Sunday, 19 October 2008

Methadone maintenance in treatment services today: a form of palliative care?

Well, my Blog on Thursday, 'The power of misinformation', certainly fired up some discussion. At the moment, we have reached 37 comments. So let's see if I can do the same with this posting.

I'm writing an article at the moment on the problems with the current treatment system and what we need to do to improve matters. I'm on the methadone section at the moment. 
As I have said many times before, I have nothing against methadone substitution therapy per se, but I feel strongly about it being used with clients being offered no, or only minimal other, support. I have written:
'Due to the approach adopted by much of the UK treatment system, this generally leads people from one addiction to another without providing a realistic opportunity to attain recovery.
Whilst methadone (and Subutex) have an important role to play in helping people take the chaos out of a heroin-using lifestyle, they should not be prescribed in isolation or with minimal other support.
The majority of heroin users actually want to get off drugs completely, not be “left” long-term on methadone or other substitute drugs. They must be provided with the choice of, and help in, finding a path to recovery, rather than just being helped to live with addiction. Much of the treatment system shows a shocking paucity of ambition for its clients. If cancer patients were only offered what amounts to a form of palliative care, it would be seen as a scandal.'
What do you think?

49 comments:

Anonymous said...

Not sure this will stir up as much! Does anybody disagree with you on this? Check this out from the NTA's 'Models of Care' update 2006:

"Substitute prescribing alone does not constitute drug treatment
(NTA expert prescribing group, 2002). A community prescribing
intervention should be provided within a care-planned package of
care with an identified keyworker. It should be aimed at
addressing the range of identified needs. The care plan should
address drug and alcohol misuse, health needs, offending
behaviour and social functioning. Interventions to tackle drug
misuse problems may include:
• Hepatitis B vaccination and HIV and hepatitis testing
• Treating drug-related infections, e.g. abscesses
• Harm reduction and health promotion interventions e.g.
overdose prevention, use of naloxone, sexual health advice
and needle exchange
• Provision of, or access to, psychosocial interventions and
support, e.g. motivational interventions.
The care plan may also include interventions to tackle problems in
the other domains, and may include:
• Provision of, or access to, interventions to address other
psychological health needs, or mental health needs
• A range of abstinence-oriented interventions e.g. mutual
support groups (including 12-Step)
• Assisting with access to suitable housing, employment,
education and training opportunities, and childcare, as
required."

Sara McGrail said...

Well I disagree. I think for some people there is a role for long term prescribing without very much in the way of other interventions. I also think that recovery is a term that can only be defined by the person experiencing it and that for a number of people recovery - and indeed being in a state of recovery that an individual may define as their ultimate outcome - may include for some people long term methadone maintenance. What I personally loathe about what is currently masquerading as a discourse in the drugs field is the assertion that it is the professional's right and the fields responsibility to define the outcomes of individual treatment. If someone cannot define it themselves the job is to enable them to access the agency (as in personal volition) that can enable them to do so, not to substitute our own views in their place. We need to ensure that they are as safe as they can be and then open up a possibility of living a different way to them. Just because you feel able to claim that the majority of people using drugs want to stop does not mean that the majority view should prevail for everyone. A sophisticated healthcare system enables choice and facilitates recovery. It does not impose it.

Anonymous said...

I disagree too but for a completely different reason. I think the whole concept of substitution prescribing is a dishonest charade. In what way is giving someone a different type of opiate from the one they have been 'abusing' palliative care (or treatment)? Really, it's a way of providing a legally regulated supply of opiates, whilst trying to give an appearance of being a medical or treatment intervention. It's nothing of the sort and shame on those who go along with the whole mendacious farce.

Anonymous said...

Everybody has this same mistaken assumption that methadone treatment is just substituting one addiction for another. Invariably this comes from people who do not understand the science of brain chemistry and addiction. Opiates are not some evil, pernicious substance--they are something our brains manufacture every day. Endorphins--the medical term for endogenous opiates--means, literally, "morphine from within". We have opiate recetors in our brains for this reason. Endorphins help regulate mood, control pain, and give us the ability to experience normal pleasure and happiness. It is thought that many people begin misusing opiates in the first place because they are deficient in the production of natural endorphins--this would explain why some have a very different initial reaction to opiate drugs than most people do. This is something that science is still exploring, but the thesis makes a lot of sense.

However, we know for a fact that prolonged use of opiate drugs shuts down the endorphin production in the brain, leaving the person reliant upon the opiates they are consuming rather than those naturally produced. When they become abstinent, whether suddenly or after tapering off, they go through a period where they experience the fallout of having no opiates, either exogenous or endogenous, on board--they feel severely depressed, anxious, lethargic, anhedonic, and are usually desperate to cease feeling this way. During this time, good support and outside referrals and assistance can be invaluable. Some gradually begin to improve as their endorphins kick back in over the next few weeks or months and this helps a lot in maintaining sobriety.

However, a certain segment of those who have abused opiates long term (or, as some believe, those who never had functional endorphin production in the first place). The damage done is permanent in nature, and does not improve, no matter how much time and care are given. For this group, ongoing substitution treatment with methadone or bupe replaces the missing chemicals in the brain, enabling them to live and function normally, and to take advantage of other services without the constant torture of an endorphin deprived system. Properly medicated patients who do not use other drugs are not getting "high" from these meds. They are simply being restored to a more normal biochemical state.

I agree with Sarah McGill in that not all long term patients require other services. Once their immediate problems have been resolved and their lives normalized, they may not need ongoing "counseling" forevermore--they may simply need their medication and that's that. Not everyone who uses opiate drugs does so because they were poorly raised or have no life skills or were abused as a child. Some are simply trying to self medicate a physiological condition that, once properly treated and controlled, does not require these types of services. Not to mention that receiving "counseling" from someone who has power over the medication you desperately need and can cut you off or remove your takehome status at the slightest hint of any problems is unlikely to provoke any real honesty or any therapeutic relationship with the patient.

Having caseworkers who can refer patients to appropriate therapy services as needed would be a better goal.

Anonymous said...

Hmm. Very impressive sounding explanation. I can't help thinking though that references to 'science' and 'brain chemistry' are rhetorical devices you are using to persuade us to accept what is ultimately an opinion. Some phrases stand out: 'it is thought that...', 'the thesis makes a lot of sense'. Basically, you are setting out an opinion but dressing it up in the language of medical science to make it sound more objective and unchallengeable. I don't believe you or agree with you. Substitution therapy is nonsense on stilts.

Anonymous said...

I wanted to add that naturally most people want to be drug free. I am certain that most diabetics wish they could live drug free lives, as do most epileptics, most cardiac patients, most schizophrenics, and so on. Many of these treatments have unpleasant side effects. However, basing treatment on the patient's wish that they did not require it is short sighted indeed.

I have seen many many patients leave medication assisted treatment with this desire. They want to be drug free--they are tapered off methadone and walk away with a wave and a smile. A few weeks or months or even a few years later, they are back, much the worse for wear. Not everyone, mind you, but a very significant portion. Some had the best care and support money could buy. But due to the biochemistry of the brain and the damage done by long term opiate abuse they were miserable, and at last, relapsed in an attempt to stop the pain. Maybe this cycle is repeated 5 or 6 times before they come to accept that for them, a "drug free" life may not be the best choice.

This does not have to be greeted with sorrow or a sense of "failure"--it simply "is". I take methadone every day--and it has restored me to a full and happy life. I am not sad, pining away for a "true recovery" or feeling like a failure because I am not "drug free". I remember exactly how I felt when I was "drug free"--I spent four years that way in the midst of a 20 year cycle of opiate addiction. I was utterly miserable, despite the best treatment and support available and despite my best efforts to do what was suggested to me. For me, there was no "happy, joyous and free" persona to go with my drug free state. I was treated for depression--unsuccessfully--by talk therapy and a variety of antidepressants. Nothing helped--because it was not serotonin that was the problem in my brain, it was endorphins. With proper treatment with methadone, I stabilized and was able to return to a full time job, raise my family, and become involved in community activities again. I don't feel "imprisoned"--I have been set free. If the price I must pay is to take a medication daily that causes me constipation and sweating, well, ok.

I would always encourage anyone who wants to try for a drug free life to do so. Many people DO succeed and it is a worthy goal. But, to encourage someone to try it again and again and again and again, while each time they relapse and return to treatment MORE battered and downtrodden than the last time, baffled as to why they cannot stay clean--when they were doing very well IN methadone treatment--is that really wise?

We had a patient at our clinic with a long history of heroin addiction. He was doing well in treatment and finally begining to make progress. However, his parents, who were footing the treatment bill, decided that he did not need that "junkie juice" any more, and pulled him abruptly out of treatment and sent him to the local 28 day rehab. He did well there, and they had high hopes for their boy.

4 days after his release, he was found dead of a heroin overdose.

tim1leg said...

Substitution therapy is nonsense on stilts.
I thought this was brilliant, and would like to ask the authors permission to use it in the future please.Once more for a good smile, Substitution therapy is nonsense on stilts. Love it.

tim1leg said...

No seriously its obvious that Methadone can part stabilise chaotic lives and has a positive impact on the lives of many people who are treated with it, ie they dont have to commit as much crime or it can remove the chase for 1 bag required for the days use but so can other substitutes but they are not as cheap as meth .

Many experts have concluded that it is entirely appropriate for methadone to be the major element of the so called treatment available for opiate dependency, but there are, however, areas of major concern for me about the use of methadone. I personally would like to scrap it to the bin of been there tried that didnt work but it looks like we are stuck with it because the experts said so,so lets start improving service delivery and access. I wonder how many real experts ie recovering addicts would reccomend methadone, now theres a survey i would like to do.

Currently in my neck of the woods the methadone has been capped for several years and it can only be prescribed at the moment to users who are pregnant!!! yes this is true and surprise surprise the drug deaths have shot up in the last year locally but as yet i cant prove a scientific link but hey its all men so far who have died;

so improving consistency of provision ; and, above all, improving integration of methadone treatment with the extra support needed to achieve the ultimate goal of recovery from addiction.

Methadone must come with genuine rehabilitation to help addicts find a route out of drugs. It is esential that we need to be more than a prescription service or a dosing pitstop. And dont even get me started about the variety of choices a addict should have when asking for help. The rich get rehab the poor get parked on methadone! simple really.

Sara McGrail said...

"Basically, you are setting out an opinion but dressing it up in the language of medical science to make it sound more objective and unchallengeable. I don't believe you or agree with you."

Oh right, but the phrase

"Substitution therapy is nonsense on stilts."

is founded on evidence, objective well argued and full of insight and intelligence?

God help us.

This is what I mean by a bogus discourse. You WANT to believe methadone maintenance is ineffective because you believe everyone should be drug free. Well you may well think so and it may even be a laudable aim, but you know what? JUST BECAUSE YOU WANT IT TO BE TRUE DOESN"T MAKE IT SO. And while you can claim again and again that its wrong, and you can push your fingers in your ears and go "nah nah nah nah can't hear you", the evidence base for methadone maintenance is unassailable and undeniable. It helps people stay well, it enables people to reclaim their lives, it stops people - like the sad case described above - from dying. Naivety is one thing, willful denial of the evidence is quite another.

Sara McGrail said...

"I would always encourage anyone who wants to try for a drug free life to do so. Many people DO succeed and it is a worthy goal. But, to encourage someone to try it again and again and again and again, while each time they relapse and return to treatment MORE battered and downtrodden than the last time, baffled as to why they cannot stay clean--when they were doing very well IN methadone treatment--is that really wise?"

Sorry I also wanted to say that this statement in this excellent posting really does go to the heart of the matter. And the questions don't end with "is it wise" but also include "is it humane", "is it cost effective", "is it healthy" and "is it fair?"

Sara McGrail said...

"Currently in my neck of the woods the methadone has been capped for several years and it can only be prescribed at the moment to users who are pregnant!!! yes this is true and surprise surprise the drug deaths have shot up in the last year locally but as yet i cant prove a scientific link but hey its all men so far who have died;"

My God - that's horrific and appalling and obscene. No healthcare provider should be allowed to ration a Department of Health mandated treatment in that way. And there you go, people are dying because of methadone rationing. (If anyone from this part of the UK or anywhere else where this practice is still happening is reading this, The DH Guidelines on Treatment (also known as the orange book) should enable you to lodge an appeal against this kind of dangerous service and poor practice with your Health Board.)

However you say that you would like to scrap methadone as something that hasn't worked. I'm really confused as to what you base that on. Your arguments seem only to demonstrate absolutely why methadone maintenance should be available to all who need it at the point at which they need it and without any necessary barriers or moral injunctions. It stops people dying. I'm wondering if therefore you prefer rationing and deaths to people staying healthy and having a chance at living a productive and healthy life - on or off methadone?

tim1leg said...

I'm wondering if therefore you prefer rationing and deaths to people staying healthy and having a chance at living a productive and healthy life - on or off methadone?

I would as said previously like to see a vast choice on offer to the addict seeking help including meth and other substitutes as you said freely available at the point of asking. As with all substitutes they are Goverment Wine/ liquid Hancuffs. Substituting a legal Narcotic for an illegal substance is not, and never will be a solution
If you are referring to the research on how well methadone works, well i have some of my own, MANY RECENT STUDIES have shown that most drug users seek help with the aim of eventually beating their addiction yet only 4% of heroin addicts in Scotland who were prescribed methadone managed to become drug free nearly three years after beginning their treatment.

These findings have once again cast doubt on the effectiveness of the methadone programme. Methadone far from being part of the solution, is now a large part of the problem.

Those who advocate the use of the substitute heroin point out that it can help reduce deaths, bring stability to chaotic lifestyles and cut crime. And i wont argue that clearly it can play a role in tackling drug problems but there are far better alternative substitutes out there but they cost more. My point was its better than nothing or death. In Scotland we have over 20,000 people being prescribed methadone with little prospect of recovery, questions have to be asked over who is really benefiting from this approach.

The same research also found residential rehabilitation services had a far higher success rate, with almost 30% of addicts who underwent this treatment becoming drug free. However, many people in Scotland are unable to readily get this kind of help. Currently, only one in 50 drug addicts can access these services and recent figures show that more than 800 people are waiting for this type of treatment on the NHS.

Professor Neil McKeganey, who carried out the research, also makes the point that methadone is being used with far greater success south of the Border. Similar studies carried out in England show that 25% of addicts who are given methadone there are drug free after two years.

Why are services in Scotland, therefore, failing to produce similar results?

It is clear that there are many questions which have to be answered over the methadone programme in Scotland. Yet the Scottish Executive’s response to the research has only been to call for an end to what it calls an “unhelpful obsession” of trying to find out which is the best approach for treating drug addicts. lets not get in to that argument either please.

It dismisses studies which show better outcomes for residential drug rehabilitation services than community-based ones, as “not comparing like with like”.

Meanwhile, the numbers of prescriptions being handed out for methadone continues to rise, at a cost to the NHS of nearly £13 million every year. Hundreds of addicts continue to die, with 420 drug-related deaths recorded in 2007.
I am not suggesting there is one single, easy solution to how best to treat Scotland’s estimated 50,000 drug addicts. But whether we need more investment in rehabilitation services, a change in the use of methadone to ensure there is some prospect of recovery or an entirely different approach altogether, surely it is a debate that we must have.
I wish we as a field could unite and see the similarities rather than the differences.

tim1leg said...

My God - that's horrific and appalling and obscene. No healthcare provider should be allowed to ration a Department of Health mandated treatment in that way. And there you go, people are dying because of methadone rationing. (If anyone from this part of the UK or anywhere else where this practice is still happening is reading this, The DH Guidelines on Treatment (also known as the orange book) should enable you to lodge an appeal against this kind of dangerous service and poor practice with your Health Board.)
The health board in question is Ayrshire and Arran and I pointed this out to Joe griffin head of the drug policy unit on Wednesday last week when i was presenting at the start on the ministerial tour on recovery by Fergus Ewing our minister for community safety.

I have mentioned nay shouted about the abhorrent nature of this health board for many years but my shouting has fell on deaf ears.
Perhaps you could help me, Im deadly serious if you can help me in my approach to them? Because what I am doing hasnt worked as yet.
Sincerely annemarie

armme said...

"""I am certain that most diabetics wish they could live drug free lives, as do most epileptics, most cardiac patients, most schizophrenics, and so on. Many of these treatments have unpleasant side effects. However, basing treatment on the patient's wish that they did not require it is short sighted indeed."""

YES!!! And to add to this further-it is not about the patient wishing to be DRUG FREE (for any of these patients diabetic, shizophrenic whatever the wish isn't to be drug free-its to be ILLNESS FREE! It's about wishing they didn't have the illness to begin with--that they were "normal".

This is the problem with "abstinant" based treatment. They continue to treat DRUG USE instead of the disease of addiction.

The disease's symptoms are unrelenting craving, lethargy, depression, fatigue, dysphoria and inability to feel happiness. If the treatment industry looks at these indicators (instead of whether a person is on drugs or not) as a gauge to whether a persons addiction is in "remission" or "recovery" it's pretty plain to see that MOST addicts using abstinance as they form of treatment are actually still in active addiction!

How is that success?

Why not focus on ending HARM, PAIN and bringing QUALITY OF LIFE and letting the patient DECIDE FOR THEMSELVES what that is?

I would LOVE to see the day a doctor told a patient with epilepsy that his wish to be drug free was a "Great idea" and if he just found more SUPPORT and did a little more work on their "inner child" they would be free of epilepsy without drugs! Because addiction is very similar to epilepsy--they only difference is how we get it.

YES! Lets fix a broken brain with a little prayer and hand holding!!

armme said...

Palliative care suggests ones life is almost over. Since I know many healthy and happy addicts whom have been on methadone more than 10years I find this question laughable.

Methadone treatment is no more a last ditch effort than antidepressants or antipsychotics are!

armme said...

tim1leg said...In Scotland we have over 20,000 people being prescribed methadone with little prospect of recovery, questions have to be asked over who is really benefiting from this approach.

Your equating recovery to abstinance from medications or drugs...not everyone needs NOR WANTS this form of recovery.

I worked for most of my adult life in a substance abuse counseling agency, my mother and stepfather are very active in 12 steps....I watched the revolving door of their kind of "recovery" watched each patient become obsessed with doing 12 steps "correctly" and living the life 12steps insists you lead. I watched time and time again as people became more and more miserable--more and more intolerant of other addicts--and more and more angry at the world.

When it was time for my recovery to bloom I wanted NOTHING to do with that kind of recovery....it's elitist, cruel and cultish. The fact that you all are even here arguing how to label what SOMEONE ELSE"S recovery IS proves my point over and over again.
\
The fact that you think methadone treatment means you live a "less than" life than someone in your type of recovery just shows how arrogant and self centered you have to be to even take part in 12 steps at all.
It sucks having someone base their entire opinion of you by the recovery you claim as your own, doesn't it?

armme said...

"""Hundreds of addicts continue to die, with 420 drug-related deaths recorded in 2007.
I am not suggesting there is one single, easy solution to how best to treat Scotland’s estimated 50,000 drug addicts. """

Not to sound callous--but this sounds like an approach that WORKS! You've got 50,000 people with a disease and 420 die...that percentage is TINY! If this were any other disease we would consider the treatment a success.

It helps that every patient entering methadone treatment lowers their risk of overdosing by 50%...its becomes so low that their chances are almost as low as the "normal" population.

How can you say methadone isn't saving lives? The question you should be asking is how did we do this?

tim1leg said...

Your equating recovery to abstinance from medications or drugs...not everyone needs NOR WANTS this form of recovery.

No I am not I am advocating for choice.

The fact that you all are even here arguing how to label what SOMEONE ELSE"S recovery IS proves my point over and over again.

Im sorry but we/I are not doing this at all again we are advocating for change and choice in the treatment of addiction.

This is the problem with "abstinant" based treatment. They continue to treat DRUG USE instead of the disease of addiction.

My addiction to substances was dealt with very quickly once i entered the recovery process, it is exactly the disease of addiction that i treat to remain and sustain my recovery.

Why not focus on ending HARM, PAIN and bringing QUALITY OF LIFE and letting the patient DECIDE FOR THEMSELVES what that is?

We are on the same page here.

How can you say methadone isn't saving lives?
I didnt say this please dont read between the lines as your interpretation is wrong.
My god i really wish the field would unite, it is exactly this nonsense that inhibits progression.

sara mcgrail said...

I think to be honest Anne Marie that you're giving some confused messages here. However if what you're saying is that for you, you wish methadone didn't exist but that for others you can see it helps and that people should have choice in how they access their own definition of recovery then you won't find an argument from me. However when you come out with statements like:

"I personally would like to scrap it to the bin of been there tried that didnt work but it looks like we are stuck with it because the experts said so,so lets start improving service delivery and access. I wonder how many real experts ie recovering addicts would reccomend methadone, now theres a survey i would like to do."

you can't be entirely surprised if people believe that you are imposing a solution on others and trying to restrict choice.

I am happy to talk through ideas or provide support that you think would be helpful to enable drug users in your part of the world to challenge the methadone rationing of the Health Board there. Just drop me an email at sara.mcgrail@btinternet.com

Sara

neil mckeganey said...

In the latest statistics from the Scottish Government it is evident that in Edinburgh there are now more deaths associated with methadone than are associated with heroin. That is a worrying development and should lead us to be very cautious about accepting such blanket statments as methadone reduces an addicts risk of overdose by 50%.

Yenwarp said...

Very fitting for myself you have posted this today David, last night i had a chat with a dear friend who i met in a mental ward back in 2001, she has been into re-hab before and is still in the addiction, she was upto 3 months ago presribed 80mg methadone by her local DAT team yet it was to much for her mind and body to cope with and put herself down to 60mg a day, still this was not supporting her through the day and was making life worse for her to live with, she feels that the DAT team thinks she a "NO HOPE CASE!" have heard that all to often! she insisted that she wanted to come of methadone and be put on subutex which she has now been on for the past 3 months on 8mg a day. Yet, which warms me dearly she finally agrees and wishes to give up all drugs and wants to go back into re-hab to once and for all beat the addiction. That is and should be the end goal for all, total mind free alterating drugs, now her problem is tying to convince the DAT and CMHT that this is what she wants and needs? there are no other services within the community to support her and what frustrates her most is none of the staff with CMHT seem to understand about the impact of addiction! and sadly no one apparantly with DAT team know very little about methadone and subutex and that it should and must be issued to individuals with what is best for their own needs and the end goal, substance free.

tim1leg said...

Thanks Sara
when i said I personally would like to scrap it to the bin of been there tried that didn't work but it looks like we are stuck with it because the experts said so, I mean that the research is based on the current treatment system and that it obviously skewed in favour of the current treatment system .

Also my reasons for wanting to scrap don't meant doing away with methadone completely, just doing away with the current delivery, I'm sorry if that wasn't clear.

Again access and service delivery across the UK and in particular Scotland is so varied that yes i would like to scrap the current system and deliver methadone and other substitute therapy's in a more consistent and fair manner.

Here in Ayrshire and Arran services are so bad that at times I find it hard to be diplomatic, It is very obvious to me that these regional, national and international differences can confuse and complicate the debate in my opinion unnecessarily.

tim1leg said...

you can't be entirely surprised if people believe that you are imposing a solution on others and trying to restrict choice.
OMG
In I am always always always advocating for choice, that is very clear in my postings sara.


So yes i am very surprised.

Jason Schwartz said...

This issue of palliative care gets to the very crux of the issue doesn't it?

From Wikipedia: "The term "palliative care" may be used generally to refer to any care that alleviates symptoms, whether or not there is hope of a cure by other means;"

It really comes down to whether once believes addiction is a treatable illness doesn't it?

I'd add that it might be possible for a methadone program to have a recovery orientation, rather than a palliative orientation, but it's not what I see.

One more wrinkle on the subject. The term palliative care implies that the patient is focus of concern, that the purpose of the treatment is to reduce their suffering. Unfortunately, this isn't the history of methadone in the U.S. It was used to reduce our suffering at the hands of the addict. It was crime and infection control.

Anonymous said...

Sara,

My comments about 'science' being rhetoric masquerading as objectivity and substitution therapy being 'nonsense on stilts' were obviously not as clear as I intended!

I do not for a minute question the evidence base for methadone maintenance. As you say, it's pretty much unassailable. What I do question though is why we're doing this at all? Why is heroin handled within a criminal law framework (except when used, as diamorphine, in medical care) but methdone isn't? For me, the effectiveness of methadone is evidence that the problem is the prohibitionist framework. Why do we not introduce a regulatory framework to control all psychoactive substances (including alcohol and tobacco), based on actual objectively measurable harm and drawing on well-established principles about 'what works' in regulation?

The recovery debate is a red herring. Motivated by compassion for some, but moralism for many others. Either way, it doesn't get to the heart of the real issue, which is about regulation.

sara mcgrail said...

Oh dear, I'm afraid after what feels like far too long in the drugs field I'm afraid I'm something of an agnostic on the whole regulation/deregulation thing. It may be that this position as someone far wiser than me suggested (in reference to religion) is a bit like standing with one foot on either side of a pile of sh*t, but i'd rather that than be immersed in it!

Annemarie, have emailed you.

Sara

Peter O'Loughlin said...

Seems as if you’ve ruffled a few feathers Prof.

Whenever the MMT debate arises, it seems to me that regardless of what pseudo scientific semantics are used by those who defend it, there is a tendency to avoid mentioning that it is a highly addictive drug, with some horrendous side effects,

The first fact which strikes me is that the vast majority of our drug treatment strategy is based on harm reduction via substitute treatment, yet whenever the subject of abstinence arises, those in favour of substitute treatment trot out the old cliché, ‘one size does not fit all’. That being the case why then with the vast majority of those who are addicted, claiming to want to become drug free, is so much of our treatment strategy devoted to keeping people locked into addiction?

We are told that long-term MMT of opioid users reduces harm and improves health and social outcomes yet relapses to illicit drug use are common. (1) On that fact alone its ongoing use without abstinence focused interventions is questionable. On the other hand Naltrexone drop out rates are extremely high.

MMT, the flagship of drug treatment in the UK, needle exchange facilities, and drug consumption rooms have all failed to reduce or prevent the increasing use of addictive substances, as well as the associated deaths and blood borne diseases. (2)

It is also true that the majority of those on MMT perceive their health negatively and experience high levels of health related concerns, but continue to engage in behaviours, including poly drug misuse, are likely to have negative health outcomes. (3) Add that to the common problems of sleep disorders among those on MMT (4) and one is forced to conclude that the chances of those in long term substitute treatment and ongoing use of other substances, of maximising their ‘health and wellbeing’ are indeed slim. Therefore the term palliative care seems to be more accurate. Perhaps if we were to practice what the evidence supports I.E treating the addicted, rather than treating the addiction, we might get more positive outcomes.

1. Minozzi S, Amato L, Vecchi S, Davoli M, Kirchmayer U, Verster A. Oral naltrexone maintenance treatment for opioid dependence. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD001333. DOI: 10.1002/14651858.CD001333.pub2.
2.Department of Health. Reducing drug-related harm: an action plan. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_074850
3.Philip James, David Spiro, Noreen Geoghegan, Anita Connor, Gail Hawthorne. Nursingtimes.net 28.Aug 2008
4.Peter D. Friedmann, citing Peles E, Hetzroni T, Bar-Hamburger R, et al. Melatonin for perceived sleep disturbances associated with benzodiazepine withdrawal among patients in methadone maintenance treatment: a double-blind randomized clinical trial. Addiction::2007;102(12):

Anonymous said...

sara mcgrail..

You have definately made it onto my cool list!!!

you rock!!!!

Anonymous said...

"""Whenever the MMT debate arises, it seems to me that regardless of what pseudo scientific semantics are used by those who defend it, there is a tendency to avoid mentioning that it is a highly addictive drug, with some horrendous side effects, """

Methadone is THE most researched drug on the EARTH--including many studies that set out to prove it didn't work. To believe otherwise is like saying the "earth is flat".

What are the "horrendous" side effects? constipation? sweating?

Try being on prendisone (also caused DEPENDENCY) for a few months and tell me how bad methadone is in comparison. All drugs come with side effects-methadone less than most (in opiate tolerant individuals).

In the latest statistics from the Scottish Government it is evident that in Edinburgh there are now more deaths associated with methadone than are associated with heroin. That is a worrying development and should lead us to be very cautious about accepting such blanket statments as methadone reduces an addicts risk of overdose by 50%.

METHADONE TREATMENT reduces an addicts chance of overdosing by 50%--very different from methadone the drug. I can bet that at least 90% of the addicts who died in these overdoses were addicts using methadone incorrectly and illegally. Addicts using this way will die one way or another: the substance doesn't really matter...I can almost bet 90% of these overdoses involved numerous drugs and not just methadone as well.

Sophia said...

Since the "harm reduction as a form of palliative care" comment came from me and has obviously hurt some folk, let me clarify what i mean by it. i regard addiction as a chronic, progressive and potentially fatal illness - same as cancer. and of course cancer isn't just one illness, it's a whole spectrum of different illnesses, and how you get on depends on what kind you've got and how far it's progressed. same with addiction........except that we don't have the huge armamentarium of different kinds of chemo, radiotherapy, surgical interventions etc etc. despite the morbidity and mortality not to mention the harm to family members and society at large, we just don't have that many treatments to offer people. hopefully that will change as the science moves along. but given that residential rehab seems to be the most effective treatment modality in rendering people drug-free and methadone the least effective, why do most people get offered methadone first and then after years of struggling and getting worse, finally make it to rehab by which time they've destroyed their physical and mental health and that of their family? isn't that the wrong way round? there must be very few patients who come along to treatment services and say "well, my goal is to be addicted to drugs for the rest of my life." my experience is of working in addictions including methadone maintenance, as well as of having been treated for both addiction *and* cancer - very educational! i was lucky enough to be sent to rehab, but that's because i'm a health professional and was therefore considered worth rehabilitating. the GMC is quite unequivocal: addicted doctors are ill, the majority will be sent for residential treatment and expected to become drug-free before they get their registration back. (of course, given that the illness varies in severity, some will not be able to, and the system lacks compassion for those who probably would do better on maintenance.) very few of my patients were able to access that kind of treatment, even those who desperately wanted it, because it was seen as too expensive. it was also considered very unlikely that they would manage to become drug-free, even when they begged and pleaded and tried to jump through all the flaming hoops and over the insuperable barriers put in front of them. those who said "i want to get clean" were patted on the head and told that it was far too hard and their chances were minimal. one of the things that impressed me most about the cancer team was how relentlessly positive they were - but not in a Pollyanna kind of way that avoided the painful reality of a life-threatening illness and distressing treatment. they knew that everyone receiving the diagnosis was terrified and thought they were going to die. even if full remission was unlikely, the message was still that they were in it for the long haul, would respect your wishes and feelings, and wanted you to have the best result possible, even when that wasn't a cure. even if you were unfortunate enough to have one of those cancers that gives you a 30% chance of surviving five years, they would still give you a jolly good bash at treatment, because who knows, you might be one of the 30%. they know the importance of never depriving a patient of hope.
when i was ill i got some emails from the late Dr LeClair Bissell, one of the giants of addiction medicine, who i'd had the privilege of meeting last year at the International Doctors in AA Convention in Boston. she spoke from the Olympian heights of 55 years' sobriety and a lifetime of experience, and had also been through treatment for cancer. she has said and thought all this long before i did and expressed it far more eloquently than i ever could in her writing. she makes the point about cancer being a "respectable" illness which attracts lots of sympathy and lots of research funding, because people are so frightened of it and so many are affected. addiction isn't quite like that..........and yet the paradox is that statistically i am far more likely to die of my addictive disorder than of my cancer. when was the last time you put money in a collecting-box for addiction research? - well, quite. addiction still kills. quite often it kills people young, and they die in pain and loneliness, leaving devastated parents and bereft children. i'm really glad to see this website up and running, and i hope we can stop fighting among ourselves and concentrate on improving the care available to our patients, who also include ourselves and our friends and families. chat on!

Anonymous said...

This whole page of "debate", as usual, falls into two camps ; advocates of recovery (whatever that means) arm in arm with the abstentionists and proponents of harm reduction and long term mathadone maintenance.
At the end of the day, the shops close and it gets dark, and the CHOICE shopuld lie with the person experiencing problematic drug use.

Anonymous said...

drug use is not an disease dammit!

Anonymous said...

Sophia,

Your last five lines sums it up perfectly!!.

Well done and i am with you all the way!!

chris g

Peter O'Loughlin said...

Anonymous said...
This whole page of "debate", as usual, falls into two camps ; advocates of recovery (whatever that means) arm in arm with the abstentionists and proponents of harm reduction and long term mathadone maintenance.
At the end of the day, the shops close and it gets dark, and the CHOICE shopuld lie with the person experiencing problematic drug use.

If you don't kno what recovery is, how can you knock it?

I don't know what problematic substance abuse is, so I won't knock it perhaps you would care to define it and what the criteria for it is?

Perhaps you would also to define what an abstentionist is?

Anonymous said...

Mr. O' Loughlin,
As I understand it, the word and use of the word "Recovery" suggests that someone is a "recovering alcoholic / drug user. Often used by people who hold with the 12 steps / Minnesota Method philosophy of the self - fulfilling prophecy "I am an addict and will always be an addict" which in my opinion disempowers people.
Feel free to correct me if I amwrong, which I'm sure you will.

Abstentionist : One who supports the act or habit of deliberate self-denial.

armme said...

Anonymous said...

drug use is not an disease dammit!


NO IT ISN'T but ADDICTION IS. This is why so many people have such a hard time (even treatment professionals) accepting MMT as a viable option! We keep trying to solve the problem of drug USE instead of focusing on the symptoms of addiction that make it so hard for the patient NOT to use.

Addiction is hard to explain to someone that hasn't lived it but let me see if I can give an analogy--however crude it is:

Addiction feels like riding in a car and having to go to pee REALLY bad, but the driver says "NO WAY--I am not stopping! Think about something else!"

That's what addiction is--much different than someone that simply ENJOYS using drugs. Addicts feel they MUST use drugs just like they feel they MUST eat. Addiction hijacks the "survival mode" part of the brain and tortures the addict until it gets what it wants. Some people assume that not giving the addiction what it wants is the way to get it to stop torturing--and for some patients it does ease up...however for many others it doesn't. So for many addicts finding a way to "feed" the addiction without ruining their lives is the best possible solution. Not a dead end street at all--but an oppurtunity to LIVE.

In the pee analogy the driver is the abstinant based therapist. They try to teach the person to live with the feeling of a "full bladder" and get on with their life feeling that way. They teach them coping mechanisms.

In this analogy methadone would be a medication that takes away the feeling of a full bladder so that you can enjoy the trip (life).....the only catch is you have to keep taking it or the need to pee comes back...and if you don't take it you can become sick. Almost ALL medications for chronic illness have this "catch".

(this isn't a perfect analogy because eventually we would HAVE to pee--we don't eventually HAVE to use opiates to get high-- since emptying your bladder in this analogy is equated to "using illegal drugs")

armme said...

Jason S said

"One more wrinkle on the subject. The term palliative care implies that the patient is focus of concern, that the purpose of the treatment is to reduce their suffering. Unfortunately, this isn't the history of methadone in the U.S. It was used to reduce our suffering at the hands of the addict. It was crime and infection control."


Actually, Jason, if you read about the beginnings of METHADONE TREATMENT (not the drug, but the treatment we know today as MMT) you would realize that the intentions of the "father of MMT" (Dr.DOLE) were never about anything OTHER THAN THE PATIENT. He may have gotten the dumb bells in government to ACCEPT the treatment by offering crime control, but it was NEVER his reason for doing the research. He believed from the very beginning that addicts were people who suffered hormonal dysfunction and opiates were a way of self medicating. He realized that many of them "caught" this illness the first time they used drugs, but he felt their was a genetic reason that made an addicts endorphins SHUT DOWN completely, while other people could take opiates or leave them without so much as a ripple in their endocrine function. Which means the comparison of opiate addiction to diabetes or hypo-thyroidism accurate.

One of the things that struck me MOST about Dr. Dole's work was a simple thing that LED him to methadone rather than simply maintaining people on heroin or other short acting opiates.

His subjects were in a trial that involved regular injection of morphine. These addicts spent most of their days watching tv and waiting for their next dose. They had no interests OTHER THAN their next shot.

However, when he gave them methadone to start the detox process he noticed that all of his subjects "came to life"...one was an artist and started to paint again-another started working on getting his GED. So began DOLES research into methadone treatment and his passion for it. Nothing to do with helping "society"--everything do to with helping his patients.

This is why methadone is MUCH different than simple "substitution" therapy. It's much different than spending your life waiting for the next dose, or obsessing about the next dose or how much the next dose will be. It's the ABSENCE of those feelings and the ability of the addict to focus on OTHER THINGS that makes methadone so much different than other opioids. It's why the comparison to heroin addiction is laughable to anyone that has ever received very good methadone treatment...that includes an adequate dose, education about addiction and methadone, supports (where needed and wanted) and medical care.

Anonymous said...

A disease is something which is communicable ; air borne, blood borne etc. Addiction is not a disease.

Anonymous said...

This blog is hilarious. I haven't laughed so much in ages. Thanks, Prof. Who said satire's dead?

tim1leg said...

Anon ADDICTION IS NOT A DISEASE!!! YOUR RIGHT. satire is alive and well.
Addiction is regarded by most as a social problem to be solved with social solutions, i.e. incarceration. But, scientific evidence argues otherwise: addiction is a brain disease. this meams then that addiction is a clinical condition and has both behavioral and social components that need to be attended to, just as other disorders, such as schizophrenia and Alzheimer’s are treated. Advances in the fields of neural and behavioral sciences have led to this new-found definition of addiction. Researchers have identified physical differences between the structure of an addict’s brain and the brain of a “non-addict,” implying that these habits are behaviors that alter pathways built by neurons and synapses, as well as altering the availability of recently identified receptors, gene expression, and even an addict’s responsiveness to his/her environment. Biologists have also uncovered elements common to all addiction, regardless of the substance that is being abused. Such standardization acts as a great advancement in treating the disease. Prolonged abuse of any substance can cause long-lasting, widespread changes in brain function and structure. This fact should then encourage research exploring ways to treat this disease—addiction—because of how universally the effects of substance abuse are felt. Its implications are even felt in the realm of public health, seeing as how drug-use is responsible for the transmission of many diseases (ex: AIDS, hepatitis), and a recognition of this abuse as a brain disorder “characterized by compulsive drug seeking and use” will help lower social costs for the consequences and ineffective treatment of the disease of addiction.
According to Webster’s Dictionary disease is defined as follows:
“Disease: Any departure from health presenting marked symptoms; malady; illness; disorder.”



Works Cited:



(1)Addiction is a Brain Disease, Alan I. Leshner

(2)Anatomy of Addiction, Ellen M. Unterwald

Anonymous said...

Tim1leg

Comments like yours just tell me that this recovery 'movement' is going to kill itself off before it even gets going. The levels of self-delusion, pomposity and self-righteousness are astounding. I should just let you and the prof keep posting and watch you hang yourselves...

Anonymous said...

Anon,

In reply to your last'outburst',could you please explain to me your reasons behind it.I have seen and have wreaped the rewards of this recovery 'movement' because 'anon',they understand addiction IS A DISEASE and where able to help me,where shallow minded and pompous individuals like you wouldnt.So whats your take on it then 'anon' is it"its not a disease you have got,your just greedy!!" or maybe you still practise drilling out the front of the brain and padded rooms!.

Honestly,people like you disgust me,how are we ever gonna move forward with half-wits like you turning the recovery movement into a mud slinging competition when it is clearly evident the huge impact that understanding 'ADDICTION IS A DISEASE' can allow us to start to come to terms,understand and deal with our DISEASE!!!!

Chris g (ex-user)

Anonymous said...

Can I just point out that the response to Tim1leg was not mine! I did state that I believe addiction is not a disease, but please dont think I responded to Tim1Leg in that manner.
Personally, I am all for choice, and if the recovery/12 step/ Minnesota Method works for you, all fine and dandy.
What I do object to is the evangelical posturing that "if it worked for me it must be the only way" and the whole "It's not my fault, it's a disease" which can lead to the self - fulfulling prophecy that "I am a drug addict and will always be a drug addict."
My view is that drug use / addiction is a learned behaviour, which means that what has been learned can be un - learned, if you like.
I've worked in addictions for nearly 19 years and have referred many of my clients to AA and other organisations which adopt the recovery process philosophy, because this is not about me, it is about my clients and what best suits them.

Anonymous said...

Addiction is not a disease ... not even if you spell it in capital letters. Have a read of John Davies' book 'The Myth of Addiction' or Stanton Peele's 'The Meaning of Addiction'. Neither of those two are 'shallow' or 'half-wits' as you charmingly put it.

tim1leg said...
This comment has been removed by the author.
Anonymous said...

If cancer patients were only offered what amounts to a form of palliative care, it would be seen as a scandal.'
Palliative Care is defined as ...
"Medical or comfort care that reduces the severity of a disease or slows its progress rather than providing a cure."
I feel as a retired oncology nurse (RN, BSN) as well as a terminal liver cancer patient myself, in addition to being an MMT advocate and patient who is a recovering prescription pill addict I probably am qualified to take issue with this statement. LOL
There is no cure for addiction. There is only treatment. If you look at the definition I would say "palliative care" applies to ALL forms of treatment for recovery as well as most forms of cancer (since many cancers are only treatable & not curable). This misunderstanding causes a great debate regarding MMT treatment. MMT does not claim to cure only to treat addiction with a medication. Like any illness, one may be able to use the medication for a short time while moving on to non-pharmacological treatments in time while others will be on medication for life. Someone who takes high blood pressure meds for life is not said to be taking them because they are addicted to them. While Methadone can cause dependency those that take it for life are taking it to prevent the recurrence of a chronic illness. Why this is so hard to accept is puzzling to me but even more puzzling is the aggressive behavior some exhibit when discussing this issue.

Anonymous said...

ANON ANON

Is thought something that appears out of our experiences and is then deduced by our selves in some part of our conscious or is it a mechanical process that arrives from electrical patterning and DNA based computing. I think it's a quantum question in that it depends who is looking..
Here we are debating chickens and eggs and guess what! You're all right and you're all wrong, depending on the observer. As someone earlier said, get over and let's get on with it and just be nice to people (Studies say that is what treatment users want most, not some highly trained robot). Stats show that if you want to stop something will help, just depends at what you arrive at. Choice IS all but some apparent advocates for it (choice) have a really strange way of putting it.

By the way methadone deaths are up in Edinburgh but how many more would be dead if there wasn't any available.
And how many are dying because of the disinhibiting factor of alcohol or benzo's
And how many sleep problems are due to benzo use rather than 'done
and i could go on but due to my quantum state I am wondering whether I actually exi...............

mel said...

I have been on methadone on and off for over 20yrs. This year is the first time I've been voluntarily clean of class a's since my teens. I have been able to do this only because of the RIOTT(randomized injectable and oral treatment trials)For the 1st time ever I'm working, start studying with the O.U. in March 09, I'm the healthiest I have ever been. I could not have done this without methadone maintanance and don't see why I should change something that quite blatently works for me. Methadone maintanance is not for everyone but for those of us that it does work for should not have to be worrying about losing it because someone decides abstinance is the only way forward.

Dr D said...

"If cancer patients were only offered what amounts to a form of palliative care, it would be seen as a scandal" It would be, but ONLY if there were alternative effective treatments, hence the analogy is somewhat flawed. Thats said, I'm behind your general position on this. I speak as someone who's technically still on a methadone script and who has been going in once a month for a 5-10 minute chat with a rather friendly drugs worker, and who pootles off with 2 14-day scripts. Palliative care indeed.

But, and I don't think I'm saying something that is over contentious here, a user must want to quit in order to quit. There is no substiture here. Sure, a dramatic intervention (aka a kidnapping, either by the family or the state; i.e. a prison sentence) may work in the short term, but any abstinence is unlikely to last [OK there is the posibility that an enforced withdrawal and major psychological work could make a recalcitrent user quit. I don't know of any theoretical reason why not, but I've just not seen it, so it's statistically irrelevant I think]

In terms of harm reduction, and I'm not going to review the literature just to post here, methadone does work. However a lot of methadone users are still using other things on top.

So, what's the solution to this? We could say (this list is not exhaustive) a) no more methadone ever, except as a detox agent. b) status quo. c) a greater access to services and information to those that want d) enforced access to services for those that want MMT.

I'd think most folk would go for c). I would. When I went in for my latest MMT I wanted counselling. I kind of talked to my drug worker in a general way, but counselling and prescribing should be kept completely apart in my opinion. One might want to say things that could jeopardise one's MMT (i.e. I sell it all to buy H. I don't want to, please help!)

"his generally leads people from one addiction to another without providing a realistic opportunity to attain recovery".

Again this is wrong, but only because it's been over-egged. There are perfectly realistic ways to obtain recovery, especially in the internet age, when all the information is on tap. Speaking personally for a second, I'm into day 19 off methadone which I quit unaided except for the help of my wonderful wife, and the use of an internet forum (drugs-forum.com). Maybe I'm not real (or simply not realistic whatever that might mean!!!) but I feel rather real, if still a bit gacky from still-not-all-gone w.d.s. For many the 12-steps are a gateway to clean living. I think a minimal treatment is justified in some senses because someone who wants to quit will seek help. The change needed is that a better set of support structures needs to be in place. When I asked about rehab I was told I'd only get a place if I essentially agreed to 6-7? months of primary and secondary care. Sure I could have done this, gone to primary for a few weeks and bolted. I've done the 6-7 month stretch before and it was incredibly helpful, but a second time I think would be unnecessary. I wanted a supportive environment to quit in, where for 4-6 weeks, I'd be able to work on myself, feel shit in as much comfort as possible, etc. But as it wasn't available, no problem.

Maybe surfing would be a good analogy; every now and again a wave of desire comes that can be ridden into the sure of abstinence (or whatever. I'm not dogmatic here), but the board (maybe treatment options) and surfer must be ready to take advantage of it. There's bugger-all point of trying to catch a trough, as opposed to a a wave!

Finally I'm all against the insulin/methadone analogy. The only truth is that on neither drug do you achieve normality. I've posted a long spiel on the "methadone wellness" thread in drug-forum.com so I'm not going to repeat what I said there here. It's in the addiction > opiates section, and I refer anyone who thinks I could be quasi-intelligent or have an inkling of what I'm talking about there. Of course if you think I'm talking shit, then you should have stopped reading ages ago!

Love to all, especially those trying to get off the nasties. It's doable, it's not how I'd like to spend Christmas, but approaching w.d.s with an "it's all good fun" attitude works far better than moping!

Dickon