When I first started work in landscape of addictions treatment and recovery support, I quickly became painfully aware of a common, ongoing and slightly worrying issue; there are way too many heated debates about service delivery quality and process efficacy.
Sometimes the conversations are valid, but sometimes they can be almost puerile and can actually border upon explosions of pugilistic vitriolic argument.
But, all these ‘discussions’ are important; change is born from learning and discourse is (usually) productive. If and when those expressed opinions are based in science and fact, as opposed to those that are often rooted in emotions and/or dogma. Sadly and more often than not, many appear to follow the latter content and direction.
A great deal of the discourse tends to revolve around issues such as; the impacts of process delivery, concerns around procedural quality, the availability of differing treatment pathways and the availability (or not) of ‘appropriate’ medications. That’s OK, until we start to add (or allow) those differing personal and organisational expectations (right or wrong, who decides?) to direct the conversations..
We also have the clinical requirements, which are (usually) based in science and supported by ongoing research. As opposed to being mostly based in dogma, morality, politics and/or financial considerations. And finally, but most importantly… we often fail to consider the specific but diverse ‘needs’ of an individual patient (service-user). We need to start by remembering… we are dealing with people here.
Clinical Ethics & Moralities
This diverse cohort of individual human beings are seeking care and support, often in difficult and sometimes traumatic circumstances. Many of these patients are impacted negatively by a myriad of socioeconomic issues, in addition to their health concerns. It is both morally and clinically unacceptable for any (arguably) over complicated system, to place additional barriers in their health-care pathways.
In my experience, too many service-users, clinicians and treatment practitioners are unwilling to take a much-needed step back from the argumentative abyss. They but heads on on a regular basis and fail to pause, in what is usually a mostly well-intentioned but often adversarial (and unhelpful) conflict process.
Observed simplistically, these problems often tend to result from… too many people failing to consider the needs of the individual. Something that might be an uncomfortable process in any situation but, even more outrageously strange within a system that purports to deliver care, which is what it is designed to do.
Methadone: Gatorade Treatment
One of the ”hot-topics’ for regular discourse revolves around the prescription and use of Methadone. A medication used in the clinical treatment for Heroin addictions, or other opiate substance use disorder (SUD).
In some respects, Methadone (Molecular Formula: C21H27NO) has evolved into the Gatorade or Mountain Dew of medicinal treatment, for any addiction to opiates. But, is this Kool-Aid suspension providing all the clinical solutions that it could or should be doing?
Does the prescribing process still ‘follow the science’ – always and on every single occasion? Have all clinicians changed or updated their practice to match the current or latest research outcomes? Do individual perceptions, around the purpose and efficacy of the medication, dovetail with the prescribing modality or even, the realities surrounding any subsequent consumption by the patients? Is methadone little more than a convenient and trendy ‘club-soda’ for the masses? The answer to some of these questions would have to be… probably not.
Methadone: Science & Clinical Opinion
Writing in The Guardian back in 2013, Dr Roy Roberston, a GP in Edinburgh and Professor of Addiction Medicine at the University of Edinburgh‘s Usher Institute wrote; “Methadone may be an imperfect treatment, but it’s a necessary one” and I agree with him.
Recent debates have concentrated on optimising treatments such as methadone. Better outcomes are expected and better interventions required allowing recovery in whatever form that might be achieved. …All mechanisms and techniques should be available and, most importantly, should be assessed for efficacy and cost-effectiveness… (read more)
Robertson pointed to the fact, that for some; recovery from addiction is all about “absolute abstinence from all drugs, for others it is stability and the absence of illegal and dangerous drug use.” Research has shown (see below) that appropriate prescribing (and consumption) of Methadone is undoubtedly an effective resource in the toolbox of addiction treatment, one that supports harm-reduction and recovery.
Research carried out by the universities of Bristol, Cambridge and Edinburgh found that opiate substitution treatment reduced the frequency of drug use. The treatment also led to a drop in the risk of death by 13 per cent each year. (ed.ac.uk)
Availability and longevity of appropriate prescribing are the key issues in play here. However, the above study also showed that treatment (with Methadone) “did not reduce the overall duration of injecting” amongst heroin users. That really isn’t a relevant issue, or at least shouldn’t be. Unless you assume that the sole purpose of opiate substitution therapy (OST) is to enforce abstinence from the use of street / illicit opiates… an incorrect belief.
In his article, Robertson was observing the (expected) angst when a child died, after consuming his mother’s prescribed methadone (see here). The parents of that child were subsequently and (arguably) appropriately jailed for the manslaughter of the child however, the incident served to to once again raise the specter of issues that are misunderstood by many people (outside of addictions and treatment).
Without the lived-experiences of addictions, or professional expertise within the treatment process, most people don’t really understand the issues, let alone talk about the subject in any rational manner. Most conversations tend to be wrapped in emotions and/or learned moralities, mostly based on contrived political rhetoric or dogmatic belief structures. Regardless of this fact, people are usually informed and empowered by the emotive media machine, expressing strong and vocal opinions (correct or incorrect) via social-media platforms.
Methadone (and Buprenorphine aka Subutex) is used for Medication Assisted Treatment (MAT) in the USA, and Opioid Substitution Therapy (OST) in the UK. Both of these clinical interventions involve the administration of a prescribed (daily) dosage of opioid medicines, to patients with opioid dependence problems.
MAT Decreases opioid use, opioid-related overdose deaths, criminal activity, and infectious disease transmission. – MAT Increases social functioning and retention in treatment. (drugabuse.gov)
When a patient first begins their treatment (MAT/OST), they are prescribed a level of methadone (or other substitute drug), that is measured/designed to minimise their withdrawal symptoms from their previous opiate (heroin) use.
Opioid substitution therapy programmes are effective in substantially reducing illicit opiate use, HIV risk behaviours, death from overdose, poor health, criminal activity, and seek to lessen financial pressures and other stresses on drug users and their families. (release.org.uk)
The current NICE Guidance for the clinical use of methadone (TA114), when managing opioid dependence in the UK, was originally published in 2007. It was subsequently reviewed in 2016, along with the use of Naltrexone (TA115) for detoxification purposes after an opioid overdose, and found to still be relevant and clinically appropriate. But again, not everybody completely agrees with the clinical guidelines, or at least the sometimes binary application of those guidelines, from an organisational (or systems) based perspective, rather than addressing the needs of the individual patient.
Methadone: Service-User Perspectives
Writing in the October 2020 edition of Drink & Drugs News, a ‘trade journal’ for addictions treatment service practitioners; Alex Boyt (see note) highlighted some of the prevailing issues that are associated with methadone prescribing. He firstly acknowledged the clinical ‘worth’ by saying “Methadone can be a life saver, both metaphorically and literally.”
Opiate substitution treatment in injecting drug users in primary care reduces this risk of mortality, with survival benefits increasing with cumulative exposure to treatment. Treatment does not reduce the overall duration of injecting. (bmj.com)
However, Boyt rightly went on to question some of the practice associated with prescribing and subsequent use of the mediccation. He presented the question, is the whole process little more than… Supervised Humiliation?
…many heroin users do not welcome daily methadone consumption – it’s harder to get off than heroin and does not address trauma in the way that heroin does – it doesn’t hit the sweet spot… Many users want methadone occasionally – it makes complete sense to them – but they must take it every day, or not at all. The treatment system demands it. (Alex Boyt)
By way of trying to provide an answer to Boyt’s valid question, in his excellent and informative article, I would have to offer a resounding but perhaps simplistic YES.
That said, many of the issues around the specific (or perceived) ‘humiliation’ actually stem from impacts within the prescribing ‘purpose’ and/or, those longitudinal factors that accompany prolonged prescribing and use. The overall efficacy of the latter is often disputed and, methadone is not the ‘panacea’ that some believe it to be.
Again, the OST process is simply one part of an overall process. All prescribing should be tailored to the needs of an individual patient. Not, as can often be the case, seen as a convenient resource to be used with a broad-brush methodology, or one that is employed in attempts to mitigate or fulfill organisational KPI measures.
Clinicians and patients should be aware of the increased mortality risk at the start of opiate substitution treatment and immediately after stopping treatment. Further research is needed to investigate the effect of average duration of opiate substitution treatment on drug related mortality. (bmj.com)
Some factors that clinicians need to consider (and remember) when formulating their medical conclusions within any ‘therapeutic relationship’ with a patient impacted by opiate addiction include;
- Illicit opioid users have complex needs and require agencies to work collaboratively to help them access healthcare, education, employment, and housing
- Users may have multiple health problems associated with premature disability and mortality
- Adopt a consistent, proactive, and non-judgmental approach in all therapeutic contacts with opioid users to counter stigma and pessimism about effective treatment
- Train patients and carers in the first response to opioid overdose, including the use of naloxone treatment kits
- Length of time in treatment with opioid agonists is the strongest predictor of positive bio-psychosocial outcomes and reduces premature mortality
(Source: British Medical Journal – Management of dependent use of illicit opioids)
My Summary Observations & Conclusions
Too many clinicians, treatment practitioners and prescribers (for all manner of reasons, not always clinical), unfortunately still view methadone as a solution (pun intended) with cure-all qualities… sadly not the case.
This particular intervention tends to be used as the sole mitigation against the self-medication of what are often multi-faceted social and medical problems. Those issues might be prominently clinical, at the point of the intervention but often, they can also result from many and diverse social causal factors, as well as multiple comorbid medical conditions, like trauma based mental-health issues. We need to constantly remember, there are multiple and varied societal (and medical) factors that lead to somebody’s resulting addictive behaviour(s).
Too many patients also view methadone as a convenient top-up, to mitigate against the reduced availability of their preferred elicit substance of choice (Heroin). That or the medication is the necessary evil, which must be consumed and/or endured during their recovery journey. Too often ‘enforced’ abstinence, from their preferred ‘street’ drugs, is still a prerequisite for accessing any available treatment or support options. Regardless of that being the choice they might have made.
I totally understand the harm-reduction principles and aspects of this process but the issues that I tend to struggle with the most are; what other resources and/or effective clinical and psychosocial interventions are put in place to support that person’s ‘recovery’ journey?
Too often resources and interventions can be too few, or simply unavailable. And mostly for the wrong reasons. Many internal/external political factors impact upon the provision of treatment services. And that is before you even start to consider any of the financial considerations and constraints, resulting from commissioning and/or funding procedures. To say these issues are infinite is something of an understatement.
But, the personal views, opinions, perceptions and requirements of patients, clinicians, commissioners (often guided by politicians) can also present significant variables, when it comes to the prescription and consumption of methadone. Finally, the varied (mostly) emotive views of the media and their subsequent readership (forming public opinion), can also be poles apart from any facts. So, is it any wonder the whole process can be a mess sometimes?
All of the above usually requires some serious work, and development of mutual trust, between clinician and patient within any clinical and therapeutic relationship, to mitigate against all the issues that are in play.
The current Covid-19 pandemic has (by necessity) resulted in some changes to past methadone prescription procedures. Protocols for supervised consumption by patients have also been impacted, as have some of the past ‘consequences’ – implemented by treatment services – for the clinical (or moral) management of the medication, amongst problematic (entrenched) patients, are no longer possible or appropriate.
How you choose to view any of these resulting advantages or disadvantages, will probably be dependent upon your personal connection to the scripts process. Clinicians, prescribers, pharmacists, the patients who are consuming the medication (or not), and even the external observers of that process, will all have differing views.
Based upon my personal knowledge and process experience conclusion is – Methadone works – if/when it is used appropriately and correctly, for its intended purpose. But, the process is something that must be agreed between clinician and patient, in isolation from any non-clinical factors or considerations.
And importantly, we need to remember, every patient is likely to benefit from additional forms of support, whilst the medication is being prescribed, if we want them to realise their personal goals. As clinicians and practitioners, we are not at liberty (and shouldn’t believe we are) to dictate any of those personal and individual aspirations.
As with the provision and delivery of any form of health-care intervention, the guiding principle should always be about making shared decisions – No decision about me, without me!
Bibliography & References:
- NIDA. 2016, November 1. Effective Treatments for Opioid Addiction. Retrieved from https://www.drugabuse.gov/publications/effective-treatments-opioid-addiction on 2020, October 14
- Kimber, J., Copeland, L., Hickman, M., Macleod, J., McKenzie, J., De Angelis, D., & Robertson, J. R. (2010). Survival and cessation in injecting drug users: prospective observational study of outcomes and effect of opiate substitution treatment. BMJ, 341(jul01 1), c3172. https://doi.org/10.1136/bmj.c3172
- Mayor, S. (2010). Specialists question agency’s proposal to time limit methadone prescribing. BMJ, 341(jul23 1), c3998. https://doi.org/10.1136/bmj.c3998
- Spence, D. (2012). Methadone is no panacea. BMJ, 345(aug22 1), e5670. https://doi.org/10.1136/bmj.e5670
- Cornish, R., Macleod, J., Strang, J., Vickerman, P., & Hickman, M. (2010). Risk of death during and after opiate substitution treatment in primary care: prospective observational study in UK General Practice Research Database. BMJ, 341(oct26 2), c5475. https://doi.org/10.1136/bmj.c5475
- Mitchell, C., Dolan, N., & Dürsteler, K. M. (2020). Management of dependent use of illicit opioids. BMJ, m710. https://doi.org/10.1136/bmj.m710
- The Royal Society for Arts, Manufactures and Commerce, Sheather, J. (2020, April 29). Why (medical) ethics may never be the same. The RSA. https://www.thersa.org/comment/2020/04/why-medical-ethics-may-never-be-the-same
- The Royal Society for Arts, Manufactures and Commerce, Webster, H., & Hannan, R. (2020, July 12). Reimagining the future of health and social care. The RSA. https://www.thersa.org/reports/future-health-social-care
Note: Alex Boyt was an intravenous drug user for 15 years, he has extensive experience of receiving treatment in rehabs, in the community and in prison. At the time of writing, Alex works within treatment services – as an ‘expert’ with lived-experience – and sits on the board of a commissioned treatment service provided by Humankind.