Short-term treatment with methadone - the ‘gradual withdrawal’ method as it is sometimes known was, until recently, the norm in many treatment agencies in and around Greater Manchester. Today, the situation has changed in most districts and the majority of users are on long-term prescriptions. James Leigh of ADAPT describes the situation in Bromley, Kent, where the agency doors are still revolving. If gradual withdrawal is the common form of treatment in your area still, why not write in and tell us about it? In our next issue we’ll tell you how poor the research evidence is for this form of treatment and why such a treatment (yet again) runs counter to the Government’s drug strategy.

CYCLES OF ABUSE

The term “treatment cycle” has become common currency within the drug treatment service industry here in London. It is the basis of measuring success - financial as well as clinical. The more clients you process the more “brownie points” and funding you get. A “treatment cycle” at our local clinic can be a short term detox over several months or an in-patient detox at Wickham Park. It all seems wonderful. Large numbers get treated and the Health Authority gets to show X number of positive treatment outcomes in its returns to Whitehall. The only problem is that it is a complete waste of time and money. Dependent drug users are coerced into short-term or into patient detox and when the user (who did not want to detox) reaches the end of the cycle, this is recorded as a successful outcome.

PHASE 1

Let me explain by way of an imaginary example. Should a dependent opiate user eventually be accepted for treatment with oral methadone, he or she will be provided with a prescription which enables them to have a quantity of Methadone linctus dispensed to them daily. It may take a number of weeks to reach this stage. Generally for the user, morning brings with it the necessity of obtaining enough money to buy some illicit heroin - this can be as little as £5 for the recently addicted heroin smoker but will generally be in the region of £15 to £30. This may not be a huge sum for many but to a sick user without even bus fare it can be a substantial amount to acquire, and it has to be done every day - for some users the amounts required may be much greater.

With a regular prescription you, the user, are relieved of all the anxieties and panic associated with the above. If the amount prescribed is suitable for your needs, then the day may be used for more positive pursuits than scoring gear. Very often you are as caught up in the culture of drugs as much as the drugs themselves, and so continue to be involved in buying and using drugs but without the desperation you experienced before. What should you do? You have few (if any) contacts and acquaintances outside of their local drugs culture. It’s a lot to ask of someone to give up all their friends - (sometimes including a brother or two) and to make new ones amongst non-opiate users who have been taught to revile you - as if this were a process akin to changing clothes!

Despite the difficulties, many users do manage to achieve a degree of stability with their drug usage which they may never have experienced before. If the user has a partner, the change in financial priorities often leads to an improvement in their relationship. The stability in drug use is mirrored by stability in other areas of life. The user may begin part or even full-time work - yes, many drug users do work, and pay taxes, contrary to popular belief.

Life is looking the best you can remember it for a long time. But the doubt and uncertainty nag at you constantly. You know this won’t continue.

PHASE 2

Perhaps two months have passed, maybe more, maybe
less. During your weekly appointment at the treatment centre you are informed that the quantity of your daily prescription is to be reduced - with immediate effect. You put up a half-hearted attempt to persuade the drug worker that you are not yet ready to cut down but you don’t expect your argument to be effective and it isn’t. This is the way you both expect it to be.

Life goes on much as before, fortunately you did not have a large habit and you have managed to reduce your intake of extra drugs so that the amount of methadone you receive is almost enough. You sleep a little less well for a week but nothing you cannot handle. Two weeks since your dose was reduced and your drug worker informs you that your dose is to be reduced again, and henceforth will be reduced by a certain amount every fortnight.

Your stomach drops with this news. It’s like a roller coaster ride followed by days of worry and anxiety and many sleepless hours at night. Four weeks later and the reduction in dosage is starting to bite. The problem is that Methadone takes a long time to work it’s way out of your system - much longer than two weeks. So, before you have adapted to the last reduction, the next is upon you. The junk lack, the sickness, is cumulative. - You begin to lose the gains that you made. First to go is work, then the relationship. At first it is the treatment centre that your partner is angry with. Why can’t they see what they are doing? Surely they will understand if you tell them what is happening - won’t they?

You talk to your drug worker and explain that you are not managing at all well. You try to explain the situation as best you can but you never were very good when it came to expressing yourself. You try to ask for the help you need, it’s not something that comes easily to you. “Typical!”, thinks the drug worker, “As soon as you start to reduce the dosage, they all complain and pretend they can’t handle it. These drug users will do all they can to get or to keep as much drugs as possible. Two weeks should be long enough for anyone to acclimatise to the lower dosage.”

Remember, this “drug worker” is a community psychiatric nurse who was working with the elderly a few months ago. He or she may have little or no specific experience in the area of drug treatment, other than a couple of weeks training and the bigotry they pick up as they go. Even so, they are bottom of the hierarchy, and mustn’t question the treatment status quo.

“Others manage well enough when cutting down - some of them on a lot less than you. Why is it only you who can’t manage?,” You know this isn’t true and that there are others, many others, who have had the same difficulties in cutting their dosage. He also knows that it’s untrue. But if you were to say as much, to get into an argument with him about it, it could only end badly. What it comes down to is that he has power over you. You have lost touch with many of your drug using mates and suppliers. The drug scene is very dynamic and changes rapidly and you have been left behind. You can feel yourself getting angry.

“I want to see the doctor”, you say. He doesn’t like this at all. If he allows it, he’d be a failure. He would be showing that he’s unable to defend the consultant’s valuable time and that he can’t manage alone. “What for?” You know he has no intention of letting you get anywhere near the doctor. “The consultant is on site for one-and-a-half days a week only and can’t possibly see everyone.” You know that half-a-day of the consultant’s time is spent talking with the unit’s manager and others. Leaving only one day in which patients can be seen. As a new patient could be in there for two hours or more and, much time is spent either on the telephone or on other tasks, two or three patients a week may get to see her. Some weeks she doesn’t see anyone. “ I really do want to see the doctor” You may be in your late thirties but you feel a little foolish and childlike, powerless and asking for something you know you aren’t going to get.

“The doctor” he say’s sternly and pauses for effect “...will tell you exactly what I have told you”.
“Of course, if you don’t want this...” he removes a single small sheet of paper from the topmost file on his desk, “...you don’t have to take it”. He waves the prescription back and forth a few times. He smiles and you know he is taking the piss out of you but there is nothing you can do. Your entire upbringing screams from inside of you to punch him on the nose. Don’t let him take the piss, don’t let him belittle you like this.

“Of course, the doctor will not be here again until next week and no one else here has the power to sign a new prescription.” That’s the deal. Take the script for the reduced amount or go without for five or six days. Of course you take the script and leave feeling mean and misused. “I should have hit him”, you think to yourself. Feelings of powerlessness and failure go through you. You pick up your methadone for the day. You know it isn’t going to be enough and that you’ll have to score anyway - so you might as well score now.

What luck! Not only have you got your heroin but you have arranged a deal with another user who wants to buy some methadone regularly for a while. The bloke’s idea is to accumulate enough linctus to go away to Cornwall and do a cure on his own. His mate knows someone with a cottage he can borrow for a month or two. No running water, no gas or electricity. The few pounds a day earned by selling the linctus will be put toward the price of the smack, not a lot but every little helps. Back on the heroin, back in the drugs culture, young wife - ever more alienated from him, not a lot is different from a few months ago - other than you’re a little angrier, a lot more cynical.

PHASE 3

A few weeks later you’re told that heroin and amphetamine have been found in your urine and that if you don’t produce a clean urine (methadone only sample) treatment will be withdrawn. You explain your difficulties in reducing your dose, say you don’t mind cutting down but could they make it every four weeks instead of every two? The answer is “no”. After all, everyone else manages ok...etc. and it is clinic policy... etc etc. You eventually reach the point in treatment where you receive your last prescription, now for a tiny amount of methadone only. At the end of this week your treatment cycle will have ended. You pick up the small amount of methadone. You’ll put it with the other bits you’ve saved until there is a useable or saleable amount. You are still, and have been, using illicit heroin. But after threats to terminate your treatment you began substituting the urine of a friend who only uses methadone. Thus you reach the end of your treatment cycle without any more incidents of heroin in your urine. Didn’t you do well?

 PHASE 4

Your young wife, pregnant, has, of course, left you. The telephone has long been disconnected, (no matter you can always lay your hands on a stolen mobile phone - useful for a few days) and you are under threat of eviction. Two weeks later you go back to the clinic and ask to be taken on the methadone treatment again as you have relapsed.
“Come back in eight weeks time “ you’re told, “...we can’t take you back on until then”.
“Why not? I need help now!”
“Because it’s against the rules, that’s why not”

 RETURN TO PHASE 1

Eight weeks later
“Hi, I was on the methadone before but I relapsed. Can you take me back on? You know, back on the methadone programme?”
“I don’t see why not, now, come with me and I’ll take your details...... “

 THE REVOLVING DOOR

We have many members who have been through, and are still going through, treatment cycle after treatment cycle. One girl has been through 14 treatment cycles in a few years.
It is obvious to all that it is the same individuals with the same problem, being given the same treatment. However due to the long interval between cycles, where the patient gets no care, treatment or support, each new cycle is treated as though it is a completely different event, problem or person. “We have delivered 500 successful treatment cycles” they say, neglecting to mention that they have only dealt with 45 people and that most of these are still either in a current cycle or are expected to turn up again in a few weeks to begin a new cycle.

 James Leigh