Jude
On a list whose primary aim is the discussion of therapeutic community approaches, I think you can expect to find a little antipathy about the over-whelming use of substitute prescribing in Europe. And this is the point. It's not that people are angrily anti-methadone but that what we are seeing is one - highly medicalised - approach to addiction dominating the field. In Scotland, over 95% of people presenting for treatment come away with a methadone prescription. A recent EMCDDA report indicated that this was pretty much true for the whole of Europe which makes those government strategic reports that say "no one size fits all" and that we need a "range of treatment options", look a little lame.
The problem is that when one treatment approach (whatever that approach might be) becomes that dominant (over 90% of the "market") it will inevitably have the effect of marginalising other approaches. TESCO (or Wallmart/Carrefour for US/European list-members) does not mean to close down your small local independent trader (neccessarily) but it does just that - just by being there.
Now, I hear what you're saying about people in long-term substitute prescribing becoming stabilised and eventually opting for detox. But that may be just your practice. The research evidence suggests that there may be a tipping point and that once people have passed that point, they become increasingly unlikely to wish to achieve abstinence.
In fact, the situation is actually more serious than that. Firstly, the psycho-social elements of MMT (the elements which are supposed to encourage individuals stabilised on methadone to review their need to make changes) are often minimalised or non-existent. In fact in two studies undertaken by David Best in the West Midlands showed that active therapeutic interaction may be less than 10% of any session.
Secondly, the political pressure to recruit and retain in treatment as many drug users as possible (overwhelmingly those Prochaska and DiClimente would have classified as "pre-contemplative") without serious attention given to peoples' routes out of treatment, has incrementally reduced the amount of time available for constructive interaction within the system. Moreover, MMT tends to utilise appointment-based individual treatment (in an attempt to make sessions appear normalised and much like any other health-based consultation) and this means that individuals enrolled in an MMT programme will rarely see other drug users who are further down the recovery road - in TC terms, the approach does not actively make use of role-modelling.
Thirdly, worse than that, the current dominance of MMT has resulted in a huge proportion of the drug-treatment workforce having never seen real recovery (or undertaken much recovery-oriented intervention work - see above, the Best studies). When I was part of the team evaluating Scotland's pilot drug courts, I regularly interviewed senior practitioners who made it quite clear that they did not think that abstinence was possible or desirable (because it was too risky).
The net result of this increasing medicalisation of addiction treatment over the past two decades has been to mainstream an approach to addiction which is highly biologically based (Jellinek's old disease model) and this, in itself has resulted in some MMT practitioners arguing that changes in the brain chemistry of addicted individuals mean that MMT should not simply be seen as an interim stabilisation intervention, but a permanent resolution of their (largely biological) problems. Thus, MMT is seen as pragmatic, radical and humane whereas recovery-oriented services such as TCs are increasingly regarded as self-delusory and unattainable dreams promoted by well-meaning but dangerously naive amateurs - precisely the sociological position we experienced in the late 1960s and early 1970s when TCs first challenged the medical orthodoxy and began to demonstrate that recovery was possible within a tightly controlled self-help environment. The tragedy now is that the return to this position simply ignores 40 years of evidence that TCs really do work!
One final thing. My only contention with Henrik's response to your mail is that TCs (and presumably other residential rehabilitation options) are more expensive than MMT. In fact, my recent work seems to show that the evidence for this is not as robust as we might think. In fact economic comparative studies have been fairly fatally flawed - either they have used a timeframe which would disadvantage long-term rehabilitative interventions or failed to compare like with like or assumed that the populations were exactly the same (your point about the different addiction groups). There is good reason to believe that when these issues are taken into account, residential rehabilitation (and particularly TCs) are fiscally comparable.
Rowdy Yates
Senior Research Fellow
Scottish Addiction Studies
Dept. of Applied Social Science
University of Stirling
Scotland
T: +44 (0) 1786-467737
F: +44 (0) 1786-466299
W: http://www.dass.stir.ac.uk/sections/showsection.php?id=4 (home)
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From: Therapeutic Communities [[log in to unmask]] On Behalf Of Jude [[log in to unmask]]
Sent: 01 August 2009 14:15
To: [log in to unmask]
Subject: Re: [EFTC] Methadone and the Damage(??) Done
Hi,
I think i may well be a "Methadone Mullah", having prescribed it for thirty years as an inner city GP.
I find the high emotion involved in what seems to be an "anti-methadone" as much as a "pro-abstinence" debate, very surprising.
I think back 30 years, to when my GP Trainer told me that people who use drugs to excess can be divided into " those who do it to get 'high' and those who do it to get 'by' " .
Those in the first group who find to their surprise, that they are waking up shivering until they take heroin each morning, will generally organise their own detox , with the help of family and friends, and most will of course succeed and get on with their lives, and some will write newspaper articles about their escape from heroin.
For those in the second group, heroin is not their only problem, and they will not generally find it so simple, because when the cushion of heroin is taken away, the pain of their lives will return. They of course need a lot more psycho social help, but also will need time to pass while they build other ways to cope.
This is the group helped by methadone or buprenorphine prescribed to replace the heroin, as unlike heroin, these are both long acting medications, which last more than 24 hours, and so allow the person to wake in the morning without shivering and shaking, to raise their heads from the immediate physical daily need for heroin , while they regain their physical, social and psychological strength and well being.
Eventually it is my experience that in many cases these people will feel able to plan a life without opiates. i have many patients who have taken ten or twenty years to reach this level of strength, but eventually they are delighted to escape from opiates (including methadone ) and get on with their lives. I certainly do my very best encourage people registered at my surgery on every occasion I see them, to continue with life plans of every kind , while i continue to prescribe the maintenance methadone which gives them the time and space and strength to do that. A daily heroin habit is of course a full time job, as funding, buying and using it generally leaves no room for anything else.
Some of the damaged and struggling second group described above will need and will eventually benefit from the kind of help only offered within a "therapeutic community", and in the end that will of course be their route to a life without heroin However most of the hundreds of thousands of people (in the UK alone) who find themselves dependent on heroin do not want or need to leave their own communities in order to get on with their lives, but they may well benefit from an interim period taking methadone . i cannot see why this is thought to be so bad.
And then there is also the research evidence .....
all the best
Judith Yates
GP Birmingham UK.
On 28 Jul 2009, at 10:08, Henrik Thiesen wrote:
Hi Rowdy
You´re so right - calling methadone treatment "endorphine replacement" is in my opinion an absolutely faulty idea. In my opinion methadone or buprenorphine (or any other long-term opioid) can be used to give people addicted to opioids a break but over time things fall apart if nothing else is introduced. I have here in Denmark seen miserable "patients" on 3-400 mg´s of "endorphine replacement" so the replacement idea isn´t valid in my opinion.
The use of methadone has, when given freely and liberally as it is in my country, a tendency to make the system sloppy. Problems are taken care of with more methadone ("because his only problem is lack of endorphines") and benzoes and lack of systematic health and social care is covered in more methadone. The result often is devastating.
I have for 5 years been treating people who are "out of the system" which may mean that they get lots of methadone but no help beside that - and we can see that methadone helps a lot in the acute phase but after a while it is just another drug for many. I showed in my initial report on street-homeless drug users that the people with the most severe social- and health-problems were using just as many drugs if they were on methadone or not (and the Danish system does not exclude people who use drugs beside methadone so the endorphine replacement idea seems not to be valid here)
If methadone management were a true treatment - it would be replaced by opioid rotation as we see it in pain management and the surrounding psycho - social care would be upgraded. As it is now I it may end up with a system that tries to force metadone on non-opioid addicted people as I have seen it at several occations - simply because they don´t know what else to do.
Methadone is a drug among others in a complex treatment of a complex situation - it is not the treatment, except for those few that responds to methadone as an antidepressant - but they only need very little (5-10mg methadone or 2mg buprenorphine - which might be given as a patch)
A new report from our center for durg research underlines the faulty system - most users on long-term methadone feels lost in a system which has lost interest in them - as a frontline treatment provider we also see it as a lowered system-interest and lowered financial support for drug free treatment.
HenrikT (reviewer of the Danish Medicines List, Opioids and benzodiazepines)
http://www.hjemlosesundhed.dk/?English
----- Original Message -----
From: Rowdy Yates<mailto:[log in to unmask]>
To: [log in to unmask]<mailto:[log in to unmask]>
Sent: Saturday, July 25, 2009 12:32 PM
Subject: Re: [EFTC] Methadone and the Damage Done
Souraya
Hello - hope things are good in Lebanon. As for Neuberger's response. This is no big surprise. As far as I can see, any time that a study produces even a partially critical result on MMT some methadone mullah steps up to say (a) this is a flawed study or (b) the sample is atypical or (c) it's the practitioners' fault for not giving the "patients" enough methadone!
Draw your own conclusions on these desperate defences at a time when it would appear that the addiction business may again be slipping from the grip of the medical oligarchy!!
Rowdy Yates
Senior Research Fellow
Scottish Addiction Studies
University of Stirling
http://www.dass.stir.ac.uk/sections/showsection.php?id=4
http://www.drugslibrary.stir.ac.uk
On 25 Jul 2009, at 10:05, "souraya frem" <[log in to unmask]<mailto:[log in to unmask]>> wrote:
hello roudy
I just take that chance to send you my warmest regards to you and everyone on the list :)
just read the article you send and also had a look on the readers comment
any clarification on that matter
just in order to have a clear unswer regarding methadone definition & effectiveness
quoting for the reader's comment:
"J.R. Neuberger | 21 Jul 09
These "results" fly in the face of decades of research in the US and point up no lacking in the effectiveness of methadone treatment, but instead illustrate the results attained when patients are chronically UNDERDOSED. At the proper dosage, methadone treatment results in longevity AND reduced illicit opiod usage. This study points up a serious flaw in how the treatment is being dispensed in the region specified and nothing more. Also, methadone is endorphin REPLACEMENT therapy and is a substitute for nothing. The use of this terminology itself points up possible prejudices on the part of the researchers of this piece. "Substitution" implies one drug being replaced with another. Methadone is, instead, a medical treatment for a medical condition--that condition being a damaged endorphin system in the brain which this therapy normalizes. It is endorphin replacement therapy and is both safe and effective at the proper daily dose. Kind regards, J.R. Neuberger National Alliance for Medication Assisted Recovery"
all the best
souraya
On Tue, Jul 21, 2009 at 11:22 AM, Rowdy Yates <<mailto:[log in to unmask]>[log in to unmask]<mailto:[log in to unmask]>> wrote:
This isn’t really about TCs but it is an interesting study showing that whilst long-term prescribing of methadone reduces mortality risks, it also increases the likelihood of continued injecting:
<http://www.pulsetoday.co.uk/story.asp?sectioncode=23&storycode=4123296&c=1>http://www.pulsetoday.co.uk/story.asp?sectioncode=23&storycode=4123296&c=1
Rowdy Yates
Senior Research Fellow
Scottish Addiction Studies
Sociology, Social Policy & Criminology Section
Department of Applied Social Science
University of Stirling
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<http://www.drugslibrary.stir.ac.uk/> http://www.drugslibrary.stir.ac.uk (library)
T: +44(0)1786 – 467737
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Academic Excellence at the Heart of Scotland.
The University of Stirling is a charity registered in Scotland, number SC 011159.
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Academic Excellence at the Heart of Scotland.
The University of Stirling is a charity registered in Scotland, number SC 011159.
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Academic Excellence at the Heart of Scotland.
The University of Stirling is a charity registered in Scotland,
number SC 011159.
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