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