I have an admission. I’ve never been to the Giant’s Causeway – what the naturalist Dr David Bellamy describes as “The jewel in the crown of the fabulous coast of Antrim”. A friend visited recently with her husband who happens to be afraid of heights. He was half way across the rope bridge when he froze – unable to go backwards or forwards. He slowly sank to his knees and gripped onto the walkway with both hands. I know. It makes absolutely no sense, but phobias generally don’t have a rational explanation.
At precisely that moment, a very large American visitor decided to cross. Seeing my friend’s husband kneeling, he began to jump up and down on the walkway, causing the bridge to sway violently from side to side. The terrified, kneeling man looked up and asked (as you would):”What the F…are you doing?” The American visitor said he’d assumed that the guy kneeling was an inspection engineer checking out the bridge and he wanted to give it a good ‘try out’. He thought he was helping. Sometimes you think you are helping when you are actually hurting. Let’s look at how this principle applies in the distribution of free methadone to drug mis-users.
Indulge me! I know that blogs, generally, are supposed to be short and punchy – but permit me a small indulgence. The issue of Methadone distribution is complex and the solutions are not easy to figure out. So, I can’t do an ‘Albert Reynolds’ (1-pager) on this topic. Given its importance, the Methadone question deserves more than a ‘sound bite’ debate. So, buckle in…
Amiens Street: You see the group along Amiens Street, standing outside the City Clinic. They are hard to miss. Close up, the individuals look completely spaced out. Their blank look and poor quality clothing screams drug user. Several will have crutches (bodies ravaged over time with drugs, develop a host of medical complications). Addicts, former addicts or drug misusers? Over time the labels change but the impact stays the same. Lives ruined. Families devastated. Children often (but not always) neglected. A litany of sorrows.
17 Centres: City Clinic is one of 17 treatment centers in Dublin City where Methadone, a synthetic form of Heroin, is distributed to addicts. The general view in most communities is that they don’t want ‘treatment services’ in their area (as this attracts other users) and most services have been ‘re-located’ to Dublin city centre. A walk along the boardwalk at the side of the Liffey is like a sociology class. Welcome to the underclass.
The numbers are huge. Officially, 8,000 – 9,000 people clients are treated within the programme. The Cost: circa €275 million a year (including the distribution of free needles). This figure does not include the money spent by the Department of Community, Rural and Gaeltacht Affairs who fund 14 drug ‘Task Force’ groups around the country and the 1,000-3,000 places on Community Employment (CE) schemes funded by FAS to assist the National Drugs Strategy. Whichever way you count it, the investment cost in these services is enormous.
Drug Testing: It is estimated that up to 30% of Methadone Clinic clients take ‘top up’ drugs, including Heroin. Service users have to complete urine analysis checks to see if they are ‘clean’ from other drugs. One view is that this is undignified and militates against the establishment of positive personal relationships. Another view, less concerned with the dignity question, is focused on effectiveness. Many users substitute urine samples (street name = ‘bogies’) to overcome the testing procedure. They feel that the system needs to be considerably strengthened and ‘the addicts are taking the piss’ (it is possible to conduct a similar analysis using mouth swabs, but this is not done at present). Yet, sitting above these tactical details is the key strategic question: What is the impact of Methadone distribution?
Is it Working? It’s difficult to prove or disprove that the distribution of Methadone is working, as there are no control studies. The central rationale is that addicts take Methadone as a ‘maintenance drug’. Their lives become less chaotic and they don’t need to become involved in crime to get a ‘fix’ of Heroin (costing between €20 & €100 per day – depending on the size of the habit). So, without the Methadone programme, crime figures (see below) would probably be a lot worse. Yet, when we turn our attention to the ‘cure’ debate i.e. whether Methadone helps people who want to become drugs free, the thread of logic becomes much more difficult to follow.
By The Numbers…
Societal Level: The number of Drug offences is rising steadily (5324 in 2003-11,647 in 2007); more recent figure suggests a continuation of this trend. By itself, this does not prove that Methadone is not working (as we don’t have comparison figures if the programme was completely withdrawn). In fact we are missing a lot of key data in this debate. We typically don’t know how long each person has been receiving treatment. It is not possible to find out how many people who had been prescribed Methadone are now living drug-free lives or how many current methadone clients are involved in ongoing illicit opiate use. We don’t understand whether the long-term use of methadone damages a person’s liver. We don’t know if methadone is damaging to a foetus, whether newborn babies suffer withdrawal symptoms from methadone or if newborn babies with methadone in their system suffer long-term damage. So, in practice, it is difficult to have a ‘data-based’ discussion around this (in the management consulting world, if we offered up an analysis which was missing so much key data we’d be shot by the client, and rightly so).
The Garda claim that the problem is steadily getting worse. Faced with the daily grind of dealing with street level dealers, shoplifting and violence, it’s difficult for the Garda to be objective. From speaking with a number of people directly involved in the treatment arena, my own sense is that there is definitely a ‘crime reduction’ benefit. Most users of Methadone report that the drug makes them less stressed, less anxious and less aggressive, keeping them out of crime and out of prison (i.e. this supports the maintenance argument). But is it a treatment programme directed towards a goal of getting people to become drugs free?
Big Questions: Lets start off with a caveat. Drug misuse is an international problem in almost every developed country. There is no ‘magic bullet’ answer to how this can be resolved. But the questions listed below, if openly debated, would go some way towards developing a more effective response.
1. Did it ever work? The original trials on Methadone were conducted outside of Ireland (by Dole and Nyswander). There is an argument that as the people who took part in the original trials were volunteers, this self-selected group was highly motivated and the outcome gave ‘false positives’. In addition, the close-knit team of researchers was able to build up a supportive, compassionate relationship with the patients. Aside from the pharmacology of Methadone, what impact did this ‘empathy’ have? Those familiar with Organization Sociology will recognize the potential Hawthorne Effect. The reality is that the group currently being treated in Ireland often has multiple issues e.g. emotional problems in addition to drug abuse and need to access a range of services. In addition, the ‘conveyor belt’ system of drug dispensing (with its underlying medical as distinct from psychotherapeutic model) focuses treatment on physical addiction – essentially seeing the client as a passive recipient of services.
2. Over-Reliance on Methadone? The original concept of providing Methadone was to ‘stabilse’ drug users, allowing them to overcome the chaos of Heroin abuse and repair damaged personal relationships. They would then be in position to begin the therapeutic journey towards recovery. Methadone would play a role in the recovery process – but it was a means to an end rather than an end in itself. The general view now is that we are massively over-reliant on prescription i.e. drug treatment should be more than a Methadone take-away service. It needs to be client focused and capable of dealing with individuals’ presenting with multiple issues. It’s as if we have built the foundations of a house and left it at that. No walls. No roof. Nothing but the basic floor of treatment. It doesn’t work. The Comptroller and Auditor General Special report on Drug Addiction (2009) estimated the level of effective detoxification is (at most) 1.25%. Let’s repeat that statistic in case you think it’s a typo. Just over 1% of people receiving treatment become drug-free. While the success rates were never going to be stellar, one percent hardly inspires hope. Would we accept this low outcome in any other area of medicine?
3. Long Time Horizon: The length of time that people can be on this treatment is often not often recognized (20+ years in individual cases; theoretically, the treatment can last a lifetime). During this time, clients typically remain unemployed and anecdotally the rates of suicide among addicts are higher than in the general population, albeit it is not possible to ‘prove’ this because of the way statistics are currently collated. Methadone dispensation is not a ‘treatment’ in the normally understood sense of that word. It’s an alternative lifestyle.
4. Poor Service Delivery: The HSE is the lead agency in the treatment of drug misuse. In fairness, a huge amount of time, energy and expertise has been invested in developing policies and treatment protocols. These include a continuum of care model, case management, and inter-agency rehabilitation strategies. The problem is that the HSE has not set progression rate targets for people undertaking treatment and the ‘gap’ between these concepts and the on-the-ground implementation ranges from patchy to non-existent. Example: One alternative is that addicts try to get off drugs completely – detoxification. There are 36 ‘detox’ beds in Ireland, a hopelessly inadequate number. The central question is how can these service gaps be bridged? In the words of Stephen Sondheim: “Everything depends on execution; having just a vision is no solution”.
5. Failed Experiments? There is a general acceptance that the Drug Courts, an initiative where special courts were set up to divert addicts into treatment rather than prison, has failed. Only 20+ offenders have actually completed the programme, which was launched with some fanfare in the 1990’s. What are the lessons, which can be learned from this? Can the system be re-activated in some more effective format? Should we experiment with even more radical alternatives? If we dispense Methadone for free, why not dispense Heroin (arguably, a less addictive narcotic which has less harmful physical affects over time). Would this be a positive for addicts and also cut the supply from criminal gangs? Should we look at putting a financial incentive in place for people to pare back on their drug use (labeled contingency management and offered in several other countries)?
6. Clashing Ideologies: Fuelling these debates are ideological differences, what can usefully be referred to as the ‘Individual Fault’ versus ‘Societal Fault’ camps. Those who see drug abuse as the outcome of individual weakness often argue a ‘lock them up and throw away the key’ response. Others, more liberal, see the current system as placing the clients in an unequal power position with service providers, want users to set personal goals (some actually wish to reduce their methadone usage and are ignored by doctors) and see the therapeutic relationship with staff as a key factor in effective treatment. “Treatment is a euphemism for methadone maintenance. This social control mechanism of ‘maintenance’ is one where progress is measured in millilitres…it highlights the tyranny of political correctness that pervades addiction treatment. This is yet another example of the sanitization-stigmatisation dichotomy polarizing the field of addiction.” (Rowley 2006). Genuine differences of how the drugs problem is diagnosed and should be tackled not only causes confusion, but it leads to ad hoc, undirected movement. Meanwhile, the addicts continue to queue outside the Amiens Street clinic and the other treatment centres.
Going Forward: The National Drugs Strategy 2009-2016 has a 5-pillar structure including supply-reduction, prevention, treatment, research and information. On face value, it looks like ‘joined up thinking’. But until we have a fundamental debate about both the causes of drug addiction and how services can be implemented, outcomes will remain poor and relapses high. Family therapists use a concept called ‘conflict detouring’ to describe how socially awkward topics are avoided. The effective treatment of drug users in Ireland is an example of conflict detouring at a national level. We need an in-depth debate on how to tackle this scourge. At a time of fiscal austerity, we have to get value for all public money spent. We also have to provide some future hope for the 9,000 addicts who are engaging with the treatment services. Otherwise we will just continue to ‘avoid eye contact’ and step around these groups when we encounter them on the streets.
Paul Mooney PhD.
PS While the opinions expressed are my own, I am hugely grateful to Declan Byrne of the Kilbarrack Coast Community Project (KCCP) for helping me to understand how the current system works. Declan knows the area well, having worked with former addicts over many years. He manages to combine compassion with pragmatism, the two divine things in one person.