Pharmacists with an interest in substance misuse maintenance cannot have missed the new debate from Scotland as to whether methadone maintenance therapy (MMT) is an adequate therapy for treating heroin addiction. Note the word "maintenance" because this is the bone of contention in the argument.The Scottish parliament are talking about ditching MMT and the softly-softly approach, and going into a programme of cold turkey. This "crusade" is led by professor Neil McKeganey's centre at Glagow university, and him being an addiction specialist to boot!! Whilst Scotland has not YET ditched MMT and gone down the abstentionist road they are going that way, and with the media, ie the BBC taking it on board, there is interest from parliamentarians south of the border.
Why am I telling you this? I would like to gauge the responses of pharmacists and staff who dispense methadone. Do you do it willingly, do you treat every "blue scripted" patient as an individual, with their needs and wants (and all their little foibles such as shoplifting<GG>) or do you look on them (albeit unconsciously) as misfits, who could rid themselves of the habit if they put their backs into it, and why should the state be funding the supply of addictive drugs to people who....etc.etc.
On my travels as a locum, I have met differing points of view - most of them negative. I would like to open up this discussion to see if my impressions are limited to this part of Britain, or are more widely held.
Much is made of evidence based medicine these days, and the Gold Standard is the Cochrane Collaboration, in a review by Mattick et al in 2003, the final paragrah reads:
"Methadone is an effective maintenance therapy intervention for the treatment of heroin dependence as it retains patients in treatment and decreases heroin use better than treatments that do not utilise opioid replacement therapy. It does not show a statistically significant superior effect on criminal activity. "
[Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002209. DOI: 10.1002/14651858.CD002209]
Ever since Marie Nyswander and Vincent Dole published their seminal paper on MMT in the Journal of the American Medical Association in 1965:
A MEDICAL TREATMENT FOR DIACETYLMORPHINE (HEROIN) ADDICTION. A CLINICAL TRIAL WITH METHADONE HYDROCHLORIDE. JAMA. 1965 Aug 23;193:646-50.
Methadone Treatment Marks 40 Years
JAMA, August 24/31, 2005; 294: 887 - 889. It's free to read!!]
Mathadone
Maintenance vs Reduction
The debate in Scotland is certainly one which has raised a huge amount of interest (and bewilderment) amongst addiction specialists. From a personal point of view, the various models of behaviour change all recognise the cyclical nature of any behaviour - we can all fall off the wagon at some point. However, the damage that opiate abuse causes is not just to the patient/client but also to the individuals in society around them - as opposed to tobacco where criminal activity tends to be to to the detriment of society as a whole.
The "harm reduction" should not be seen wholly as harm to the patient/client then, but to all those who may be affected - violent crime, shoplifting, burglary, intimidation, etc..
What I have refelcted and recognised (and this might be a useful exercise for all), in my meagre 18 years of serving substance misuse patients both in and out of treatment, is that every single incidence of anger, abuse, threatening behaviour or just plain unpleasantness it was not any form of illicit drug that caused it but the fact that they were drunk or had at least been drinking heavily. The very sad and dangerous fact that drinking and substance misuse are very closely linked in the literature and reality means that the line between the two are often blurred (no pun intended). Your comments about our profession's view of this client group reflect my own experience amongst my peers - not surprising considering we see them at some of their worst times - and this can only be remedied with significant action and support from... who? DATs, PCTs, CPPE, community drug teams - all have a part to play but this requires local coordination and advocacy at a time when the leadership locally of most pharmacy organisations is already stretched to breaking point. Where are our champions?
Within community pharmacy, a great deal could be done by those of us working there in recognising when a patient/client who is undergoing MMT needs a dose increase - if they are using in addition to therapy, then an increase is not a "reward" but a direct clinical response to that desire to use on top in order to gain stability (and abstinence) in the patient. Of course, individual response to therapy is also variable with a variety of theories and proofs of why that might be but it is the best we've got at the moment and to dismantle it with, as Bob says, nothing to replace it would not seem at all logical.
The education and understanding of this clinical area is not easily gained - it requires effort, dedication and exposure - but is eminently professionally worthwhile. What is interesting, is that those pharmacists who do, are recognised and respected by their clients for that - this in turn, allows them to open up and trust you as a healthcare professional.
I intend to watch and wait with baited breath for the Scottish debate to show some sort of resolution - but if given the opportunity, I would not wish for MMT to become MRT as a matter of course but would advocate the opposite and strengthening of community services to allow more people into treatment. As Gordon Morse said in a recent SMMGP newsletter:
"Abstinence and harm reduction are not mutually exclusive, they are mutually dependent: for what is abstinence without harm reduction alongside to scoop you up when you fall off the wagon? And what is harm reduction, without the hope that one day you can regain your independence and self-determination?"
I shouldn't imagine that
Either or
Treating individuals
Either or