Lynn Ruane 20 years on from the introduction of the methadone strategy, where are we now?

ACCORDING TO FIGURES  from the Health Service Executive 10,316 people are officially listed as receiving methadone maintenance in 2018. Of this number 4,069 have been on the drug for ten years or more.

Methadone was perhaps the core policy response from the Irish State to heroin use amongst working class young people. Communities had placed enormous pressure on the State to do something throughout the 1980s and early 1990s.

The question today is how effective has that methadone strategy been and what is the legacy we are left with when so many people are on the drug for so long?

The purpose of methadone as I understand it was to provide a bridge or a gateway to help people stop using heroin and to help them lead lives to their fullest possible potential.

It seems that for many the bridge has become infinite with no end in sight other than continued methadone maintenance.

Before I was born the first treatment clinic was set up to respond to what was termed then as ‘the problem of illicit drug use’. It was several years or so before responsibility was passed to the Eastern Health Board resulting in the establishment of the Drug Treatment Centre Board.

Throughout the nineties there was an expansion of services across Dublin to respond to the rising need for methadone maintenance provision.

Twenty years ago this month the Opioid Treatment Protocol was introduced. But where are things now, especially from a service-user perspective?

‘Something is failing’

After years of working in the services and after many conversations in recent days with past and present users of clinics; there was one big question on my mind: Why, when patients ask for their dose to be reduced do doctors refuse?

There is also the question as to the changing form and nature of drug use in general from the days of the monolithic hold of heroin in body and public imagination to what is now called a ‘polydrug’ use society.

Something is failing and there seems to be some level of secrecy or impenetrability around clinics when it comes to the treatment of the person using that clinic.

One woman described the experience as: 

“I have no rights, I feel controlled and have no say in my treatment plan, every-time I ask to come down on my Phy I am told ‘no you’re not ready. That doctor sees me once a week and has no idea how ready I am, nor does he seem to care.” (Many still refer to the drug as Phy – the original brand name was Physeptone). 

When we unpack this we have an individual looking for involvement in their treatment plan but the service is self-perpetuating and becoming an end in itself.

Here are just some of the responses from my own friends who have experience of being on methadone programmes.

Methadone treatment is not supposed to give you a stone, it should support stability, rehabilitation and harm reduction and yet we are on doses that is way beyond that. That is not a failure on behalf of the person but on the delivery of the treatment.

They never listened to us, I couldn’t breathe with their judgement. The General Assistants looked and operated like prison guards.

No-one should have over-all power over the individual’s treatment.

A few years ago I was docked in my Phy because I was late for an appointment.

The doctor should listen to the patient and assess whether they have already been practicing harm reduction, and if they have, then supported by medical monitoring can determine the amount of methadone they should be on.

The woman had been street buying methadone for two years before starting on a methadone programme. She had successfully stabilised herself on 25mg of methadone and the clinic refused to listen to her and insisted she be put on 40mgs.

She did not need to be on this amount and she felt her two years and getting to that point had been completely ruined. Throughout her time in the clinic she said that she was constantly offered increases in the amount due to her poly use of drugs.

Service providers 

This frustration with the system is also felt at a service provision level. Communities who have been at the coalface of the heroin problem for years have always sought greater investment in services and in people. Community workers often champion a whole community approach to addressing substance misuse.

This has become almost impossible due to lack of investment and lack of acknowledgment of the inequality of conditions of the communities most affected.

The feeling on ground amongst many people involved in the running of Local Drugs Task Forces is that they are having less and less involvement in the decision-making process at a local level.

One community worker said that the HSE “is effectively involved in a power and resource grab and the democratic power-sharing approach that characterised the work of drugs task forces for many years is, the way things are going, increasingly a thing of the past to be replaced with a much more centralised authoritarian approach.

This is austerity’s second wave as it were. The new national drugs and alcohol strategy says ‘health led’. That doesn’t and shouldn’t mean total HSE domination and control.

The issues that arise at this macro level also arise for individuals as they enter a treatment centre. If we were really interested in removing the powerlessness of someone in addiction we would strive to include them in their treatment.

We must create a more equal relationship between the individual and the doctor, one that doesn’t reflect the dehumanisation they face in their daily lives.

Twenty years on from the Opioid Treatment Protocol and one thing is clear, we need to address the culture that has emerged in methadone treatment programmes. It is crucial we place the person at the centre of their own treatment.

We must also place the communities they come from at the centre of the strategy. There is a ‘community goal’ in the new national drug and alcohol strategy. It should be more than words on paper and really do what it says on the tin.

The community and voluntary sector that does most to support community responses to the drug problem was cut to pieces during the austerity years and there was nothing in the new national strategy to suggest that a proper funding restoration process would happen, as it is happening in almost all other sectors of Irish public life.

The restoration of funding to the community and voluntary sector must be accompanied by an acknowledgement that many of the successes of recent years were due to the autonomy and creativity of community led responses.

Let them get back to doing what they do best. Let me be clear in saying that I believe methadone has its place and is a form of harm reduction, however the big clinics and the culture that exists within them is not the way to deliver the programme.

We need to move to a more personalised approach to methadone that involves general practitioners and more integrated approaches at primary care level, with wider integration with the community projects, with a full removal of the punitive approach that is felt by service users in the clinics.