Stuck on Methadone

DJ Mac reviews a recent German paper looking into why patients stay on methadone. His review is easily the best post I’ve read on the complicated relationship between methadone and recovery. Read the whole post.

The paper’s starting point:

The paper outlines that retention in ORT is not great, with just over half of patients sticking with methadone and fewer with Suboxone. Despite this, in Berlin, as we have said, there are growing numbers of people on ORT. These are people who are not moving on; I suppose the ones the press call ‘parked’ on methadone. Hence the question the authors pose: “Why is this?”

Their findings:

1. Both patients and staff thought ORT helped physical and mental health. Beneficial effects of ORT on the ability to work and on crime were considered significantly higher by patients compared to staff.
2. Staff and patients agreed that coming off ORT was hard. Patients thought it harder than coming off heroin.
3. Patients wanted to eventually come off ORT at a significantly higher rate than staff estimated.

. . .

The thing that intrigues me the most is the “striking discrepancy between the patients’ and staff members’ assessment of the patients’ desire to end OMT on the long term. The large majority of patients report the desire to end OMT on the long term, whereas only a minority of staff members believe that their patients might really have such a desire.”

David Best found much the same thing (in aspirational terms) in a sample of drugs workers in the UK. They believed only 7% of their clients would eventually recover.

DJ Mac’s take:

It’s clear to me that where there is such a mismatch, when the bar is set so low and when there is little hope pervading treatment settings, then it’s no wonder that so few move on.

By the conclusion the authors find themselves at odds with the assertion at the start of the paper (that ORT has an aim of ‘abstinence from opioids’.) Here’s what they say (my emphasis):

“Finally, detoxification of OMT is not the prime objective of treatment. The prime objective of treatment is continued physiological and social stabilization. As yet, there is no validated medical cure for opioid addiction. Until a curative medication or a safe curative procedure is developed, many of the patients may have to remain in treatment for the duration of their lives to avoid relapses, increased criminality, subsequent overdoses, and death during the post treatment period.”

So the solution to the mismatch between the low expectation of staff and the higher expectation of patients is to lower the expectation of patients to that of staff?

It’s clear that issues identified in this paper are not isolated. They report on the patient experience in Germany. It resonates with DJ Mac in the Scotland. And, it resonates with me, here in the states. (Methadone’s problems in the US are often attributed to a system that’s dominated by abstinence-oriented providers who stigmatize ORT. That can’t be said of the other countries.)

The post, to my mind, ended up being a great informed consent document on one of the more concerning hazards of ORT.

Read the whole thing here.