Methadone: the ‘government drug’
The State is official opiate supplier to 10,000 people. Methadone stabilises, and sometimes even saves, the lives of heroin users, but many are in their second decade of dependency
Darren Balfe reaches under the sink and takes out a cornflakes box. From it he produces a plastic bag containing a nearly empty plastic bottle with a green liquid at the bottom. “That’s one day’s dose,” he says. His girlfriend is playing with their baby in the next room. It’s a “takeaway”, which means that Balfe is trusted to receive a full week’s supply of methadone.
What does it taste like?
“Want to try it?” says Balfe.
I must look as if I’m considering it, because Balfe puts it back in the bag and laughs. A dose of methadone prescribed for a seasoned drug user, I’m later told by Dr Joe Barry, an HSE public-health specialist, could easily kill me.
“It tastes a bit like cough syrup,” says Balfe. When he drinks it he goes “from itchy, agitated and wanting, to feeling normal.” It does not, he says, make him high. For heroin users who want to straighten out, methadone maintenance is the only option widely available.
Balfe was first prescribed methadone 18 years ago. He is one of about 10,000 people for whom the State acts as an official opiate dealer. (There are another 10,000 or so heroin users not in the methadone system.) We’ve been prescribing methadone since the late 1980s.
Originally developed as an alternative to morphine in the 1930s by a German company, IG Farben, it wasn’t until the 1960s that Rockefeller University researchers Vincent Dole and Marie Nyswander pioneered its use to stop heroin withdrawal and block the heroin high. They argued that “the status of insulin for diabetes was comparable with methadone for heroin addiction”, says Shane Butler, who is associate professor of social work and social policy at Trinity College Dublin. In their view “you put heroin addicts on methadone and left them on it indefinitely”.
The idea of giving opiates to opiate addicts was then revolutionary, but around the world maintenance drugs now include methadone, morphine, buprenorphine and, in some countries, even heroin itself.
In Ireland, until the 1980s, we preferred the abstinence-based approach favoured by Narcotics Anonymous and referred to as the Minnesota Model. Methadone maintenance “would have been philosophically alien here” at that time, says Butler.
What changed in the 1980s was the spread of HIV. Methadone was “snuck in in a quite covert way, with little or no debate, not on the basis of any great liberalisation but as a purely pragmatic public-health thing,” says Butler. “This is a terrible thing to say, but as long as heroin addicts were only killing themselves there was a kind of public indifference.
“However, what became clear very early was that, by sharing injecting equipment, heroin users were transmitting HIV among themselves – and through sexual contact they were a bridge for taking HIV into the general, so-called respectable population. That was the impetus for the introduction of mass methadone prescribing.”
Barry, who was the Eastern Health Board’s Aids and drug co-ordinator in the 1990s, recalls visiting the Netherlands in 1991 to see how it dealt with heroin addiction. Its more liberal “harm reduction” policies sought not to entirely eradicate drug use but to minimise damage to the user and to society. “It was a northern European rationalist approach, including needle exchanges and maintenance outreach to drug users.”
Back home Barry attended public meetings in heroin-ravaged communities where he explained methadone to locals and met public-health nurses and GPs. “It was a big change in policy,” he says.
Widespread methadone maintenance began in 1992. There were some hiccups, says Barry, such as instances of “rogue GPs” prescribing out of the boots of cars.
But a legislative framework, the Methadone Protocol, put in place in 1998, compensated doctors and stemmed the leakage of methadone on to the black market.
Tony Geoghegan, chief executive of Merchant’s Quay drug services, outlines how methadone treatment works. “A GP will refer you to a clinic, and there they will take a urine sample, to ascertain if there are actually opiates in your system. Then they’ll try to titrate a dose for you and prescribe that for you on a daily basis.