Moving beyond maintenance in drug addiction

On Saturday June 3rd a large, expensive advertisement appeared in newspapers

On Saturday June 3rd a large, expensive advertisement appeared in newspapers. In bold letters it warned all heroin-users not to inject. It went on: "If you wish to have treatment go to your local Health Board Addiction Centre where you will be immediately assessed."

A young man who is a heroin addict and who lives in Father Peter McVerry's hostel rang the 24-hour freephone Drugs Helpline number. He was given an appointment for the next day. Father Peter McVerry was impressed, particularly since this was a bank holiday weekend. The young man went and was told that he would be written to about treatment. Some three weeks later he still has heard nothing. Needless to say, Father McVerry is no longer impressed.

Had this young man been contacted, he probably would have been told that he would be put on to a waiting list for methadone maintenance. If that was one step in an integrated rehabilitation programme that might be all right. The reality is that maintenance has almost become an end in itself.

However, pointing out the limitations of methadone maintenance can seem almost perverse, when many people cannot even get as far as a maintenance programme.


That is not to play down the advances made in the last few years. There have been many positive steps, such as the setting up of the Local Drugs Task Forces. Major resources have been allocated to dealing with addiction. Government initiatives to set up treatment centres in local areas have been stymied at every turn, so the public bears a good deal of responsibility for the fact that more is not being done.

But it still remains problematic that methadone is being seen as a solution. Youngsters will tell you proudly that they are "off everything", only for it to emerge that they are actually on maintenance.

Methadone is in itself an addictive drug, more addictive than heroin, and has more severe withdrawal symptoms. While it does much that is valuable, it does not tackle the core problem of addiction. A person's ability to function still revolves round the availability of an addictive drug, albeit in this case a legal and prescribed drug.

Some campaigners are deeply impatient with these caveats, believing that methadone maintenance is similar to prescribing insulin for diabetes or lithium for manic depression. They have no particular difficulty with the fact that methadone means that a person copes with life by being partially stoned all the time. Yet the analogy with insulin or lithium is very weak, because in both those cases the person's body does not manufacture essential substances.

Although recent debate has centred on prescribing heroin to certain addicts, the real issue is much more basic. Should we aim to help all drug addicts become drugfree? Or is this is an impossible goal, and should we reduce the chaos in people's lives by harm-reduction measures?

There is no neat dividing line between these two stances. Some who are most vocal in support of harm-reduction measures are also the ones who know drug addicts by name, and who represent a lifeline for the human casualties the rest of us hastily walk round on the street and forget.

Some who argue most strongly that methadone must not remain the primary focus of intervention also recognise that methadone has a place in a treatment process.

But perhaps it is most important to ask why as a society we are so accepting of methadone as a solution. The benefits are obvious. Methadone does not involve injecting and therefore reduces the risk of infection from sharing needles. Crime is reduced, as the addict no longer needs to steal to support a habit. Because the highs and lows are less extreme, the addict may even be able to hold down a job.

Methadone maintenance is not without controversy. People die from methadone overdoses, even though this has become less common since distribution protocols were tightened.

But the central question still returns. Why do we accept so readily the notion of stabilising addicts by using a more addictive drug? Could it be ultimately selfish, because we are happy that there is less chance of our handbags and wallets being snatched, and fewer comatose bodies on the streets?

We still have not dealt in any sense with why people become addicted. Poverty and deprivation are huge factors. Yet arguably there was more poverty in the past than today, although deprivation now is more shameful because we have the means to tackle it.

The rise in addiction rates is very complex, but at least some of it has to do with the loss of meaning and with a feeling of having no place in the scheme of things. It has to do with powerlessness, with feeling overwhelmed by pain which cannot be tolerated without drugs. Why do we not want to look at that basic reality?

PRESCRIBING or not prescribing heroin deals only with those for whom every other intervention has failed. We need a multifaceted approach, which sees prevention, early intervention and treatment as an integrated process.

We are light years from that. The Government is flinging money at the drugs problem, but mostly in capital cost grants. It still remains unwilling to invest in recruiting people to deal patiently, consistently and intensively with the kind of chaotic lives which prompt and sustain drug-taking.

Ponder this. In one deprived area it was found that 194 individuals were being targeted by no fewer than 35 agencies, both State and voluntary. Thirty-five different bodies tapping into the lives of those individuals and their families in a piecemeal and unco-ordinated fashion is ridiculous.

Such an approach fails to acknowledge that there is an organic link between one child's problems with school attendance and his big brother's drug-using. To be fair, the State has acknowledged this by setting up the Integrated Services Project which is designed to iron out such wasteful overlapping services, but much more needs to be done.

There is no magic wand to solve drug addiction, but some practical initiatives could help those most in need. First, we need to increase residential treatment places dramatically, and acknowledge that many people need this intensive structure.

Second, set up a dedicated service for young addicts in Dublin. They hate lining up in Trinity Court with adults and so often won't even go there. Third, build on the detox and therapy programmes available in prison by ensuring that prisoners do not risk going straight back to using drugs because they return to lives with no support and no prospects.

Finally, and perhaps most importantly, we need to start a debate about the nature of the emptiness which afflicts so many people's lives.