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.”
Liberal policies
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.
“The way it’s supposed to work is that you commence your treatment in a clinic, where there will be a high level of support, with a psychiatrist usually in charge of the clinic, GPs, nurses, psychologists and a good level of resources. Once you’ve attended the clinic for a while, and they see that there is no other opiate in your urine, they will farm you out to a GP, preferably your family GP if he’s willing to get involved.”
The benefits? “It’s a healthier drug than heroin, because it’s regulated and clean,” says Geoghegan. “People on methadone use less illicit drugs and are less involved in acquisitive crime than drug users not on methadone. And it does improve their lifestyle in general, because it takes that pressure off them having to find money all the time.” This is borne out in the Rosie Study, from 2009, on drug-treatment outcomes.
Often methadone users continue their illegal drug use, but the maintenance programme reduces risk-taking behaviour and keeps them in regular contact with the medical establishment, so they suffer less from infections and neglect.
At best, says Geoghegan, users stop all other drugs and “get to a point where they’re just visiting a GP and getting methadone from a pharmacist once a week and can hold down a job or study . . . It’s a stepping stone they can move on from.”
The problem, Geoghegan says, is that a lot of people do not move on from methadone, which is highly addictive, because they don’t have enough support to do so. By the HSE’s own estimate, 2,690 people have been on the drug for 10 years or more.
Francis Doherty of the Peter McVerry Trust talks about people “languishing”. Some methadone users speak of the drug almost as if it’s a conspiracy. At the McVerry Trust drop-in centre, where many still refer to it as Phy – the original brand name was Physeptone – one man calls it a “government drug”. Another woman complains that nobody ever told her when she was first prescribed the drug that she would still be on methadone a decade later.
Green handcuffs
Seated in his own sittingroom, Darren Balfe tells me he’s tired of it. He has a long history of drug use. He tells me about running away from an abusive home and sniffing solvents at the age of seven before being coaxed into an armed robbery at the age of 13 by a friend’s father.
“I remember being woken by him one morning, and he’s giving me a hoody and a scarf, and all of a sudden I’m down in a shop doing an armed robbery. And I loved it. That’s the mad part . . . He was nice to me.”
Balfe was homeless, living in “pram sheds” behind flats in Inchicore and taking methadone as a street drug before he ever took heroin. “It gave me a sense of lostness. You’re not there: it takes you away. You wake up 24 hours later and there’s the day gone. I slept through a prison sentence on methadone.”
He has been prescribed it off and on for almost two decades, but for years he refused to stop taking other drugs. He would, like others I spoke to, often sneak in a urine sample he’d acquired from a non-drug taker.
He says he would be dead if not for Fr Peter McVerry. He has been free of everything but methadone for nine years, and he’d like to get totally clean for his daughter’s sake. “One little human being can change your course of history,” he says.
Methadone “is like a pair of green handcuffs”, he says. It makes his mouth dry and his skin sweat. “I could take a tablespoon of sweat off my forehead and I’ve just walked from the bus stop.” He hates what it has done to his black and broken teeth – earlier forms of methadone were preserved in sugar.
And he worries about what it has done to him psychologically. “It suppresses your emotions,” he says. “I’m pushed to a corner. It’s like: ‘We’ll give them methadone. That’ll shut them up. That’ll stop them from committing crime.’ It’s like a pacifier. That’s the best way I can put it. It’s a pacifier.”
Balfe says he’s scared to detox. GPs tend to be concerned about long-term users detoxing, and they are often dissuaded from doing so. There are some good reasons for this: without support, staying clean isn’t assured, and relapsing when your tolerance is low can be fatal. For clinicians, keeping people on the programme is often the surest way of keeping them safe.
At the bright, custom-built Clondalkin Lucan Addiction Centre, Dr Denis O’Driscoll, a pharmacist, says that harm reduction, not detoxification, is the aim. He is acutely aware of the hazards of the drug-taking lifestyle.
Two hundred people get their methadone here. Some also have their other medicines, for HIV or psychiatric disorders, managed here. There are nurses, doctors, counsellors and a creche. The toilets are designed for supervised urine sampling, with mirrors around the bowl.
Behind the hatch where he distributes medication, he shows me a big metal safe filled with powerful drugs. “I’m here to prevent harm,” says O’Driscoll. “And how I prevent that harm is the provision of methadone.”
He is happy to discuss detox options with his patients, he says, but “we used to encourage detox along a very strict regime, and people would relapse. It wasn’t fair. It wasn’t a safe way of looking after patients . . . Retention is one of the biggest measures of success.”
Shane Butler of Trinity College notes that the word “rehabilitation” was absent from the first draft of the National Drugs Strategy. “The pillars were ‘supply reduction’, ‘prevention’, ‘treatment’ and ‘research’. ‘Rehabilitation’ was only added as a fifth pillar after a hue and cry. Everyone was fed up of methadone maintenance.”
But he cautions against any drastic policy shifts. “We don’t have any great technical developments making it any easier now than it was in the past to get people drug-free,” he says. “So the idea you’ll get better outcomes if you take people into long-term rehab isn’t borne out at all.”
Dr Fiona Weldon, clinical director of the private Rutland addiction-rehabilitation centre, thinks people deserve more options. She points out that methadone is “the only way offered to treat heroin addiction at the moment. Nobody is offered any other approach . . . Outpatient abstinence programmes should be available as a choice.”
Tony Geoghegan still believes that methadone helps people, but he has reservations about the length of time people are kept on the drug. “I don’t think there are enough resources put into supporting people on methadone to move beyond it,” he says.
“The international research evidence would say that it takes an average of two years for people to stabilise their lifestyle. The optimum would be to have people on it for two years and in that time sort out the other issues in their lives before moving on from methadone. Now we have a third of methadone users on it over 10 years.
“The reality is that we’ve got 10,000 people on methadone but only around 40 beds where you can go in and detox under good supervision. That’s a pretty stark juxtaposition . . . This is probably being cynical, but methadone is the cheaper solution.”
Methadone services currently cost €1,723 per user each year.
“I do think we need to focus more on recovery than we have in the past,” says Joe Barry. “There’s certainly a body of opinion that not enough has been done to help people who want to stop . . . The biggest criticism is, ‘Oh, you’re just doping up people to keep them quiet.’ But I don’t think anyone in the service is doing it for that reason. They are genuinely trying to help people.”
He stresses that, for many drug users, acquiring methadone means ongoing contact with medical professionals – and that this regular contact is saving lives. “If we stopped methadone tomorrow,” he says. “10,000 people who come to the GPs and health centres every week would stop coming.”
