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The methadone trap?

At the dawn of 2016, some 5,768 people in Ireland were on methadone maintenance treatment for over five years and 3,640 for more than 10 years.

In total, 10,043 people were engaged in HSE methadone treatment services as of April 2016, up from 9,852 the previous year.

Simple maths tell a story: around one-third of people have been on methadone maintenance for over 10 years and over half for more than five years. Numbers on methadone have stayed relatively static over recent years.

According to the HSE, 710 people were recorded on the Central Treatment List as having successfully exited treatment in 2014. The following year it was 773. “The Central Treatment List records details when a patient leaves methadone treatment, including the reason the treating doctor gave for ceasing treatment. The reasons are not fully validated, as it is not possible to follow people longitudinally,” stated the HSE.

Debate

Methadone maintenance has prompted debate nationally and internationally, with suggestions of an ‘epidemic of treatment’ and calls for a ‘stopwatch’ approach. But many medical specialists working in addiction services feel that this narrative defies the evidence base.

Dublin GP and addiction specialist Dr Patrick Troy underlines that addiction is a treatable, long-term, chronic disease.

“We in the medical field would believe it is a long-term illness, a relapsing illness,” he says of addiction. “People will be doing great for a long while and then all of a sudden they relapse into their addiction again. It is all based on the pleasure and reward circuit of the brain.”

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Dr Patrick Troy

There are brain changes associated with addiction that are “in many ways irreversible”.

Detoxing puts people “in great danger because their tolerance to opioids goes down and, of course if they dabble again, they believe they have the same tolerance”.

He knows of two deaths in the last two years where people “desired to ‘come down’ off methadone”.

In that context, the fact that one-third of people receiving methadone maintenance treatment are doing so for over 10 years does not concern him. People on methadone have a superior quality of life than if they were on heroin, he emphasises.

Dr Troy maintains methadone has been “a wonderful success”.

“We often think in terms of the individual and there is no doubt about it, their physical health gets better, they spend less time in prison. But then on the peripheries of that, they manage to get back into their home, they manage to reconnect with partners or children, with parents, they are not being constantly hassled by the police, they can get welcomed and be allowed go into shopping centres. They can actually do well.”

Are some services inappropriately directing patients towards detox?

“Yes,” says Dr Troy. “Detox is a mantra you have to maintain in the community because of the perception people have towards addiction… ‘why can’t you just stop?’”

This is the “desperately naive” view of some within the community, judicial system and even in the medical field, he claims.

But the notion of detox is attractive. Sometimes it works, acknowledges Dr Troy, but not often.

“There are some people — and you hear it time and again, ‘I stopped drugs, I gave them up and I am great now’. That is wonderful. You will always have those cases but when you are dealing with the bigger numbers, collective numbers, it is not quite like that.

“When I started off [in this area] 15 years ago, I naively went in to say, ‘let’s detox people’. It is only after years and you see the people coming back again… unfortunately, I have to say that about 80 per cent of them came back, just another way.”

Redrafting of the methadone regulations to incorporate buprenorphine (alone or with naloxone) treatment was recommended in a HSE-commissioned review of the methadone treatment scheme six years ago. In early 2016, the HSE recommended the phased introduction of Suboxone (buprenorphine naloxone) and Subutex (buprenorphine) subject to “the required resources being allocated and legislation being in place”.  The Department of Health has said this amending legislation will be published in the coming months, with the intention of having it enacted later this year. 

Dr Troy believes there is a role for alternatives such as Suboxone but warns that this medication isn’t “manna from heaven”. As of April, there were 81 people on Suboxone through the HSE. Buprenorphine naloxone is estimated at an additional drug cost of €2,186 (per person per year within HSE Addiction Centres, based on a daily average of 80mls methadone/16mg buprenorphine naloxone).

A number of Dr Troy’s patients are doing “extremely well” on Suboxone but they tend to fit a niche profile, being “very disciplined”. Some patients ask to come off Suboxone, as they say it prevents them getting a ‘hit’ from heroin.

Improvements

However, service improvements are needed. Dr Troy has previously raised concerns over methadone finding its way onto the streets, for example.

Most methadone prescribing is undertaken by GPs in the community and HSE clinics. The former must hold level one methadone prescribing certificates (allowing them to treat stabilised, opiate-dependent patients) or level two certificates (where they can initiate treatment). These certificates are issued under the auspices of the ICGP.

Dr Troy says some GPs sometimes “grant these ‘take-aways’ or privileges to patients” who then sell their surplus of methadone on the streets”.

There is a major difference between treating addicts and non-addicts, he points out. 

“If [non-addicts] tell you they’ve got a cough, they probably have. If they tell you they’ve a temperature, they probably have. But addiction medicine is different, insofar as the addict sees you as a source of supply. So telling lies, from an addict’s point of view, is all part of the disease.”

The average community GP will be treating a mother or child and then moving to a consultation with an addict “saying he can’t sleep, is anxious, stressed out, and needs benzodiazepines”.

Going forward, Dr Troy also believes that addiction clinics need to have better control of the range of chronic diseases affecting patients.

Waiting

Dublin GP and addiction specialist Dr Garrett McGovern believes there are at least another 10,000 people who need opioid maintenance treatment, due to codeine, analgesic and heroin addictions. He says some are waiting two years to access treatment.

“What we know about methadone is the longer you are on it, the better you do. And when you come off that medication, it tends to be associated with worse outcomes in terms of overdose, death and relapse,” he says.

“I can only speak for myself and colleagues who I’d be quite familiar with… None of us are encouraging anyone to get off methadone because the medication isn’t really designed to get off in terms of outcomes. So we try to keep people on treatment for as long as they want to be on treatment. But if somebody wants to detox, we give them the information about the risk or relapse and we support them.

“[Just recently] I referred a patient into Fr Peter McVerry’s Trust to detox, and I hope it works out. I think we need to look at people who are going in to come off methadone — about relapse prevention — because a lot of them are at risk of death when their tolerance falls, and that is a real worry.

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Dr Garrett McGovern

“I read an awful lot about ‘long-term parked on methadone’ and ‘liquid handcuffs’ — none of it is faithful to the evidence, and that is the problem. The evidence says that the longer you are on this treatment, the better you do. I don’t see anybody talking about the length of treatment where people are on warfarin or cardiac medication.”

Dr McGovern points to the Research Outcome Study in Ireland: Evaluating Drug Treatment Effectiveness (ROSIE), which found that long-term methadone treatment was very beneficial across various quality of life parameters.

Meanwhile, a prospective follow-up study of consecutive opiate-dependent patients admitted to a residential addiction treatment service for detoxification was published in the Irish Medical Journal in 2010 (Smyth et al).

Researchers measured the rate of relapse following discharge and sought to identify factors associated with early relapse (ie, a return to daily opiate use). Follow-up interviews were conducted with 109 patients, of whom 99 (91 per cent) reported a relapse. The initial relapse occurred within one week in 64 (59 per cent) cases.

Dr McGovern says the outcomes “aren’t great” internationally in respect of detox.

“I have had a number of patients over the years who have detoxed,” he adds. “Some of them have done well; some of them have not done so well. Some of them I don’t hear from again. One thing I instil in the patients who do go and detox is that they keep in touch with me and if things are difficult for them, we fast-track them back into treatment again if they need it. I don’t think it should be either/or.

“I am not against detox and I want to be very clear on that. I don’t think patients should be forced to detox. Evidence-based quality of life indicators that we use include relationships, drug use, psychiatric illness, housing — if all those are working well on methadone, and the person is happy to be on methadone, and they may be back in gainful employment, it shouldn’t be a judgement for me or anybody else to say ‘get off that medication’.”

Criticism

There are a lot of people who are “very critical” of methadone, acknowledges Dr McGovern.

“It is a very, very hot potato and that is fine — people are entitled to their opinion. Methadone isn’t perfect, no medication is; the treatment delivery isn’t perfect, people often feel stigmatised, the whole thing of urinalysis and going to see a doctor regularly. I get that.”

Dr McGovern has concerns about the way people are treated in some clinics, “almost like a sub species”. He has come across instances of patients having their doses terminated or reduced due to behavioural issues, which is clinically inappropriate.

On the matter of Suboxone, Dr McGovern says it should not be viewed as a better or worse treatment than methadone. “The evidence is excellent for Suboxone; it should be looked at as a different treatment — in other words, similar but different.”

There is some evidence that it might be easier to come off due to its pharmacology. “But I am not convinced that [hypothesis] is supported by great evidence… I don’t think how quickly you get off opioid substitution treatment is the issue; it is if you do get off it, how can you stay off opioids? That is a more pressing issue than how long it takes to get off it.

“I can understand the expense side of it, but still, cost-effectiveness shows that it works very, very well. It is a little bit of ‘fake economics’ to question the price of Suboxone, when the benefits of treatment will result in huge savings in the long-term.”

There is a “huge group of people”, especially those with codeine dependency, who would do “very, very well on buprenorphine and unfortunately, it is not really available to them and a lot of those patients are not really going to go to clinics to sign up for methadone, unfortunately”, he adds.

Complex

Dr McGovern has approximately 300 patients on methadone. “It is complex in terms of their functioning. If they were off methadone, I think they’d come to great harm, particularly in an area that is just rife with drug use, drug dealing and gangland and all that stuff… ”

Not enough people are getting treatment, while the quality of treatment is mixed, he outlines.

“People getting their treatment terminated — I see it all too often. I have seen it over the years, where a patient has consulted me following discontinuation of treatment in circumstances where there are no medical grounds to do so.”

Some people have their treatment removed or reduced for behavioural issues in the clinic, such as alleged drug dealing. “Now, alleged drug dealing is not a clinical reason to reduce your prescription, it is a criminal justice issue, if that is what it is.” The evidence dictates that if someone is using drugs while on methadone, one needs to consider increasing the dose until they cease or reduce injecting.

“Some doctors say ‘I don’t want to increase your dose, I think you’ll overdose’, but worse still, there are doctors actually reducing the dose. When you reduce the dose in somebody who is using drugs, they are at risk of harm. You read all the guidelines — Australian, American, English, any peer-reviewed guidelines — they will always say, do not reduce the dose in someone who is continuing to use drugs, and in fact consider dose increases.”

He believes training for methadone prescribers could be improved and expresses concern at the low numbers who attend for counselling, an issue he feels requires examination.

Despite being pro-methadone and buprenorphine due to the evidence base, Dr McGovern feels bad about addictions being “a prescribing service”. He says it also fails alcohol-dependent opiate users.

Dr Ide Delargy, Director of the ICGP Substance Misuse Programme and National GP Co-ordinator with HSE Addiction Service, adds that communication channels between primary care and drug taskforces, Community Drug Teams and various non-statutory agencies need improvement.

“Because sometimes the GPs may not even know that support services exist and support services are working away, often without communicating with the GP,” she says.

She also reveals that the ICGP is developing support webinars for level one and two doctors who wish to present or discuss problem cases “with a panel of experts”.

A recent study identified “overwhelmingly positive” GP attitudes towards the methadone treatment programme, she adds.

On the subject of detox from methadone, Dr Delargy says it is achievable for stable patients. However, for more complex patients, it is neither the preferred nor safe option.

  1. john O grady on September 19, 2016 at 10:17 am

    I am a Dublin GP who has worked in the HSE Addicton services for close on 20 years. I Acknowledge Dr Mc Governs contribution in this article. I do wonder why Dr Troy’s concern regarding the success/failure rate of voluntary methadone detoxification appears to have no bearing on his willingness to forcibly reduce patients methadone, a methodology which carries even more potential risks that voluntary detoxification and is condemned by all international guidelines. Dr Mc Govern also refers to and condemns this practice in his contribution to this article.
    I note also Dr Troys division of patients into addicts and non- addicts. According to Dr Troy the addicts are all potential liars. This is an interesting base point from which to observe/treat a cohort of patients who are amongst the most marginalist and vulnerable groups in the country. Dr Mc Govern refers in the same article to patients being treated in some clinics like a ‘sub species’. I fully concur.
    Dr john O’Grady
    HSE Addiction services, Cherry Orchard primary care centre.D 10

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