Methadone Maintenance Treatment: Becoming Otherwise

2015

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 with it a sense of mere repetition understood as sameness, it may not do justice to treatment as it is lived. There are other ways of conceptualising repetition, for example, as a condition of possibility for change, and, as we have seen, clients sometimes report experiencing treatment repetition in this alternative way.

To consider this question of representation more generally, we must also consider the argument made about the role of media representation in materialising treatment. Press and other media coverage of drug use and drug treatment is inevitable and in some respects ubiquitous. Our suggestion is that those working in methadone maintenance treatment acknowledge this, and view it as an opportunity for materialising treatment in new or better ways. Where silence is maintained, we argue, this opportunity to generate change is lost.

From a discussion of the discursive basis of treatment in Substitution, Metaphor and Authenticity, we move to an examination of its regulatory basis in Governing Treatment. Here, we make some quite different recommendations, for example, we argue that consistently applied treatment standards need to be devised and enforced. This is difficult to achieve as the poor standards of treatment currently in place are at odds with the intentions of many of the people who work in policy, advocacy and delivery. The shortage of pharmacists and doctors willing to be involved in treatment, and the political difficulties of improving care for drug users, mitigate against measures requiring service providers improve their treatment of clients. As we found during our research (and other research concurs), doctors do not like being told what to do, and pharmacists and nurses feel the same. If individual doctors and pharmacists withdraw from the field of pharmacotherapy treatment, this can have drastic consequences for clients in their area. Usually the program relies heavily on each service provider involved. Nevertheless, there is probably no more direct way than this of improving the experience of treatment for clients (and for clinic and pharmacy staff who dislike the poor standards of treatment they witness). It might be that service providers’ equally strong preference for clinical support could be more effectively folded into the rationales provided for any such moves to codify acceptable standards of treatment. In both this and the previous recommendation the emphasis is on elaboration and expression rather than silence.

Related to this focus on elaboration and expression in treatment, we argue that risk management principles should be communicated more effectively to clients if they are to remain embedded in treatment. If, for instance, the limitations imposed on takeaway provision are mirrored by limitations imposed on the broader community when strong pain medications are prescribed, then this should be made known. Our data suggest that, at present, methadone clients believe themselves exceptional in terms of the limits placed on access to their medication.

Addressing the practices of individual service providers, while useful, is not the whole answer, of course. As Treatment Identities demonstrates, service providers recognise the needs and capacities of clients, and would like to be able to refer clients to other services where appropriate: housing, employment, counselling and parenting assistance are the most obvious. methadone maintenance treatment does not exist in a vacuum, and cannot address all its clients’ needs. Issues of interagency partnership and referral are often discussed in the context of meeting the complex needs of drug users, but a more pertinent question is often the existence and accessibility of these services in the first place. As we have argued, the forms that solutions take reflect the efficacy with which problems have been formulated. To generate valuable solutions we must formulate problems insightfully and clearly. Treating methadone maintenance treatment as the provision of a drug and little else entails a particularly narrow view of the ‘problem’ of regular heroin use, and is unlikely to generate the necessary resourcing or, in turn, produce optimal results.

There is, of course, a burgeoning literature on poverty as a ‘determinant’ of problematic drug use. Our focus has been on the responsibilities of the state to meet the needs of its (present and potential) citizens ― nevertheless, it is clear the retreat of the state has the greatest impact on those without resources, and methadone clients are often among these. This point invokes another potent binary with which we have been concerned, that of the opposition between the material and the intimate (between base and superstructure; between the economic and the cultural). Connected very closely with the real/representation binary, this is also concerned with ‘material’ in a different register from Barad’s materiality: that of materialist criticism, especially that concerned with the lives of the socially marginalised. We have operated from a critical perspective on any distinction between the material and the ideal. Poverty and privilege do not ’cause’ the practices of everyday life, any more than everyday habits cause poverty, but neither do intimate practices and material resources float free of each other. While rejecting the trend to enumerate the cultural deficits of clients, caused by their poverty or drug use or both, we have nonetheless been concerned throughout to elaborate the enfolding of the material and the intimate.

Such enfolding practices include those noted in The Chronotope of the Queue, where excesses of waiting and queuing were described, along with alienating treatment such as outdoor dosing. This post included the most directly formulated recommendations of all posts, many of which relate to the conclusions drawn in the others. Is treatment adequately funded? Are enough places available? Are the environments in which treatment is delivered given sufficient attention as to comfort and security? Is urine testing conducted in the most efficient, most humane way? Indeed, is its indispensability regularly reviewed? If, as we have argued, methadone maintenance treatment produces the very subjects it seeks to cure, how can it be redesigned to minimise this tendency?

Part of this process of elaboration also involves generating greater awareness of the heterogeneity of clients, and this was in part the aim of Treatment Identities. The most visible clients are usually the most marginalised. The majority of methadone clients do not make demands on an overstretched system, do not place themselves or their children in danger, and do not require extra surveillance or support. The right of these clients to be ‘invisible’ within policy and media debates must be protected, at the same time as their existence is acknowledged. Where adequate recognition of the diversity among clients occurs, insufficiently respectful practices will neither be conceived nor tolerated.

In the last post we examined the operations of gender in materialising treatment, and found, among other things, that asymmetrical understandings of men’s and women’s agency significantly influenced treatment decisions among service providers. Decisions about continuing to treat clients or referring them on, decisions about allowing clients’ takeaways, decisions about dosing levels: all these are co-produced through gender, though rarely in considered ways. As we argued, the notions of agency informing these decisions are directly linked to concepts of repetition and passivity at work in treatment, and all these related concepts (again, those found in the dualisms laid out earlier) impact on male and female clients in different ways. This post prompts two quite different recommendations, then. One returns to a point made earlier on questioning the benefits of conceiving treatment as repetition (in particular as sameness), and proposing new ways of thinking treatment that incorporate the possibility of change without elevating it to an ideal. The second is more local: training for service providers needs to consider carefully the ways in which understandings of gender result in male and female clients being treated differently and, in particular, responsibilising women not only for their own acts, but for those of their male associates as well.

In making all these observations and recommendations, we stress that our main emphasis is not on individual (be they client or staff) deficiencies and solutions, although of course we have relied on the time and generosity of individuals in sharing their experiences of treatment, and this book has been animated by their accounts. Instead, we call for change that involves a different scale of analysis ― the reconceptualisation of key concepts, the rethinking of central relationships, the expansion of funding. In keeping with our argument, of course, the changes we propose do not invoke sobriety, autonomy or rationality. In all this critique and construction, however, we take a risk. This is the very real risk we call on others to take: that of representation, and its concomitant (yet unruly) materialisations.

Our intention is that amid the many ideas and paradoxes thrown up by this book, our central set of concepts, and the relations between them, repeat, and in that repetition, propose and even signal change. What does methadone maintenance treatment do? What is the relationship between concepts and matter? What, and who, acts? How can agency be understood within a critical approach to liberal values? Lastly, what is research, what is its action and its responsibilities? This final question is, of course, merely a specific instance of the three questions that came before ― concepts, matter, agency. All these questions, these terms, are contingent. Indeed, they are entirely intra-active, or we could say, ‘intra-dependent’. Here, of course, we invoke dependence deliberately. As this book has suggested, aversion to dependence is at the centre of addiction’s denigration, and methadone maintenance treatment’s marginalisation. Yet dependence is intrinsic to us all: clients; service providers; those in policy and the media; researchers; and families, friends and acquaintances of those in treatment. All co-constitute, albeit some more directly than others, the phenomena of addiction and treatment, so all are intra-actively responsible for their materialisation.