In recent times there has been something of a step-change in the UK Government’s attitude to the use of methadone in the treatment of heroin addiction. The result has been a new emphasis on ‘recovery’, with the term being used to convey the transition to a completely ‘drug-free’ lifestyle. Many drug services in the UK are now pressurizing their clients to reduce rapidly and to come off opiates altogether, rather than offering long term or indefinite maintenance on prescribed methadone, which was often their previous approach.

The new situation has involved the appearance of two opposing factions. One is the recovery faction, arguing that methadone treatment involves, fundamentally, the substitution of one addiction for another. The more reasonable adherents of this point of view accept that methadone has value, but see it as a short term tool to be used sparingly. The more extreme belief is that methadone has no place in drug treatment, for anybody.

The opposing position holds that methadone is a much more valuable therapeutic than such views suggest, and stresses the large scientific evidence base in support of its use. This approach tends to favour the maintenance method, which, at its strongest, understands methadone as a sort of ‘insulin’ that alleviates the ‘diabetes’ of addiction, metaphorically speaking. The substitution of street heroin by methadone enables the patient or client to function in comfort, without cravings and withdrawal symptoms, thereby freeing them up from dependence on the black market, with all of its criminal and health related dangers.

To state the two sets of positions in this way is a little crude, but gives a basic outline of what has, both in the UK and in many other countries, become a very heated debate. The intention here is to explore the ground that exists outside this conflicting sets of positions. To those who know nothing of addiction and its treatment, it might seem odd that such a battle is being fought over a simple therapeutic option. The fact is that this struggle reflects the heated and morally saturated field of drug policy, where fundamentally opposing beliefs about the use and misuse of drugs underpin the views of those in the debate. In ‘ordinary’ medicine, one of the basic tenets is that therapy and treatments must be tailored to the needs of the individual patient. This, of course, should also be the case with drug treatment: a ‘one size fits all’ approach to therapeutics is unlikely to produce the best results for the patient. And this is what we find.

Case: Paving the Road to Hell

I know from personal experience of a case where an individual- let’s call him John- has been on methadone for several years, has stabilised his life, established a decent diet and recovered his health; he stopped injecting, he abandoned the petty crimes that had funded his heroin habit, and he found part-time employment. John’s life had been turned around and he was feeling good about it for the first time in a decade. Then a new senior doctor arrived at his treatment service, a doctor who believed that methadone was little better than street heroin- just another addiction, this time sponsored by the state. John was given a week’s notice that his dose was going to be reduced to zero over the next few months. When John protested, he was told that treatment should be ‘challenging’, that he had done well but now was the time to push on an reach full abstinence, not just from street heroin but from all drugs.

John was not at all happy about this prospect, nor about the fact that his own feelings and wishes were not being taken into account. But he was powerless to prevent it, and tried to make the best of this enforced reduction in his dose. However, he quickly found that he could not cope with the discomfort involved (it was the psychological aspects of it that was most problematic), and that he was craving heroin again for the first time in years. He was given counselling to help, but it didn’t; he felt that the counsellor just did not understand what he was going through. The end of this tale is a predictable one. Soon John was using street heroin again, and caught up in the old cycle of scoring, using, getting the money to score (by shoplifting), using, scoring....ad nauseum. This was not the sort of recovery his doctor had had in mind, but it was what happened.

Case: Sledgehammers Cracking Nuts

Let’s consider another cautionary tale: the story of Jill. Jill was in her 30s, depressed about the state of her life, the place she was living in, her boring job (which she hated), the routine loneliness she endured. By chance, she discovered that using over-the-counter codeine medications helped her feel less stressed about all this stuff. At first, she began using a little at weekends. Soon it became a daily ritual; she bought codeine-based cough medicine, she bought the pills from pharmacies (for headache, toothache, the flu, whatever small illness she could think of at the time to persuade the pharmacist that she needed it). She had to go further and further in search of new pharmacies as the local ones got to know her, and to suspect that Jill lived with a secret addiction. In the end, she realised that this solution had turned into a bit of a problem, and, after much hesitation—for she was ‘an ordinary woman, not a junkie’—she approached her local drug treatment service. Here, having briefly seen an inexperienced drugs worker and a hard-pressed doctor who believed in methadone maintenance, she was given a methadone prescription; her tiny codeine dependence was replaced by a hefty methadone dependence, which she had to pick up daily and drink at the pharmacy, where a neighbour saw her. Soon it was common knowledge on her council estate that Jill was an addict. Her depression plummeted to new depths and her life disintegrated. Her consultant had meant well. But once again, the results of the intervention were disastrous.

When is a medicine more than a medicine?

The reason that these cases provide us with such unhappy narratives is that the prescribing was inappropriate for the individuals concerned. While John had benefited from his methadone script, and should have been allowed to stay on it until he felt ready and able to come off—however long it took—Jill did not need methadone at all; she should have been offered support and advice, and helped to taper down from the low codeine dose, before addressing the unhappiness that she sought to relieve through self-medication. The problem is that the conflicted nature of drug treatment tends to make people opt for a universal response (a one size fits all intervention), which is born out of a sense of the wider ethical and political commitment that apparently underlies it.

This situation has been made worse in the UK because treatment has become entangled with party politics and with the eternal battle between the two major parliamentary parties. The last government was a Labour one, and it did much to improve and extend drug treatment in Britain. This remains true despite the fact that the intervention itself is sometimes clumsily and inappropriately handled. Its most important impact was to make the use of methadone maintenance politically respectable. The current government is a coalition dominated by the Conservatives, who have seized upon a populist reaction against methadone and embraced what is known here as ‘the recovery movement’, which is by and large anti-substitution treatment, with some of its proponents holding extreme views on the topic. This government, therefore, sees methadone as part of the Labour party’s drive to make people dependent on drugs doled out by the state. The question of whether and when to use methadone in addiction treatment has become bound up with ancient (and probably endless) political war-making over questions of state intervention, personal responsibility, the role of ‘experts’ in government, and a host of related and unanswerable metaphysics. From the point of view of the humble patient, this is not a positive development.

It means that when physicians prescribe methadone, they may feel that they are at the same time prescribing the intervention of the ‘nanny state’, chemical slavery, the abdication of personal responsibility, the interference of mad professors in affairs that are best left to ‘ordinary people’ with ‘common sense’, and probably the legalisation of all drugs into the bargain. The doctor who gives his patient a shot of amoxicillin is fortunate indeed in being free from the burden of such momentous baggage. One can only hope that the relatively simple practice of providing medical care suited to the individual needs and wishes of the patient will eventually prevail over these strictly ideological commitments. If we are, as a society, going to deal with problems related to drug use within the terms of a medical model, then let’s do it properly. The first step involves keeping the heavy hand of the politician out of the consulting room.