States, the Promises Treatment Center in Malibu provides a range of facilities including equine therapy, tennis and yoga classes. It counts Britney Spears, Charlie Sheen and Ben Affleck among its former clients. Little wonder, then, that rehab is often viewed as the ineffective 'soft' option.
'The idea of rehab has become tainted by celebrity,' admits Gyngell. 'But the top-end is in no way representative of rehab services across the country. You don't get any celebrities at Phoenix Futures in Sheffield, where they are dealing mostly with ex-offenders or those with a low socioeconomic status.' The reality is that the average weekly cost of a residential drug treatment place - UKP 674.10, according to a 2006 parliamentary question - remains cheaper than the UKP 800 a week required to provide prison accommodation.
In response, Paul Hayes, the chief executive of the National Treatment Agency, insists that: 'There is a common misunderstanding that residential rehabilitation offers the only path to abstinence. Rehab is one form of treatment that is suitable for some people, but is not a one-size-fits-all answer for every drug user.' He adds that, in accordance with National Institute for Health and Clinical Excellence ( Nice ) guidelines, the agency uses methadone as 'the standard front-line treatment for opiate dependency' but also introduces rehab where appropriate, specifically for addicts 'with mental-health and housing problems. Those who have been detoxed but not benefited from psycho-social treatment.'
Ultimately, the ideological argument between the abstinence and maintenance lobbies centres around what constitutes 'recovery'. For Michelle Kerry, recovery meant taking the medication she needed in order to provide a stable life for her son. For Kevin Manley, it meant something else: it meant giving up drugs altogether.
Kevin is a 31-year-old former heroin addict from Cardiff. He got into drugs as a teenager, smoking ganja, then progressing onto the harder stuff - speed, ecstasy and, finally, heroin. He first smoked heroin at 18. By the age of 22, he was suicidal and sought help.
He was referred by his GP to the Community Addiction Unit but there was an 18-month waiting list ( paradoxically, if you are on drugs and committing crime, you get fast-tracked but because Kevin was not offending, he had to wait ). When he eventually got his appointment, Kevin was told the only treatment option was methadone, despite insisting that his objective was to be drug-free.
'It was very hard, if not impossible, to control my heroin use as my methadone went up,' he explains. 'I think that's something every addict has in common. So I ended up on 80ml a day and still using the same amount of heroin. As for the support I was told I'd receive from my key worker, I was lucky if I spoke to them for 20 minutes a month. That isn't support.'
What Kevin most wanted - and what he felt would be most effective - was a residential rehab placement. 'I asked them if I could go to rehab and they said I wasn't ready. While I can understand there could be valid reasons for that, people should still be told that rehab is an option. Basically you're given methadone and that's it - you are forgotten about.'
Kevin took charge of his own treatment. He arranged his own rehab in a modest end-of-terrace house in Cardiff that offered a traditional 12-step treatment process, run along Christian lines. He spent five months there.
'I finally began to understand the mental side of addiction. I definitely needed a lot of support and encouragement during this time and both the counselling and group fellowship really helped. The sharing of troubles and worries that you get from peer support helped me to feel human again.'
Surprisingly, although Kevin wanted to reduce his methadone intake, his key worker at the CAU would still not allow him to do so. 'I was refused on the basis that I would be at greater risk of relapse if I reduced. No matter what I said they wouldn't listen to me. I ended up having to reduce myself, measuring it out every day and throwing away the remainder. Every time I went in for an appointment, I was chastised for reducing myself, despite the fact I was stable and drug-free.'
For Kevin, the prevalence of methadone treatment is to do with a government seeking to pacify its electorate, rather than the development of a programme aimed at helping the drug user overcome their addiction. 'When someone is "in treatment" and being given methadone then, statistically, you can show to the voter: "That's what we're doing. We've got people into this programme and they're not breaking into your houses." It's about placating society, not treating addiction. Simply giving someone methadone and nothing else doesn't fix the problem, it's just a holding pen.
'We need to address the reasons why that person became an addict. It's no use just treating the symptoms, that has no long-term benefits whatsoever.'
Of course, residential rehab does not suit everyone - as Kevin discovered, it relies largely on the self-motivation of the individual. Nor do proponents of the maintenance model seek to claim that methadone is a fail-safe solution for all addicts. Both sides of the debate point out that there is no one-size-fits-all solution.
Rob English is a 44-year-old former heroin addict from Peckham, south-east London. Arrested for the first time at 15, he funded his habit through petty crime before rapidly progressing to robbery. In 1999, a court ordered him to complete a course in residential rehab in Plymouth. It didn't work.
'My whole attitude was fight, fight, fight,' says Rob. 'On my way from London to Plymouth, I was smoking crack and taking heroin all the way down on the train. When I got there, I went straight into a pub. I got a cab to the rehab, fell out of it, and got admitted. For the next 28 days I disrupted everything. I was totally still in denial about everything. After 28 days, they said: "We've got no choice but to eject you." Rehab didn't work for me. The thing is, if you're spending 24/7 finding drugs, living for drugs and the whole thing is taken away from you, then of course you're going to be disruptive. You've got to want to change.'
He went back to heroin. Three years after his failed stint in rehab, Rob finally decided he'd had enough. At 38, he was homeless, sleeping rough in the streets around Waterloo. He had 15 abscesses over his arms and legs from injecting. An outreach worker took him to a hostel and, in October 2002, Rob started to get treatment. He was put on a methadone programme but was also given the support of a twice-weekly counselling session with a psychiatrist, something that he insists was crucial to his recovery. 'Without the counselling, these journeys are very hard to make,' says Rob, who is now a youth worker for Turning Point, the UK's leading social-care organisation. 'It's not just the methadone that gets you sorted out. It's a small part of the parcel.
'People who take drugs all have their own stories and backgrounds so you've got to tailor-make the treatment package to the person.'
But the debate among those in charge of drug treatment programmes has become so bitterly polarised that this sort of co-operation between the abstinence and maintenance lobbies is extremely rare. According to Professor David Clark, the director of Wired In, a grassroots initiative that advocates greater collaboration between harm reduction and rehabilitation, current treatment 'focuses on the drug rather than the drug, person and social context'.
He adds: 'Sooner or later, people will realise that the treatment system is not delivering. Methadone prescription needs to be part of a better-designed care model, with the central focus being on the client's wants and needs, and their desire to find recovery. They must have choice, opportunity and hope.'
How does one define successful recovery for a drug addict? Is it the replacement of one harmful drug by another, less harmful and more closely monitored substitute? Is it the reduction in HIV infection rates and crime levels that ensure the rest of us sleep a little more soundly at night? Is it tackling the underlying issues that cause a person to self-medicate? Is it total abstinence? Is it the chance to live a life governed by hope and ambition, rather than fear and deprivation? Or is it, maybe, a combination of them all?
For Rob, recovery was about finally realising he wanted to change and being given the different kinds of support that enabled him to do so. For Carolyn, recovery meant undergoing therapy to challenge her past and overcome it. For Kevin, it was a question of conquering his addiction and living totally free of drugs. And for Michelle, it has been about managing her own addiction to give her son a better life.
To judge these personal experiences in an abstract sense, to claim that one of them is right and condemn the other three for being somehow wrong, is to ignore the profound complexity that lies at the heart of individual addiction. Perhaps this is the greatest failing of the current system: that in all the ideological to-ing and fro-ing, we run the risk of ignoring the needs of the very people who most need treatment. Because, in the end, recovery can only truly be defined by the person who underwent the journey.
Author: Elizabeth Day
Pubdate: Sun, 16 Nov 2008
Source: Observer, The (UK)