Wednesday, 18 June 2008

You are wrong Mr Hayes: the treatment system is NOT working!

For the last few years, I've thought a lot about how to change the treatment system so that helps more people overcome addiction and gain a better life. At one stage, I had come to the conclusion that I needed to work with the people at the top, to help them understand the shortcomings of the current treatment system and see how it could be changed. 

I gave a talk at the FDAP Annual meeting last year where I described the shortcomings of the system and emphasised that unless we did something we would end up like the American treatment system in the late 1980s and early 1990s - money was slashed and the system collapsed. I also pointed out the way we needed to move forward, which I have reiterated in the Wired In 'Way Forward'.  
I had a very positive response to my talk from a senior person within the NTA and I thought that I could enter into some long-term dialogue with the NTA that would lead to positive change. A change to a treatment system that is based on people attaining recovery - and I mean a genuine recovery, not some politicised excuse of recovery - is inevitable sooner or later. I thought that I could help speed up the process.
Well, after seeing the Paul Hayes article in the Guardian today, I realise how naive I have been. I'm not going to go into any great detail about the article, but I have to confess that it has made me angry. I quote, 'Hayes dismisses his critics as a few academics, politicians and "ideologues" stocked up by the media'. This is absolute rubbish - Paul Hayes either has his head very deeply buried in the sand or he is deliberately being untruthful.
There are many, many thousands of people out there who know that the current treatment system is NOT working and is causing damage to many people. These people who know the truth come from many different aspects of life - they are users, ex-users, family members, practitioners, commissioners, members of the general public, etc. 
I've been in the North West for the past couple of days and it was quite clear to me that the people I spoke to all knew many people who know the system is not working and are tired of the NTA spin. Even some commissioners who do not really care about people with substance use problems realise that the way methadone is being used in many treatment programmes is not reducing crime and is storing up problems for the future.
Anyone can use words to create a false story, mislead people by playing with facts, and distract them by creating false concerns. Sooner or later such people are found out for what they are doing. It is time that Paul Hayes is found out for what he is doing. I encourage those people who do not believe that the current treatment system is working to write to Gordon Brown and tell him. Write and complain that Paul Hayes is misleading the country about what is truly happening. 
We are talking about people's lives here. They are far more important than defending the current treatment system. Mr Hayes may think that few people will stand up and be counted - and maybe initially this will be the case. But there is a gathering momentum in the country for a treatment system that is focused on improving people's lives - rather than giving them a pill to keep them quiet - with an increasing number of people getting fed up with Mr Hayes's spin. The day of reckoning will come.
People with substance use problems need opportunity, choice and hope. The UK treatment system is not providing these key elements. 
I leave you with a quote from Stuart Honor,
'It is no great trick to take an impoverished, unemployed individual who is addicted to heroin (and crack?) and turn him (sic) into an impoverished, unemployed individual who is addicted to heroin, crack, methadone and/or alcohol and benzodiazepines.'

29 comments:

Kev said...

I agree totally, the system isn't working and more and more people are realising this. Mr Hayes, your job is on the line.

Thankyou Prof D for all your hard work, effort and commitment, for and to, the REAL people out there.

Your a star!!

tim1leg said...

Thankyou yet again Prof for a courageous and timely blog on Mr Hayes comments that critics as a few academics, politicians and "ideologues" stocked up by the media'.
Well Im I dont know many politicians or academics but i do know hundreds of pople working in the field throughout the UK so we must be the "IDEOLOGUES" he referrs too. Well in reponse to Mr Hayes name calling I would like to say you sir are a Troglodyte.

For those of us not familiar with the phrase troglodyte, please let me explain, The common day Trog seems to have emerged from the mists of time untouched by human evolution. (in Mr Hayes case the drug Treatment field of the last 30 years.)

He is devoid of a single progressive idea and lacking the slightest awareness of social and cultural advances, Troglodyte has developed an incoherent political philosophy that he characterizes as "conservative" or "libertarian", but which could be more accurately described as "bigoted narcissism". His aggressive posturing often frightens off weaker, more timid Warriors. In pitched battle, however, Troglodyte easily loses control and his attack quickly degenerates into a rant.

Mr Hayes Im afaid you are now ranting and we know, you know, that we know, you are ranting, the games up!
If you know what I mean!
please can we now move on and help people who are suffering instead of getting in to the old debates,, Mr Hayes you should be ashamed of yourself for using such tactics.

Peapod said...

I'm saddened to read the limited assessment of our treatment system made by Mr Hayes in the Guardian. I suppose he'd call me one of those idealogues whipped up by the media. I'm not actually a great fan of the media and I realise that the media has the power to distort which in kindness, I'm hoping is what's happened with Mr Hayes' interview.

There are a couple of things we need to remember here. Firstly, methadone developed primarily as a treatment in the UK for reasons of public, not individual health. It was feared HIV would leak from the IV drug using population to the general population. It was a reasonable public health response, but it is not focussed on the needs of the individual. When asked what they want from treatment, individual service-users don't list 'I want to reduce my offending rate; I want to reduce my risk of catching Hepatitis and I want to achieve better social functioning'. A majority say they want to become drug free and have 'normal' lives. Where I live, 80% of those on methadone top up with other drugs. They remain firmly enmeshed in addiction cultures. Few are working. Many start the day with the trek to the chemist. They have little hope that things could ever be different.

If most of our service users want a drug free recovery (and lets not fudge the issue here with concepts like 'a recovery based on maintenance': that's a recipe for carrying on doing exactly what we are doing), then we have a problem. Our treatment services are hugely and heavily geared to methadone maintenance. This 'out of kilterness' is the elephant in the living room wearing the emperor's new clothes and tap dancing on a pedastal. It is so bloody obvious, but many choose to ignore it.

Now methadone is one of the most studied interventions and has a weight of evidence for its benefits. It has its place and needs to be part of what we do. However, we've studied it at the expense of other things. The fact that we haven't done the work on recovery and abstinence does not mean that we can't. We can and we must. How did those who have recovered do it? Let's find out.

Earlier this week two clients I work with spoke to a visiting official. One told how he resisted methadone for years because he felt that if he went onto a prescription his chances of getting drug free would be reduced (evidence supports his viewpoint). He swam againt the tide in services that didn't know how to help him achieve his goal of becoming drug free. After a few years of struggling he entered an abstinence programme and is more than six months in recovery.

The other said that he went onto methadone 17 years ago and has tried over these years on many occasions to come off. His prescribers 'wouldn't let' him and he lost hope. Nobody mentioned the concept of recovery; nobody talked about recovery communities like Narcotics Anonymous and for years nothing changed. You can hear versions of that same story repeated again and again in treatment services who know about recovery and who have asked the client what they want.

Now if that is a treatment system that is working to help people achieve their goals then I'm an elephant in the living room wearing some pretty fetching invisible clothes tapping away on my plinth. Nobody appears to be watching...

brendan georgeson said...

Fortunately I reckon most addicts are unaware of the NTA and more aware of peer support groups like AA, NA, CA which carry on despite policy and career posturing by politicians. Also methadone only affects a minority of addicts as the vast majority are addicted to nicotine and alcohol, it's just convient to make heroin addicts the scapegoats of failed social policies whilst hiding the biggest killers behind bogus health warnings

David Clark said...

Thank you peapod for a nice balanced argument.
I agree with you that most/many reporters do distort, but Mr Hayes knows that when he goes to be interviewed. His message seems very clear, no matter what distortion has been added.

sara mcgrail said...

Few things are ever totally wrong or totally right. There is a lot about our current treatment system that is good. A lot of the money has been well spent, there are a number of people benefiting from the treatment that is available. In my 20 years in the field I have seen a decent script make more positive difference to more people's lives than any other single intervention. Obviously limiting whats available to methadone and nothing else would be a mistake, as would limiting services to abstinence. I am also deeply depressed by the tendency this debate has - as exemplified by Stuart Honors quote - of objectifying people, or describing them purely in terms of what is done to them rather than what they do. Surely this is the antithesis of recovery? But maybe I just don't understand this debate at all any more.

David Clark said...

Sara, Of course there is good as well as bad. But an extreme commentary from Paul sometimes needs an extreme response. I've tried the balanced response for a long time. I sometimes feel that efforts to change the system gently are just ignored and you end being labelled an 'ideologue'.
There are many practitioners and commissioners I know who need the Honor quote thrown at them - their level of comprehension and/or care of what this is about is appalling. Of course, there are also many good practitioners and commissioners out there - I hope they understand what I am trying to do here.
I hope my Blog stirs some good debate and makes people think about the issues here.

Anonymous said...

I do not wish to be too negative but people are always going to blame the system for problems from 'I can't get a script quick enough' to 'the system hasn't made me abstinent'. People who are entering the system have very different views from those who are in it or have been through it. People all too often quote statistics out of context and conflate the issues with personal opinion. The focus on abstinence plays into the hands of the people who wish to stigmatise and punish substance users. The lurch towards spiritualism and religion present in many contributions sets dangerous precedents too, religion has done little but try to control people - is it not swapping one set of comforting yet ultimately false things for another?

Derek WIlliams said...

The new abstentionist movement is gaining ground isn't it?

I'm worried that the move away from methadone will be replaced by an almost evangelical push for enforced abstinence being promoted by certain politicians.

There is no point on jumping from the frying pan into the fire and from what I'm hearing that is precisely what's about to happen.

David Clark said...

Derek,
I wouldn't know about the gaining ground of the abstentionist movement.
I am one of those people who are pushing the recovery agenda, and that for sure is gaining ground. Please do not assume that I stand for abstentionism alone, that is incorrect.
My colleagues are I have no desire to jump from methadone to enforced abstinence, as you well know from our writings. Nor do the many people who are supporting the move to set up a 'true' culture of recovery within society.

cheval man said...

Once again the focus is on Methadone. Yes it has a role but ...and there are several buts.

1) Why this focus on only opiates when the majority of drugs (alcohol, cannabis, cocaine, etc) are not opiates but some of us, at least, are providing services for people using these.

2)Methadone often has a deskilling effect on workers and services end up limited, expensive and medically dominated. I have been in services where conversation re clients never moves beyond methadone levels (rather than people) and this conversation often between well paid individuals.

3) Mr Hayes, well yes there have been some changes incl improvements in the system but it is certainly not the vision painted by you at the NTA launch (it maybe rather sad but I was there, as I remember the food was quite good). There it seemed we were going to get something really new but in fact it has mainly been more but of the same, hence the continued emphasis on methadone/opiates/crime. The main difference (i.e in terms of how we work rather than there now more of us doing the work) is the level of paperwork. SOme new ways have got through but it is still the exception.

4) What is wrong with recovery? Surely it is what the work is really about even if we have some varied ideas about the breath of this definition and what it incls. I think we can all agree we know when it is at its best. Again I do not like the put down on those who have been thro the process and say living a more fulfilled life in recovery is an aim worth trying for and it is not just a 12 step thing.

5) Sorry, Paul aged 59 again, no need to make it political and try to make out that recovery is just some Tory party idea that everyone is now jumping on. Remember you once work on the ground as well.

There is more but there is still work to be done and I need to get on with some of it.

David Clark said...

Quick time out for me cheval man. It does annoy me when services tell me that they are not really supposed to be dealing with people with other problems (according to their commissioners), in particular alcohol. It places them in such a terrible position - why should they have to turn anyone way (and I guess many don't)?
Add to your list benzos, for which few services are set up to be able to help people.

Matthew said...

Er, could you possibly stop the "Commissioner bashing" please? I've worked in Drug and Alcohol treatment services for 11 years and currently work as a joint commissioning manager. I have as much of a personal commitment to delivering good treatment that really works and is what people really want (or need?) as anyone else I know working in the treatment system.
Of course there are bad commissioners, but believe me I've worked with quite a few bad drugs workers, nurses... and even a few "bad" service users in my time as well, so please stop the stereotyping!!!


Thanks.

David Clark said...

Matthew,
My apologies that you feel like this. It is always the problem with a single posting - particularly when I take one side of a black/white argument - that people may feel I always generalise.
I know good commissioners, good practitioners, good service users, as well as bad of all. In other postings, I have stated there is lots of good in the field and we will learn from this good.
I really hope we can get more good commissioners to sign up to helping us change the system. They have such a wealth of valuable experience, which is so sorely needed to help the move to a culture of recovery.
Keep up the good work and feel free to contact me personally any time. My apologies again.
PS. I've had many good practitioners and commissioners tell me that I need to stir up the system - and they know I am not 'attacking' them because they know they are doing good. But they do not feel appreciated by the system.

Anonymous said...

Yeah – I found the Guardian article a little aggressive too, but I read Haye’s ire as directed at his recent media mauling(s) and Tory odd-ball rantings – rather than at the field… Maybe we’re being a little over-sensitive here?

I’m also a little confused about the pro or anti methadone and/or abstinence debate that seems quite polarized us all to bits on here… Surely through local needs assessments, the NTA is asking DATs to determine who their most at risk populations (albeit in a limited way as determined by ministers – ie away from alcohol and nicotine) and to provide a range of services to meet that need?

I see Methadone, Subutex, Beupronorphine, counselling, abstinence, day-programme, recovery, whatever therapy all as being subsets of harm reduction (abstinence being the ultimate form of HR, I guess - for those who get there) and that current thinking (reflected in the recent strategy) seems to be to aiming to provide those options??? Maybe I’m being overly-optimistic, I don’t know, but surely the outcomes data will begin to point the way for some of this stuff…

Peapod said…
“…When asked what they want from treatment, individual service-users don't list 'I want to reduce my offending rate; I want to reduce my risk of catching Hepatitis and I want to achieve better social functioning'. A majority say they want to become drug free and have 'normal' lives…”

Yeah me too, but that ‘normal life’ thing always makes me SO curious! - I’ll usually ask something like “what does a ‘normal life’ mean to you?” and I start to hear things like “I wanna stop getting busted”, or “I’m tired of feeling tired all the time”, etc, etc… Hey that’s about crime and health huh?

David said…
“…It does annoy me when services tell me that they are not really supposed to be dealing with people with other problems (according to their commissioners)…”

Yeah me too – I’m not aware of anything the NTA (nor anyone else for that matter) produces that says services should not be holistic and cater to clients needs in a joined up way… It’s kinda bonkers huh?

-----------

I dunno though – Ultimately I feel a little confused about what the recovery movement is… I’m a little scared to admit that, but maybe like Sara, I’ve lost what the debate is and I worry about being told off on here. I read the links on the site, but I can’t see specifically what the proposals are…

What kind of treatment systems would you seek funding for?

What is it about?

I don't mean those questions in a confrontative way - just curious is all :0)

David Clark said...

I'm deep in accounts at mo, but will get back to you later today. Thanks for your time on this. Yeh, it can get very confusing at times. Why be scared about admitting not knowing - I've spent years trying to get my head around this field and all the issues and I'm still learning.
There is some stuff on recovery amongst my Background Briefing Blog (look for link at right side of Blog) - I wrote a few recovery articles. A leading writer is Bill White from States who has volumes of literature
http://www.facesandvoicesofrecovery.org/resources/publications_white.php
Email me directly if having problems working out what best to read.
Better get back to accounts.

Anonymous said...

As a methadone patient & patient advocate, I would like to toss in my own thoughts if I may. I am in the USA, and our system of care is different here. We have long had the 12 step model as the primary recovery offering--over 97% of rehab facilities use this model, despite the fact that the success rate is quite low, particularly for opiate addicts. By the time most methadone patients have gotten to methadone treatment, they have been through quite a few abstinence-based rehabs without success--it is almost never a first, second, or even third offering here. I failed at 13 seperate abstinence based rehabs, was even jailed for prescription fraud (I was addicted to Rx opiates), lost my career as a nurse and was in a horrible state, and not once was methadone treatment suggested to me by any doctor, nurse or counselor, ever. It is seen by many as the last resort of a pathetic, doomed creature--one of AA's "those unfortunates". I finally went to the clinic on the advice of another addict, expecting to see a room of vagabonds, ne'er do wells, bums and prostitutes on their last legs. I was in for a big surprise.

A few persons did resemble the earlier description--but by far the majority looked just like anyone else. There were people in suits, on their way to work at office jobs, young moms from the suburbs, college students on their way to class, laborers on their way to a jobsite, and a few grandparentish types. They almost all looked healthy and productive. No one was drooling, nodding, or fencing drugs in the parking lot.

I was also amazed that I was able to set down the drugs from my first day in methadone treatment. I had been through one earlier episode of MMT for a short time (4 months) 4 years prior, and was on a very low dose the entire time and continued using. This time, however, I made it my business to learn all I could about methadone and how/why it worked, and I got on a blocking dose asap--a dose that kept me comfortable and craving free for a full 24 hours. It did not and does not cause any euphoria or "high". I work full time and pay all my own bills, care for my family, and give back to my community--all thanks to MMT.

I have learned a lot about brain chemistry and how it works in the addicted brain, and although I don't think anyone knows exactly how all this works, many scientists believe that for some opiate abusers,the shutdown of endorphin production that occurs with long term opioid use can be permanent, even after years of abstinence. Possibly, some may even have a natural deficit of endorphins, and are therefore more susceptible to opioid abuse from the start.

If that is the case, and there is a good bit of evidence to support it, then placing time limits on how long a person can receive methadone or pushing people off MMT against their will is pointless and dangerous. Methadone helps restore a more normal balance in the brain chemistry, but does not "cure"--so to remove the treatment simply causes resurgence of the disease.

Not all addiction is based on childhood issues that need psychotherapy, nor joblessness that requires job training, nor a "spiritual malady" that requires faith an "higher power" to overcome. Sometimes it is largely a matter of brain chemistry issues, and when that is resolved with medication, the person resumes a normal, productive life.

I don't believe that persons on Suboxone ar Methadone should be left out of the "recovery" community, treated as pariahs looking in through the window, or as people "still in active addiction". There is a big difference between addiction and physical dependence--they are not one and the same, and the patient is not simply switching addictions, as many think.

In closing, I feel that recovery is defined by the fruits of a life--are you happy? Productive? Stable? Employed (if able)? Giving back? Responsible and dependable? THAT is living in recovery--not whether or not you take a medication daily.

Methadone does not treat all ills--it works best for those with an opioid addiction instead of a poly-drug addiction. But for some, it can be a life saver when abstinence fails.

Peter O'Loughlin said...

Denial is a common charateristic of addiction, and Paul Hayes is addicted to numbers in treatment and those who are discharged; simplistic is a kind way of describing what he claims as succes.

He is also heavily dependent on rhetoric and spin.

The spin:

'We have stopped the sharp increases in drug-related deaths in the 1990s';

The truth:

Although there was an overall decline in deaths
related to drug misuse between 1999 and 2004,
the percentage reduction, at 9 per cent,failed miserably to meet the Government target of 20%

Nor did Hayes bother to mention the increase in heroin/methadone and morphine deaths between 2003-4. Nor the sad fact that mortality rates were highest in young adults, or the fact that an increase in mortality rates within this group was the cause of the rising mortality trends during the 1990s


Crime the spin;

Drug-related crime has fallen among those referred for treatment.

The Truth:

Given that shoplifting and other acquisitive crimes has been relegated from the highly sanitised crime figures it should have done. the fact is that violent crime which is also closely associated with drug use has increased, and continues to increase.

As for the definition of recovery which has been mentioned, not only is it an oxymoron but it ignores the universal evidence that those who are addicted have lost control over their use, and therefore are incapable of what is referred to as 'sustained control'.

David Clark said...

Anonymous from America,
I totally agree with you - people who are on methadone or subutex prescription should not be 'left out' of recovery. There are many people who find their personal recovery whilst on a prescription.
However, the government-led treatment system here is different to that in the States. If focuses on opiate and crack problems, and on the prescribing of methadone and sometimes subutex. Most clients are not given the choice of other options, and generally receive little other support (certainly not psychological support). Very few practitioners have seen anyone in recovery and many believe that recovery is not achievable. It really can be very soul-destroying, not just for clients but staff and people like myself.
There need to be the basics on offer: opportunity, choice and hope. Our Mr Hayes is more concerned with protecting the National Treatment Agency than helping people overcome their problems - that is what many people in this country believe.

Anonymous said...

I believe you are right, Mr, Clark--things are different in the UK. Part of it stems from chronic underdosing of MMT patients. Although the average effective dose has been determined to be somewhere between 80-120mg (with some needing less and others more), the average dose in the UK is far below this, leaving many patients to spend each evening in withdrawals, struggling with cravings and temptation to use to stop the pain, and often giving in. As a patient advocate I hear regularly from patients in the UK and even at times here in the USA who are being kept on very low doses and are told to simply "hit a meeting" or "pray" if they go into withdrawals each evenining. They are usually desperately trying to stay off illicit drugs and have tried all the right paths to get an adequate dose only to be refused and/or accused of "drug seeking behavior". In the UK this leads, I believe, to a lower success rate and a higher rate of illicit drug use.

Obviously, including therapy and mental health care with MMT is necessary. Also, offering a wide variety of treatments to people who suffer from all kinds of addictions is necessary. But the fact is that MMT came about NOT because abstinence based treatment was working great--the majority of opioid addicted patients were NOT doing well, even with inpatient hospitalization, counseling, therapy, 12 step meetings, etc. MMT was created to help those who did not do well on these therapies.

One thing I found very misleading was the recent Scottish study that showed, allegedly, that "only 3% of patients are helped by methadone treatment". It sounded appalling on it's face, but if one reads more, they will discover that the study includes, as treatment failures, anyone still on methadone after 3 years--even if they are free of illicit drugs, employed, and doing great. A casual reader of the news would take it to mean that only 3% stopped using illicit drugs, but this was NOT the case.

In the USA, although rates vary from clinic to clinic and are better at private pay clinics, the proportion of illicit drug free patients varies from 65% to as much as 90%. This is far more effective than abstinence based treatment centers--the best of which can boast only about a 30% recovery rate overall, and lower still with opioid patients, usually.

Dr Dole, the "father" of MMT, stated back in 1969 that he did not consider it important whether a patient got off methadone or not. What was important, he said, was that the patient be happy and useful, in himself and in society.

I feel that all patients deserve to be able to choose from a wide variety of treatment options--cognitive therapy, motivational interviewing, behavioral modification, 12 steps, medication-assisted treatment, therapeutic communities--whatever works for THEM--and the goals of treatment should be decided by the patient, not the government.

I understand that the UK has not been inthe habit of offering non medication modalities and that should change, I agree, as everyone needs a variety of options, not just one. But methadone is a very effective modality, and restores many people to a useful and productive life--people who would not otherwise get there. Marginalizing these patients to the fringes of recovery--or compelling them to attend 12 step recovery meetings where they are forced to remain silent because being on MMT is considered to be "active addiction",(see NA bulletin #29) is counterproductive and unsupportive. Their recovery counts too--their efforts at reclaiming their lives are just as valid, their successes just as real.

Regarding the recent rise in methadone related deaths and Rx drug abuse--in our country, it has been demonstrated in many studies that the increase in diverted methadone and methadone deaths comes not from the clinics, but from the rise in prescribing methadone for pain. These patients are given 5 or 10mg tablets rather than liquid or diskettes, and that is what is appearing on the streets and in the deaths, in vary large majority. Pain pts, are being victimized, medicine cabinets burgled, and pharmacies stolen from. It is sedom related to the use of methadone for addiction. Perhaos the same is true in the UK--I do not know.

Dr Dave said...

Great to see so many responses and so much reflection on this topic. I've worked in maintenance services and in abstinence services. We need both. So many of us have been working in the predominent service (harm reduction/maintenance) for so long without seeing recovery that we've lowered our sights for our clients and either don't really believe recovery is possible, think it's too dangerous or don't have a scooby where to start.

Services filled with recovering addicts attract and engender further recovery. If clients want recovery then we need to find out how to help them find the resources (internal and external) to help them get there.

Personally I believe that at its core, recovery is above all else a spiritual process. Finding meaning, purpose and identity are essential elements. Recovering folk find lost values and start to rebuild relationships. That is simple spirituality. Lets not get it mixed up with religion.

As for all being rosy in the treatment garden: I'm not happy with the report card from the NTA. Your robust rebuttal is welcome David. I can smell some manure in this particular garden.

David Clark said...

Anonymous USA,
I'm afraid the Scottish study 3% is reality. BBC TV, using NTA figures, came up with similar numbers. VERY few people in the UK government-led treatment system give up using illicit drugs. Many people believe that recovery may be achieved more easily by NOT entering the treatment system. And we give high doses of methadone.
You need to come over here - and then you will see, and believe. And be stunned!

tim1leg said...

Anon in America, the MMT you speak of taking place in the USA sounds fantastic, however I know of none thats 0, not one, Zero, nada, Zilch, and have never met a methadone patient from my area of Scotland who leads in their own eyes not mine a productive satisfying life. They use on top, pure and simple out of the desperate need you spoke of and are offered if they meet the criteria to get a script, which is quite a hoop jumping exercise, one 50 min appointment per fortnight not even with the same worker in most cases. As Dr Dave said So many of the pros in the field here in the UK have been working in the predominent service harm reduction/maintenance) for so long that they cant see the forest for the trees. The real problem being we have a culture of addiction and maintaining addiction and not a culture of recovery outwith the felowships. For the most part traditional treatment in Scotland either don't really believe recovery is possible, or think it's too dangerous or as David said don't have a scooby where to start.

Scoobey Doo= Clue!! Ive got a clue for them....

Ask people in recovery and who have recovered how to do it. Simple really!

Anonymous said...

Are you saying then that the average dose in the UK, and in Scotland in particular, is 80-120mg? That goes contrary to every report I have ever read and every patient in the UK that I have communicated with, and as a moderator of three of the busiest MMT patient support boards on the net, I talk to a LOT of them. But, I don't live there and have not visited any facility there.

About the 3% figure--again, it states that only 3% are off all drugs INCLUDING methadone. I am not debating that--it may be so. What I AM debating is the assumption that anyone still ON methadone is a "treatment failure", even if their life is otherwise great and they are off all illicit drugs. The study makes it appear at first glance as though only 3% are illicit drug free, but when you read it you see that it is saying that only 3% are free of all drugs including methadone.

Speaking of a culture of recovery as though someone on MMT cannot be considered part of such a culture, or that being on MMT means you are in a "culture of addiction" only adds to the stigma and marginalization these patients feel. No matter how well they may be doing--maybe they have been illicit drug free for decades, have built up a business or advanced in their career, successfully raised a family, given back to their community, and met the goals they set for their lives, because they are on MMT they cannot be in the "culture of recovery"?

For some people, MMT IS "harm reduction". Perhaps they no longer use injectable drugs, but they still smoke pot or drink to excess, etc. Perhaps they have only reduced, but not eliminated, their use of drugs. This is till worthwhile and better than no progress at all.

However, for others, MMT IS recovery. They have ceased using illicit drugs, and the medication does not cause a high--it simply stabilizes their brain chemistry. They have returned to a productive life. Why should they be seen as being a "second class citizen" in the recovery world? So many see them as someone who just didn't "want recovery bad enough" or wasn't willing to "go to any length", etc. This is extremely frustrating to those of us who have been though the revolving door of abstinence based treatment many times over, and who have tried with all our might to make it work--did every thing we were told, followed every suggestion, made every meeting, read all the literature, only to fail again and again. This is not the case for everyone of course--but different people have different needs. Addiction stems from different causes and not everyone does well with the same modality of treatment.

For example, someone said to just ask people in recovery how they did it. BUt--what worked for that person may not necessarily work for the next one. And trying to cure this partcular disease with hefty doses of "spirituality", or assuming all addicts are in need of it is incorrect, IMO. We don't treat any other illness, mental OR physical, with prayer and spirituality as primary components of therapy.

When I was in active addiction, I did some things I was not proud of--I lied to my family, hocked items that did not belong to me, and other things. However, upon receiving proper medical treatment, I immediately ceased these behaviors and returned to being the person I was raised to be, without benefit of spiritual support groups, counseling, etc. I know many others in the same situation, who are doing extremely well. I know others who can and do benefit from therapy. Treatment must be indvidualized to the patient, without the one size fits all assumption.

Peapod said...

Anonymous: I like your take and the quality of your recovery and couldn't agree more that treatment needs to be tailored to the individual. I wish more people over here (UK) had positive experiences. UK Guidelines state that we should aim for a methadone dose of 60-120ml. Where I work we achieve this, but 80% top up with other drugs. Around a third of MMT patients are drinking at hazardous or dependent levels and very few are employed or in education. People may be seen once a month for 10-15 minutes, essentially to pick up their prescriptions and the option of a drug free recovery is not remotely on the table. I ask my clients on methadone where they want to be in two years and the commonest answer is 'I want to be drug free'.

Now, if recovery communities are healthy, MMT clients need to be welcome. Almost all MMT clients here are still firmly enmeshed in an addiction culture. Their friends are using, their partners are using, they are still on benefits (welfare) and their lives still revolve around addictive drugs. This is not a recovery culture.

The DORIS study did find that only 3% stopped using ALL drugs (illicit and prescribed), but the point here is that for more than half of the 1000+ people in the cohort, their ONLY goal from treatment was to be come drug free. Lets do the maths: more than half want to 'get clean', only 3% do. Is that a system geared to helping clients achieve their goals?

On the brain chemistry: there is a worry that we will find that methadone does to the brains of addicts what heroin, cocaine and alcohol seem to do: reduce the number of pleasure receptors available over time making it more difficult to experience normal pleasures and decreasing motivation to move on. This might not be for everyone all the time, but it does look likely for many people much of the time. This is a worry.

I applaud your personal recovery and your contribution to the debate. Also your open mindedness on other options which have not suited you. As the prof says, if you could see how it's done here you would be surprised.

Great thread on this topic! It's been fun to read all the views. I'm interested to know if there was any 'official' feedback from the powers that be.

David Clark said...

Peapod,
Yes, it has been a fun discussion. No feedback from on high. The highest number of readers for the Blog since the first day high. And the most comments.
As an aside for My Hayes, we conducted a survey last year on Daily Dose which included one question:
'Do you believe the current UK government strategy is addressing substance use problems effectively?'
95% of 204 people said NO.
Feel free to contact me at david@wiredin.org.uk

David Clark said...

Anonymous USA:
I admire your recovery and we have a lot to learn from it. Please take a look at Kevin's blog for an example of what happens here:
http://kevrecovery.blogspot.com/2008/06/my-experience-of-methadone-reduction.html

tim1leg said...

Ultimately recovery is what every and whenever the individual deems themselves to be recovering, if an addict on methadone or abstinent claims to be in recovery then that is there business, it is for no one to judge, especially not professionals. As I'm sure you are aware having experienced abstinent based services that just because you are clean it can still be a long way from recovery depending on the quality of guidance and support you receive. We are all advocating for better services whether your recovery pathway is about choosing abstinence or medical assistance these pathways have to be choice driven by the client and supported equally by the service provider a situation we don't have at the moment. Can we stop muddying the waters now ?

Anonymous said...

On the brain chemistry thing--a study done a few years ago by Dr Mary Jane Kreek (a renowned addiction specialist with vast knowledge of MMT) showed that methadone, unlike most other opiates, does not attach to ALL the opiate receptors in the brain, leaving some of them open to encourage the production of natural endorphins. This can assist the brain in recovering normal function even while the patient is still on treatment. If anyone would like the article about this just let me know.

It is certainly true, as peapod said, that long term usage of opioid meds can cause a permanent or long term anhedonia, depression,and anxiety. This is what drives so many to relapse. AT this point, with the person being unable to produce these natural chemicals, they may need supplemental opioids to enable them to experience the normal range of feelings and pleasure. Well, then, you may say, but what if continued use of metyhadone worens the condition further? Well---it may, I don't know, though there seems to be some evidence that it may not, as I just mentioned above. But even if it does--and if you may perhaps need to increase the dose to adjust for tis--it is still better than being deprived of happiness and pleasure, and of living each day under a black cloud of depression, IMO. When I was abstinent, I experienced this. People kept saying it would get better, to just hang on. after awhile, when it did not get better, I was truied on antidepressants--Prozac, Paxil, Zoloft, Elavil, Wellbutrin, Effexor, Trazadone, celexa. None had any effect. The ONLY thing that helped was opioids--but that led to it's own black pit of lies, stealing, and wild swings between high and sick. Methadone is the only thing I have ever found that works for me without subsequently causing problems of it's own.

Regarding the fact that most want to be drug free--of course they do. Who wouldn't? Similarly, most patients who take chronic medications--insulin, heart pills, schizophrenia meds, epilepsy drugs, Lithium, etc--also want to be "drug free". They don't like the side effects, or being tied down in some way, or the expense of the meds, etc. But the fact is that for many of them, though they may WANT to be drug free, it just is not possible. They NEED the medication in order to function optimally.

I have observed, so many times, people here saying they want off methadone, and then either jumping or tapering off, and relapsing within a few months. Sometimes they repeat this a dozen times before accepting their need for treatment. And these are not people who have not had the benefits of abstinence based treatment, which is far more available here than in the UK--these are people who have a lengthy history of relapsing time and again after abstinence based treatment even with good support.

So, I guess what I am saying is that yes, each patient should be able to set their own treatment goals, but they also need to be given appropriate info about the risks and benefits of each type of treatment, and the risks of withdrawal from treatment as well.

If I were counseling a patient who had relapsed after abstinence based treatment many times, and had left MMT twice before only to relapse and return, and who then said to me that he "wants to be drug free", I might then encourage him to take a good look at the patterns so far and the cause of his relapses, to see if this might not be the wisest plan.

Just some thoughts--thanks for listening.