Archive for category Methadone'

Methadone Maintenance Treatment: Dependence, Contingency and the Productivity of Problems

As Deleuze has reminded us, intellectual freedom lies not so much in devising answers or solutions but in formulating problems. As he puts it, A solution always has the truth it deserves according to the problem to which it is a response, and a problem always has the solution it deserves in proportion to its own truth or falsity … The processes by which problems come to be formulated, and the shapes they are given, powerfully influence the kinds of answers and solutions thinkable and enactable. This insight into problems and solutions is precisely what Substance and Substitution has been about. There is no doubt that methadone maintenance treatment is a curious phenomenon. It is a means of converting an illicit practice into a licit one, largely through two strategies. The first strategy is the replacement of one substance with another only marginally different in molecular makeup. Indeed, as Emilie Gomart (2002) so crucially says, despite our deepest convictions, the properties of substances such as methadone and heroin are performed in practice: they are not ontologically anterior to it. The second strategy is to change, again only marginally or in some respects (as we have seen, the changes are not as radical Read more […]

Gathering Methadone Maintenance Treatment

Our aim has been to explore the tensions and contradictions entailed in methadone maintenance treatment’s role within Western liberal societies, to consider the ways in which it attempts to produce the proper, law-abiding, autonomous, responsibilised subject ubiquitous to liberal discourse. As the preceding posts attest, these tensions and contradictions exist in abundance. Indeed, perhaps the most significant of the book’s overall themes is the way in which methadone maintenance treatment takes up and then confounds almost every familiar dualism in Western liberal discourse’s exquisitely interlinked series of binary oppositions. As we have argued throughout, addiction or dependence is one of liberalism’s most despised, and most necessary, creatures. After all, dependence is the concept against which the individual is produced. The elaboration of the binary relation between autonomy and dependence is one of the many operations of the concept of addiction, one partially undertaken by methadone maintenance treatment, although, as we have seen, holding this binary stable is no easy feat for this profoundly riven phenomenon. methadone maintenance treatment, then, can be seen as a point of condensation through which a whole Read more […]

Methadone Maintenance Treatment: Becoming Otherwise

To return, then, to methadone in its specificity, this book makes a range of recommendations for improving the conceptualisation and delivery of treatment. Our first recommendation is broad in scope. It relates to the argument we make in Substitution, Metaphor and Authenticity about the implications of routinely describing methadone maintenance treatment as substitution or replacement therapy. Our view is that understandings of methadone as substitute or replacement operate, at best, as a double-edged sword in defining treatment. While there is no doubt that, for new clients, the notion that a drug might succeed in replacing heroin and circumventing withdrawal can be attractive and comforting. However, as our analysis suggests, these terms do not confer legitimacy or status on treatment or its clients, indeed the opposite is the case. All are associated in culture with inauthenticity, and as a result, their value is permanently in question. It might be that, endemic as this language of substitution has become within treatment and within public discourse on methadone, new terms should be found. The argument made in Repetition and Rupture: The Gender of Agency supports this suggestion. If replacement or substitution carries Read more […]

Methadone Maintenance Treatment: The Lay Carer

Diversion of methadone to street sale is one of the two major problems associated with methadone, the other being overdose (of the client, or of someone else). As a category, ‘diversion’ sits readily alongside ‘drug dealing’. The latter term is so freighted with meaning that diversion can then be seen as a pathological activity by a client who, as an unreconstructed chaotic user, uses methadone only as a means for getting more drugs. The drug dealer is a demonised figure and mythic predatory characteristics are ascribed to them. For example, a few health care workers in our interviews reported their horror that methadone is sold to young children, a practice for which no evidence exists. Diversion recurs in our interview data as problematic for both clients and service providers, but in ways that complicate these stereotypical ideas of the methadone client as a compulsive, black market seller. For example, clients may be victims of diversion: some report being threatened and otherwise intimidated outside clinics to sell their methadone. This pathologising is also troubled by recognition of the fact that many clients are impoverished, that most have to pay for their methadone, and that diversion of a partial dose or Read more […]

Methadone Maintenance Treatment: In Need of Guidance

In the language of drug treatment, judgements about the reliability and stability of clients often give rise to assessments of the guidance they need. In our interviews service providers reported that treatment brings benefit to clients through the provision of ‘structure’. Their point and the language they used to make it echoes the NSW Clinical Practice Guidelines’ description of treatment as providing stability and structure, and within methadone programs the therapeutic relationship established with each patient can facilitate social reintegration and access to other services. (NSW Health, 1999) Assessments of drug users as requiring introduction or restitution to legitimate, routinised ways of life are not unfamiliar, and have been subject to analysis for some time. Getting up in the morning, conforming to normal standards of grooming, keeping appointments, having self-discipline, accepting life’s disappointments and inconveniences: all of these are assumed to be lacking in the drug addict and present in everybody else. Recall Jacques Derrida’s argument that drug addiction is vilified because it is read as an escape from reality: What do we hold against the drug addict? Something we never, at least never Read more […]

Methadone Maintenance Treatment: The Stable User

When drug treatment is discussed as transformative, familiar typologies of drug use such as addicted and ‘clean’ are used. Our interview data revealed less use of terms such as recovered or recovering addict than of other terms, particularly ‘stable’ and ‘chaotic’. This may be because, as Substitution, Metaphor and Authenticity suggested, methadone maintenance treatment functions in public discourse as an extension of addiction, or, as Repetition and Rupture: The Gender of Agency will argue, a repetition rather than escape from addiction. Both ‘stable’ and ‘chaotic’ recur in service provider and client interviews, and the terms recur partly because their meanings are flexible and can be vague, as the following examples show. Barry, who worked in NSW policy and is also a doctor, uses ‘stable’ to refer to compliance with treatment agreements, arguing that takeaways should be seen as an indicator of stability. [A client’s reaction to receiving takeways should be] ‘shit, I’m being quite stable, I’m attending and getting my dose, I’m not being refused my dose, I’m not using drugs in a dangerous way, this is, this is a good thing’. (Barry, Sydney, NSW, policy/prescriber, 40) Beverley, a nurse in Melbourne, uses the term Read more […]

Methadone Maintenance Treatment: Dissatisfied Customers

Some of the rhetorics of drug treatment offer only two subject-positions that clients can occupy: the chaotic addict or the compliant/subdued ‘stable’ consumer. However, much of our interview data show resistance to these narrow categories and activity in a mode familiar from other contexts, notably consumer complaints. Here, is a description of the day-to-day frustration of being made to wait for no apparent good reason from Steve, a Sydney client. A description of the experience of attending a methadone clinic for dosing, it would not be out of place in a register of complaints of poor service anywhere: And, it’s like they get their kicks out of you sitting there and making you wait. You go in there and they’ll be having conversations, drinking coffee, and then like, and you’ll stand there, and they’ll finish the conversation before they dose you. (Steve, Sydney, NSW, client, 29) Similarly, Lisa, also a client from Sydney, complains of distracted and ineffectual treatment from her doctor: I mean I tend to get on okay with my doctor although at times I think she is inconsistent and she, she works very long hours and often seems tired and only seems to be half listening to what I’m saying. She’ll get interrupted Read more […]

Methadone Maintenance Treatment: Biological Citizenship

It is here that the work of Nikolas Rose () becomes particularly useful, in its analysis of the ways in which contemporary negotiations of medicine co-produce new forms of responsibility and obligation, as well as new kinds of social action and claim-making. Rose and Carlos Novas (2005) refer to ‘biological citizenship’ to describe specific instances of this. Making up biological citizens refers both to changes in the means by which medical, legal and other authorities understand people and those in which people have come to understand and produce narratives of themselves. Identity categories such as ‘the chronically sick, the disabled, the blind, the deaf, the child abuser, the psychopath’ now organise the ways in which groups of people are regulated by experts. Equally, biological citizenship describes the creation of persons with a certain kind of relation to themselves. These citizens use biologically inflected language in narrating their own experience and subjectivities: For example, they describe themselves as having high levels of blood cholesterol, as vulnerable to stress, as being immuno-compromised, or as having an hereditary disposition to breast cancer or schizophrenia. (Rose and Novas, 2005: 12) They Read more […]

Methadone Maintenance Treatment: Making up People

Barad cites Ian Hacking’s Representing and Intervening as an inaugurating text for critiques of representationalism in science studies (). The phrase for which Hacking is best known, however, is ‘making up people’, and the project of historical ontology is one of his elaborations of that phrase (). Historical ontology describes ‘ways in which the possibilities for choice, and for being, arise in history. It is not to be practiced in terms of grand abstractions, but in terms of the explicit formations in which we can constitute ourselves’ (). Making up people is a process where new kinds of being are created, both through the actions of people ‘from below’ and the effects of expert discourses ‘from above’. The identity categories of homosexuality and heterosexuality are very well-known examples of this process: before the nineteenth century, people did not identify and were not identified as heterosexual or homosexual, because those categories were not available. There were of course practices and desires that can be retrospectively identified as homosexual, but to map a gay or lesbian identity onto them is anachronistic. Identity is not formed only through practices and desires; it does not exist until it is an object Read more […]

Drug-Drug Interactions of Methadone

Antiretroviral drugs Methadone is often used for opioid replacement therapy in intravenous drug abusers. The incidence of HIV infection is significantly higher in this population than in the general public, and interactions with drugs used for the treatment of AIDS are therefore important. Methadone is predominantly metabolized by CYP3A4. Antiretroviral therapy with a non-nucleoside reverse transcriptase inhibitor (for example efavirenz, abacavir, and nevirapine) and/or a protease inhibitor (for example amprenavir) will induce the metabolism of methadone. This therapeutic combination is becoming increasingly common in HIV-positive substance misusers. Two studies have explicitly shown a significant reduction of methadone concentration by 28-87%. In the first study, 11 patients taking methadone maintenance therapy were given efavirenz and had a mean increase in methadone dosage requirement of 22%. In the second study, five methadone-maintained opioid-dependent individuals were given a combination of abacavir and amprenavir; the methadone concentration fell to 35% of the original concentration within 14 days. In a prospective study of 54 patients taking antiretroviral drugs who also took methadone and a further Read more […]