Crutch or cure? The realities of methadone treatment

June 9, 2010

The Tories’ actions in the run up to the election showed a worrying conviction that methadone is a short term solution to addiction. One option they appear to be considering is to encourage opioid addicts to seek “cure” rather than continued treatment, achieved by limiting the duration of methadone treatment, say to 6 weeks. This ambition would be both scientifically inaccurate and economically insane. It is based on a discredited view of addiction being a transient single event equivalent to moral lapse that can be cured – in medical terms the equivalent of a fractured bone or a chest infection.  All medical evidence in the past 40 years has supported the centuries old view of addicts themselves that is incorporated in the Alcoholics Anonymous axiom – once an addict always an addict.  This doesn’t mean that drug or alcohol use is inevitable, merely that the addiction reflects both a personal vulnerability and a learned behaviour so that once experienced there is no “resetting” back to normal: experience can’t be erased! The risk of relapse is always present and most people will experience more than one episode of drug misuse during their life.  Addiction is best conceptualised as a chronic recurring illness such as diabetes and asthma where life stresses and other factors predispose to relapse so ongoing prophylactic treatment is required. Longitudinal studies of many addictions show that the outcome for long-term treatment is similar to that for these other enduring illnesses.

Even if you deny the medical model of addiction, the economic evidence also strongly supports the value of maintenance methadone treatment with multiple studies over the past 50 years proves that enduring treatment with this heroin substitute leads to reduced deaths and other medical illnesses and less crime both acquisitive and violent. For every unit of investment in methadone, three are saved from these other sources. It seems likely that similar values obtain for other heroin maintenance treatments such as buprenorphine, and for treatments of other addictions e.g. varenicline in smokers, acamprosate and naltrexone for alcoholics. This does not mean that abstinence treatments should not be offered or that psychological interventions have no value, rather if these don’t work or are unacceptable to the addict then maintenance should be allowed.

It seems perverse that the UK government might be considering reverting to a primitive discredited moral model of addiction when the USA – previously the bastion of this approach – has recently appointed Tom McLelland to the role of deputy director of drug policy. Tom’s research played a major role in the medical model of addiction gaining acceptance and will play an increasingly important place in US policy.

The Conservatives see residential rehabilitation as the alternative to methadone. It certainly may be for a proportion of (although not all) addicts. However, the costs involved in residential rehabilitation are significantly higher than methadone treatment. Whether the Conservatives prove willing to fund such treatment, particularly in an era of austerity within the public sector, remains to be seen. Methadone treatment may yet survive, if only for reasons of financial expediency.

McLleland AT Lewis DC O’Brien CP, Kleber HD  (2000) Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcome evaluations J American Medical Association 284,1689-1695 doi:10.1001/jama.284.13.1689


21 Responses to “Crutch or cure? The realities of methadone treatment”

  1. CommunityCriminal Says:

    It will never work, people lost to chemical slavery need more than 6 weeks of methadone they need more than a quick fix.

    An addict needs to be stabilized before any work with them can start, Our local area is full of such chaotic people, life gets no better for them on the methadone treatments they just go around in circles until they break the program ‘use’ get ‘tested’ and get kicked of the course.

    What is called for is treatment with real heroin god knows there is enough of it pouring out of Afghanistan into Russia and other boarder countries 2.5 million addicts in Russia because of our war on drugs in the UK.

    Control the lot before they control us like we see in Mexico and Coastal Italy/West Africa

    Id like to ask my brother how all his different treatments went which worked the best but we lost him 8 years ago to a lifetime of heroin use so the treatment cant be that good.

    Its just like an insane roundabout were addicts are talked about but very rarely helped into long term support which is what they need.

    If they do get this sort of thing of the ground I can tell you now after many years dealing with community drug problems we will see more crime more illness and more death. with only the light users ever getting out of the system of abuse.

    Take an addict right out of their current life and never return them to it is an immediate answer, after all even though they may get clean who have they got to return to once treated..? family ? nope the same group of people because they look and act like them through Th debilitating actions of long term heroin use on the motor responses(that slow sluggish talk and action even recovered addict have) The rest of the people around just see an addict whom remains untrusted and unwanted at all costs, they know the actions of such people in their communities so they remain alienated with only downwards to go back to the life and the friends they have and can to some point rely upon.

  2. Wendy Says:

    To say Residential rehab is more expensive than methadone is not helpful for people considering their options. There is little transparency on costs of methadone for example one has to calculate in the cost of production, drug worker time, prescriber Dr time, pharmasists costs etc. Residentail rehab has one cost which covers treament, board and lodgings in a safe, clean environment. To many times we have seen Methadone being used instead of enabling people with serious additicon problems access to rehab. Recovery should be about the person’s needs and choice. It is not unusual for us to receive a referal from someone who has been prescribed methadone for 5 yaers + without ever having been offered rehab. Our treatment programme is 12 months with a comprehansive Aftercare post discharge. People leave the Ley Community drug & alcohol free and enter full-time employment and independent living. No longer in treatment. Contributing to mainstream society. This is cost effective.

  3. Evaluator Says:

    Wendy – in the interests of making fair and transparent comparisons, (a) what is the unit cost of 12 months treatment in the Ley Community (b) what percentage of people who start treatment complete the 12 months, and (c) what percentage of people who start treatment are in full time employment at 12 months?

  4. Matthew Says:

    Did anyone actually use the figure of 6 weeks in the run up to the election? Not sure I heard that.

    Worth bearing in mind that for at least a year the current model of opiate substitute prescribing treatment was being directed towards “12 weeks”, with “12 week retention in treatment” being the flavour of the month target. This has now been dropped in favour of a focus on “planned exits”.

    I personally find all these proxy targets rather repulsive.

    In my area the completion rate of residential rehab is significantly higher than that of substitute prescribing. This is because:
    1. You have to try, or be unsuitable for, community interventions before you reach residential rehab
    2.The majority of chaotic people with low motivation to change access substitute prescribing.

    What this doesn’t tell me is how many of the people that became drug free through rehab were able to stay alive long enough to get there through substitute prescribing.

  5. Steve Rolles Says:

    Just to note that, rather dissapointly, McClellan, has already announced his resignation from the ONDCP, claiming that ‘I’m just ill-suited to government work’. Make of that comment what you will.

  6. Anneliese Smyth Says:

    I am a addict and have been for 10 years. Methadone is a stabliser and only a short term solution. It is very difficult to come off completely and I myself have been on it for 8 years ( on and off ) and my partner for 10 years ( without a break ) the answer long term is to work closely with the person and give counselling and find the ROOT of the problem and the reason WHY they need to take Heroin in the first place, and 9 times out of 10 the reason will be low self confidence and esteem issues and /or something has happened in their past that has NOT been dealt with and has remained unresolved and only then they can begin to look at a drug free live.

  7. Astonished Says:

    I actually thought that this was a joke or some sort of hoax when I read it. There might well be ‘evidence’ that methadone reduces deaths and even crime but there is no shortage of walking talking ‘evidence’ on our streets today that demonstrate that methadone condemns people to a lifetime of misery.

    The majority of those people who are prescribed methadone in NE Scotland (and almost certainly in other areas too) are not complying with their treatment anyway and continue to use heroin and diazepam.

    The entire notion that a drug problem can successfully be treated with a drug is absurd in any case. It really is about time that the “experts” like Dr Nutt got out there and saw the scale of human misery that the failure of UK drug treatment policy has caused over the last 40 years. Areas of entire cities and generations of families have been abandoned to live their lives in squalor thanks to reckless methadone prescribing.

    In many services ‘stabilising’ the client on methadone is a successful treatment outcome, and unfortunately, for many patients this becomes the accepted ‘goal’. And that’s it, treatment completed……

    If methadone really is reducing crime it is surprising to see that the evidence shows that the prison population are being prescribed methadone at all time record levels, discuss…

    What is very clear is that services, particularly the medical based ones, have very little aspiration for their patients, it’s just a case of writing a prescription and claiming another positive outcome.

    I personally feel that if we are ever going to see change for the better we need to get rid of the establishment, the NTA, ACDMU, ADATs etc, Mr Osbourne could save a few million ££’s binning that lot and directing the cash towards frontline services. We don’t need more research, we don’t need more policies and procedures, we most certainly don’t need more conferences where the ‘experts’ all go and drink too much whilst debating the evils of addiction amongst the plebs.

    We need change, drug and alcohol treatment in the UK has been a miserable (but lucrative for the ‘experts’) failure for several decades, I am no tory but if they are going to have a look at what really is going on I wish them all the best.

  8. Mr B Says:

    With the amount of real heroin being seized in the UK why can’t they just treat addicts with that instead of the NHS having to purchase synthetic alternatives.

    And there’s no way that 6 weeks is long enough to ween someone off heroin – it will vary by individual and the level of the addiction.

  9. Wendy Says:

    a) what is the unit cost of 12 months treatment in the Ley Community £24,700 (b) what percentage of people who start treatment complete the 12 months, %60 and (c) what percentage of people who start treatment are in full time employment at 12 months? %100 complete into full-time employment at or just after 12 months depending on job market. People stay living on site for their first 3 months in employment as part of our Aftercare

  10. HDjemil Says:

    Can I challenge the view in David Nutt’s blog above that,

    “All medical evidence in the past 40 years has supported the centuries old view of addicts themselves that is incorporated in the Alcoholics Anonymous axiom – once an addict always an addict.”

    500 years ago there was a centuries old view that the world was flat and until Columbus all evidence confirmed this – presumably sponsored by map makers with a vested interest!!

    If you read AA history you will see the organisation was birthed in-spite of and not because of the clinical services of the day (with the exception of a few enlightened clinicians). Clinicians generally were at a loss as to what to do and in effect were managing the decline of their patients (managing the harm of alcohol use) and they saw the condition as untreatable. AA, founded as one addict worked with another to gain sobriety, was an astonishing phenomenon to the clinicians of the time.

    It is therefore not surprising that David Nutt and clinicians of his ilk are repeating the same mistakes today, classifying drug addiction a chronic recurring illness / or chronic relapsing condition and trying to manage the decline of the health of their patients

    I also work in the drug treatment field (and am my self a recovered addict) and while I would agree we need good clinical services I would welcome a review of the current system which has grown like topsy and traps addicts rather than helping them to move forward into independent living, an entirely reasonable proposition among drug users but beyond the pale it seems for most hard core prescribers.

    In my experience of working in and commissioning services, (prescribing services) have grown in line with short term govt. targets, and not in line with evidence, as Nutt suggests. DAATs buy services in line with NTA guidance and direction. Those services are procured with targets in mind to secure future funding and every year daats deliver needs assessments to justify this position, again in line with NTA guidance and expectations. Wo-be-tide the daat whose needs assessment flags up a need that is at odds with national guidance and targets – no future funding would be the effect

    The tier 3 prescribing bill has got so huge that a typical daat, spending say £3 – 5 million on the local treatment economy will spend 80 to 90% of resources on services that prevent harm or prescribe. Of the remainder only 1 or 2 percent is spent on rehabilitation services and as a result very few people are getting better and more and more addicts are being trapped in state sponsored addiction.

    To not see or refuse to see this is akin to telling the emperor how wonderful his imaginary clothes are, its crazy. A spell in residential rehab, say 6 – 8 months with some aftercare support is more cost effective than years on methadone and is much better for the person concerned, their family and society and the sooner we rebalance our treatment system the better.

    In practice, there will be no knew money to do this and there may be less money overall but it still needs to be done. We need to divert resources from managing the decline in health of our patients to supporting services that help them to get better.

  11. saalders Says:

    Addiction is an illness like diabetes…hmmm, i think not. Don’t take heroin/methadone you live, don’t take insulin you die. Therefore the argument is based upon flawed logic.

    Luckliy people in the UK can have access to fantasic free treatment options, but the time has come for the addict to engage and make changes within a system that must provide viable, sustained opportunities to exit addiction. Within a system like that it is reasonable for the addict to have a responsibility to maintain engagement with services and for services to work with the addict.

    We don’t have this sort of system across the country granted, but should be working towards it. Falling back on methadone maintenance and maintaining the current indifference and flawed perceptions to addiction costs the nation billions, let alone the human cost.

    It’s time to move on and away from the old stand point delivered in the blog and actually make treatment work. The past ten years have been spent taking away personal responsibility this must be reversed in my opinion. we owe it to ourselves, the country and those trapped within the system of indifference!

  12. CommunityCriminal Says:

    @11 addiction is an illness its the final manifestation of a coping method one which happens with both legal and illegal drugs.

    Addiction is an illness of the mind not the body the way diabetes is so it seems there is no flaw in the argument or the logic within the argument. Why is it people refuse to see the broken mind behind the person, a broken foundation within the mind is as bad as cancer, eating its way through your thoughts feelings effecting every outcome within life.

    Ask any doctor the best way to treat a broken mind.. NUMB IT WITH DRUGS. hide the person away from both themselves and society, ask a doctor how to fix an addict…NUMB THEM WITH DRUGS….
    Doctors and dealers are much the same they both fix your problems and create new ones.

    Wendy fantastic work and I’m damn sure that the cost in policing and damage to communities greatly outstrips the price of a 12 month treatment for the average addict within the same time frame. Id love to see more centres like yours one in every community across the UK.

  13. saalders Says:

    @12 the point I was making was that addiction isn’t a physical illness like diabetes and therefore doesn’t require the same sort of long term medical drug based intervention. The diabetes standpoint has been used to change the emphasis within the policy direction of treatment and driven us to the parlous state we are now in. Under the flawed logic that methadone saves lives, stops crime and is in some way better for the addict. Using long term drugs to ‘cure’ addiction as we currently do is flawed.

    I agree with you that the medical model response isn’t working and that ‘treatment’ must enable the person to repair the damage within themselves as well as the external damage.

    I also agree that fixing the psychological ‘foundation’ is fundamental to sucessful recovery. Methadone or somesuch, in my opinion, has a short term role in this but not in isolation from other, more pertinent, psychological interventions and deffinitely not long term i.e. more than a few months.

    Only a few places have been able to weather the particular storm of medical model failure over the past decade, so lets hope we are able to save those like Wendy’s and others and move into a system that provides real, sustained exit options.

  14. Szwagier Says:

    “All medical evidence in the past 40 years has supported the centuries old view of addicts themselves that is incorporated in the Alcoholics Anonymous axiom – once an addict always an addict.”

    500 years ago there was a centuries old view that the world was flat and until Columbus all evidence confirmed this – presumably sponsored by map makers with a vested interest!!

    Attempting to compare “40 years of medical evidence” with the folk beliefs of Western Europeans half a century ago is comparing quantum physics with “apples fall because the Earth sucks them down”. In fact, the concept of the spherical Earth has been around for 27 centuries that we know of.

    Clearly for many of the commenters here, medical evidence is to be discarded and replaced with personal anecdote. That’s not research, that’s fairytales.

  15. CommunityCriminal Says:

    David what do you make of the Lords refusal to follow the actions of the UN in recommending that drug use should no longer be criminalised and that a treatment is the way forward with decriminalisation for personal use.

  16. Kenneth Eckersley Says:

    The National Audit Office et al tells us that it costs the taxpayer £49,000 per year to supply and maintain each prescription methadone user “IN treatment”, that only 3% ever quit opiate / opiod usage, and that they have an average lifespan of 40 years as a methadone user.

    For £49,000 addiction recovery residential training can train and help 3 (three) users of practically any sort of addictive substance to return to the lasting state of relaxed abstinence into which 99% of our population is born.

    Over 10 years, that delivers a saving per addict of £475,000 – then multiply that by the official number of problem addicts including those on methadone . . . . BILLIONS !

    However, there is a snag with addiction recovery training. Because it trains addicts to cure themselves, they stop using methadone (and Subutex and Naltrexone and Antabuse, etc.) and thus rob pharmaceutical companies of large numbers of daily prescription consumers – paid for by all of us.

    So until there can be found a way for the psycho-pharms to profit from training addicts to comfortably abstain for life, they will continue to attack successful residential self-help abstinence training.

  17. admin Says:

    David Nutt:
    Just to clarify, I am not in any sense an enthusiast for methadone over any other form of evidence-based treatment and I know that there are particular problems in coming off it, into which much more research is necessary. However, it does have a very good evidence base that should not be dismissed for party political reasons. The concept of maintenance treatments should be accepted as a valid alternative to abstinence for those who want it.

  18. admin Says:

    David Nutt:
    5. Steve – Thanks for the information re Tom McLellan’s resignation which I hadn’t heard. Presumably, he had similar problems getting US authorities to deal with evidence as I had. Another opportunity wasted.

  19. John Ellis Says:

    Admin as there is no contact email i can find for Dave can you please email me in regards to a new campaign group that is being setup now. We really could do with a chat about a few things and the time would be very much appreciated.

    Many thanks

    John Ellis

  20. James Phillips Says:

    Just a brief comment and inquiry:
    Is there any news/chance that Professor Nutt may write a book on this? A popular book can often catalyse open discussion, just as “The God Delusion” did for the Atheism/religion discussion (although the character of the subject matter is obviously very different).

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