Although a number of drugs cause problems in the UK, the country is remarkable among developed nations in the extent to which heroin dominates as the primary illegal drug. The main treatment response to the heroin-addicted population in recent years has been to dramatically expand methadone maintenance.
According to Professor Susanne MacGregor’s new book on drugs in the UK, the number of drug users in treatment in the UK has grown from 67,000 in 1994 to about 200,000 in 2008, at a cost to the National Treatment Agency of Â£398 million pounds (This is NTA’s “ring-fenced” budget in 2007/08). Most of this treatment is methadone provided to heroin addicted individuals. The extensive use of methadone coupled with the closure of many residential rehabilitation programs that do not prescribe medications generated a firestorm of criticism against the Labour government. With the arrival of a new government, the critics have receptive ears into which to speak, and an overhaul has been promised.
The criticism of UK methadone maintenance has several strands which are important to untangle. One is that the care in UK methadone clinics is often of poor quality. Researcher David Best has documented that a patient who spends an entire year receiving methadone might get a few hours of counseling, total. Clinic time is devoted to providing, managing and recording the methadone dose and doing other paperwork, with almost no attention given to what should be a staple of drug treatment: Trained, concerned staff members taking a genuine interest in patients as individuals, finding out what is happening in their life and helping them tackle the problems they face. Another serious problem is the lack of careful monitoring for continued use of illegal drugs, which in some cases seems to reflect a mentality that a little less street heroin consumption is a good enough outcome because it might translate into less property crime. I have heard no one in the U.K. (on either side of the methadone debate) disagree with the proposition that methadone services in the UK have serious quality problems.
The second strand is more philosophical, and is reminiscent of the cultural battles that occurred in the U.S. in the late 1960s and 1970s over methadone vs. â€œdrug-freeâ€ treatment. A significant camp in the U.K. objects to methadone on principle, arguing that a methadone patient is still a drug user, and therefore has not achieved the desired outcome of substance-free living. Iain Duncan Smith, MP and the Centre for Social Justice (A centre-right think tank with influence and gravitas) are most associated with this viewpoint, which also resonates to a certain extent with the woman on the Clapham omnibus. Smith is now heading the Department of Work and Pensions and I am led to understand that his Cabinet Committee on Social Justice will make addiction a signature issue. One still hears fundamental philosophical objections to methadone in the U.S., but they have become less common as recovery organizations (e.g., 12-step fellowships) have enjoined their members from “playing doctor”, historical research has shown that AA founder Bill W. asked methadone pioneer Dr. Vincent Dole if he would invent a methadone for alcoholics, and well-known recovery advocates like Bill White have endorsed the principle of “many pathways to recovery”, explicitly including medication-assisted treatment (This is also the position of President Obama’s National Drug Control Strategy).
The third strand of methadone criticism in the UK is political. Some conservatives in the U.K. and the U.S. believe the expansion of methadone prescription without concurrent monitoring of drug use via urinalysis (or even, apparent concern about it) is a sign that “left-wing harm reduction extremists have captured the UK treatment field”. This raises the stakes in their eyes because this becomes not just about policies they don’t like, but about people they don’t like and want to battle politically. I have friends among these critics, but with respect I think they have misread the situation, for two reasons.
First, a long government career including being involved in managing a huge substance use disorder treatment system tells me that what likely happened in the UK was not some philosophical epiphany among methadone providers but a scramble to respond quickly to great pressure to expand the number of people in treatment. The easiest way to do that was to give everyone less service and build a lot more outlets (The same phenonemon has occurred in other areas, for example when Congress demanded a massive increase in the number of children enrolled in Head Start without specifying no detriment in quality). Maybe some people of a particular political persuasion like the end result, but in terms of how and why the system changed I think the best explanation is that a massive bureaucracy adapted clumsily to demands set upon it rather than a cabal of ideological insiders nimbly implemented their worldview. Second, to think of methadone as a leftist plot distorts UK political history. The suggestion to expand methadone and needle exchange in response to the AIDS epidemic came from the non-partisan Advisory Council on the Misuse of Drugs (ACMD; Dame Ruth Runciman was a key member) and the policy was implemented by a Tory’s Tory, PM Margaret Thatcher.
A few years ago the UK Drug Policy Commission and David Burrowes, MP kindly hosted a private briefing session for me with Tory backbenchers and other players, during which I explained how methadone was used in the U.S. and why I consider it a valuable part of the treatment system. We were under the Chatham House rule so I can’t go into details, but I can say that the extreme views expressed in the Daily Mail et al. (e.g., close all methadone services tomorrow) were nowhere in evidence. Indeed, it was as thoughtful and nuanced a discussion of drug policy as I have ever had with elected officials. This is in line with a general rule that press-mediated “drug policy debate” often makes everyone involved sound less reasonable and intelligent than they are (cf. the debate between Home Secretary Alan Johnson and ACMD head David Nutt, both of whom come across in person much better than they did in their recent tussle, which was fueled by high emotion and too sloppy by half press coverage). I left the briefing session with hope, which I still consider realistic, that if the Tories got into power they would take a “mend it not end it” approach to methadone maintenance services.
David Burrowes (who is now a PPS) has continued to be my man of the match on methadone issues for saying things such as the following quote, which comes from a Guardian story from which the photo above is cribbed: “It’s not for me to cast moral judgments about whether methadone is wrong or right…We need to look at outcomes, and the outcomes are just not good enough.”. To my way of thinking, this is really the only question at issue. I respect and like Professor Neil McKegenay, but I disagree with his proposal to limit the amount of time anyone can receive methadone (e.g.,
six months or a year or two, UPDATE: SEE NEIL’S COMMENT BELOW). If care is poor and/or the patient is doing badly, one day is too long. If care is good and/or the patient is doing well, one year may not be enough. I hope the new government will take this to heart and try to get the best outcomes it can from the potential life-saving treatment that methadone can be, which will entail changing the practice style of some clinics, shifting patients who continue to use drugs to other forms of treatment, and communicating a new set of expectations to all methadone providers (e.g., if you want public money for your program, test for illegal drugs and put contingencies in place for immediate response when use continues). If the end result is that fewer patients are in methadone treatment, but the treatment they receive is of higher quality, that should be a net gain for public health and public safety.
The methadone controversy ties into two other issues that are currently hot in the UK, namely what should count as “recovery” from addiction, and, what policy levers could make the treatment system produce it more often? These questions will be the subject of my next posts in this series.