Methadone Maintenance Treatment: Dissatisfied Customers

2015

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 with phone calls and she’s sometimes written the wrong thing down on my prescription.

(Lisa, Sydney, NSW, client, 34)

Being made to wait, and being treated indifferently, has happened to most of us at some time, for example in the queue at the bank or the airport. In this sense the experience of treatment is described as comparable to other experiences of customer service. However, as Rowan indicates, there is an inflection to poor service provision in the retail environment of the pharmacy that is peculiar to methadone maintenance treatment:

Like [in a rural pharmacy] they used to, they used to make me wait a bit, and maybe that’s just paranoia, I’m not sure, but, you know, I got the feeling that ‘oh, yeah, he’s just a junkie, we’ll, you know, just let him wait there and serve him when, when we’re ready’ sort of thing.

(Rowan, Melbourne, Victoria, client, 41)

Drug users often are not seen, and often do not see themselves, as the same as customers who are not drug users. Their drug use separates them from others. In some cases clients are constituted as quite radically different from customers. For example, Sam, a client from regional Victoria, describes the hostility between staff and clients in one setting as an effect, rather than a cause, of deliberately impersonal and distant service:

They, they were behind a sheet of glass so you couldn’t even talk, have any contact with them. They just passed your methadone under a little window. Because, and that fostered an atmosphere of tension and animosity between the staff and patients. To the point where people would throw furniture and yell and scream at them, because they couldn’t, they didn’t feel they were having contact with their provider. And, you know, they felt like they weren’t listening because they were behind the sheet of glass, you know, someone is pressing a button to talk to them.

(Sam, regional Victoria, client, 31)

As we have seen in other posts, everyday conflicts, frustrations and degradations can play important roles in the experience of treatment. What is perhaps less obvious is the uncertain boundary between patient and customer at work here. Ivan, a Sydney client, describes getting his methadone from a pharmacy as ‘just like shopping’ and in some ways treatment is enacted through procedures that resemble buying a newspaper or catching the bus: turning up to the same place every day, paying, collecting the same thing. In other ways, however, it is performed through biomedical repertoires and constitutes clients as patients. It requires intimate information, such as that gained through urine and blood testing, and these requirements can enact conflict or humiliation. For example, Faith, a client from Sydney, says that ‘it just seems like even if we just need to use the toilet to [pass] urine you have to go through this big spiel with them’.

Disrespect, poor communication and lack of flexibility appear to characterise relationships in some cases. Faith and Kimberley describe attitudes of hostility and the threat of withdrawal of service that would not be countenanced in most shops, or indeed in most health services:

I walked in there one day and they were running late with their dosing and I said to them ‘running late?’ next thing they’re saying, she turned around and says ‘oh well we’ve got things to do, we’ve got to set up this machine, we’ve got to do this, we’ve got to do that’, you know all these excuses and then it ended with ‘if you don’t like it go somewhere else’.

(Faith, Sydney, NSW, client, 50s)

That’s what I notice with, um, my new pharmacy, is that it’s got like a stand over tactic. You’ve got your hostage here, if you don’t like it, go somewhere else. And going somewhere else out there is like, going three suburbs away.

(Kimberley, Melbourne, Victoria, client, 27)

When daily dosing is required, proximity to home or work and to transport is critical; refusal of service at one place can mean massive disruptions. Moreover, discipline to the extent of removal from treatment altogether is a possibility for all clients at any time. Ned, a pharmacist from Melbourne, reveals the contradictions in treating clients as both retail customers and unreliable drug users:

[W]hen I have an interview with them I ask them to treat us like a normal retailer, and we’ll treat you as a normal customer. Now, if, if they understand that, I mean I ask them not to come in with anyone else. Um, I mean, we’ve got a few with kids but, so that’s fine, but the kids have got to be kept under control.

(Ned, Melbourne, Victoria, pharmacist, 48)

To risk labouring the point, ‘normal customers’ are not routinely told that they have to come into shops without their family, nor warned as a matter of course that they have to keep their children under control. Other logics are also at work here. Conflicts are not rare, and, as The Chronotope of the Queue showed, the operations of treatment are often conducive to conflict. Yet the identity categories circulating around drugs place these conflicts in a particular frame, such that complaints about treatment dovetail readily into interpretations of ‘chaotic use’ or ‘drug-seeking behaviour’. This underlines both the limits of clients’ capacity to legitimately complain and the consequences when complaints are judged as unreasonable. Some clients reported that staff expect or assume dishonesty from clients. This means that changes to client routines or occasional requests for treatment variation, which in most circumstances would be regarded as normal practice, are treated as suspicious.

I get, sometimes like even last week I had to ring up my doctor and he, I can hear it in his voice, he gets a bit annoyed and, and probably suspicious. I can hear that as well like because, I mean I know people that will ring up and chuck on that many excuses. I feel sorry for the doctors because some people genuinely do it just to rort the system.

(Ivan, Sydney, NSW, client, 34)

This constitution of clients as unreliable and dishonest is also enacted through practical measures. For example, in some locations intrusive and humiliating procedures have been implemented as a blanket response to methadone diversion, implemented universally. Isaac, for example, describes the response of a hospital (where many rural clients have to receive some of their doses) in regional Victoria to diversion of buprenorphine:

[T]here’d be a couple of nurses just watching you have it, and they’d both just sit there and stare at you the whole time, then you had to come up and lift your tongue up and all this shit. It was just embarrassing. Because sometimes, you know, someone would come in the door, you might know them, and you’re standing there with your hands in your mouth with these two nurses looking down your throat, you know. And that was because of what, what somebody else did.

(Isaac, regional Victoria, client, 38)

Our interviews with service providers also illustrate assumptions of client dishonesty. Bob, a pharmacist from regional NSW, reports implementing systems to keep track of what clients tell him because they cannot be trusted:

I’m a bit smarter now. I record the date their grandmother died in my files. And I record, you know, the date their grandfather died and all of that sort of stuff, and the date that their children died. So they can’t go and tell me […] it’s the anniversary of their grandmother’s death, or whatever, because I’ve already got it recorded.

(Bob, regional NSW, pharmacist, 52)

Scott, who works in policy in Victoria, makes a more general point about the trustworthiness of clients reporting drug use when they receive takeaways:

There’s a lot of trust involved in it. And there’s a lot of self reporting. I’m not saying that urine testing or whatever is a, is a good idea, but, um, yeah, it’s trust and self report, and, ah, I mean these, these are people who have drug issues otherwise they wouldn’t be turning up to the service. It’s a big point.

(Scott, Melbourne, Victoria, policy, 47)

William, a pharmacist from Sydney, reported dishonesty or unusual behaviour as an indicator that clients are using illicit drugs or misusing prescribed drugs:

[T]he urgency and the height that the arguments reach just suggests something else is going on. Uhm, the lack of rationality, or the lack of response to rational argument, but you know the construction of these incredibly elaborate reasons.

(William, Sydney, NSW, pharmacist, 43)

The pharmacy or clinic shares elements with retail settings, and complaints about poor service follow the logic of the dissatisfied customer, at least in some respects. However, there are very important limitations to this. Beyond a certain point ― and the location of this point resides mostly in the judgment of workers ― complaints reveal more than their content, become suspect, and shift or entrench the complainer not into the category of difficult customer but unreconstructed, chaotic user.

At work here, then, is the deployment of some existing categories and the creation of new meanings for them. Dissatisfied customers complaining about indifferent or inefficient service are hardly unfamiliar types, and neither are disaffected service workers talking about having to tolerate unreasonable things from customers. However, there are also some new things going on in this context that are not often recognised. The first is the very presence of the register of customer complaints at all. When methadone clients are constructed as intelligible only as either out of control drug addicts or functional and stable clients, there is little space for recognition of the grinding, quotidian harms and insults that enact the client as dissatisfied customer. Binaries like this also foreclose the possibilities of recognising clients as people with expectations of service that are sometimes met and sometimes not. Such recognition brings to light the particular frustrations of occupying the position of ‘dissatisfied customer’ simultaneously with the position of ‘drug addict’, when the latter places significant limits on complaints being heard or respected at all, much less acted on.

There is a further point to make from this, to do with the ways in which the quality of treatment and service has been recognised. Research on respect and courtesy in services indicates that the manner in which services are delivered is important (). Yet a focus on treatment retention tends to present clients as either in treatment, an indicator of treatment success, or absent, an indicator of treatment failure. The effect of treatment on participants is oversimplified in these kinds of binaries, as is the understanding of what and whom treatment produces. Further, these binaries assume a one-way process of treatments acting on clients, pre-existing subjects who remain constant in every respect except for the fact of receiving treatment, being acted on. While this can be a valid approach to improving treatment services, it is of limited use in improving understanding of how treatment acts on people and changes them. The relationship between clients and treatment is not a one-way process and, as we argued in The Chronotope of the Queue, treatment both makes changes to people and is changed by the people on whom it acts. A more nuanced approach is needed to think through some clients’ readings of surveillance and care, as suggested by this comment by Rowan:

Well I don’t think she cares that much really. Um, and I just get the feeling that she just wants to get people through and, as quick as she can. Whereas I used to go to another, another doctor for a while in Melbourne, and, um, he was really good, and I got a urine test every time I went there. And, I’m happy to do that.

(Rowan, Melbourne, Victoria, client, 41)

Rowan suggests that the time and labour of urine testing equates to care, whereas for other clients the procedure is humiliating and an indication that their word is not trusted. Clients and service providers also discussed the gratitude with which basic courtesies are sometimes received by clients, which supports other research into the reduced expectations of disadvantaged groups, including drug users (). However, the comment below from Jack indicates that more is going on in treatment than this:

I see all of them every day or every second day. You know I’ve been out with them to music, music’s one of my things, and often they’re musicians and things. And, I’ve been out to a couple of things, I’ve been to a couple of their funerals. I, they would say, and I would say, I treat them with respect. Um, they often say, ‘this is the first place that I have not been treated with suspicion and as a lower form of life’.

(Jack, Melbourne, Victoria, pharmacist, 62)

Participation in the program changes service providers, and positioning health care workers as static subjects misrepresents the impact of worker-client relationships on workers as well as clients. Some pharmacists reported very close connections with clients, some clients very close connections with pharmacists. In-kind arrangements for payment were sometimes in place, for example, whereby a methadone debt was paid by fixing the pharmacist’s computer, or doing some gardening. Pharmacists and clients see each other between two and seven times a week, often for periods of months or years, and this can lead to tension, open hostility or, sometimes, friendship and closeness. Alongside the dissatisfied customer and instances of startlingly insulting treatment, then, are instances of relationships and support that cannot be captured under the rubric of either customer or patient.

What is revealed by a consideration of the case of the methadone client as dissatisfied customer? In the first place, we can see that complaints and criticisms made by clients and workers are part of the activity of the drug and program, working to change the program and also working to change people such that they inhabit particular spaces relating to consumption, service and obligation. Examples of these are the changes in service brought about through such things as conciliation meetings between clients and workers, through the rapport between service providers and clients just described, and through clients positioning themselves successfully as entitled to higher standards of treatment. Second, we can see that the consequences of this can also be invidious in that situating the client as a customer can occlude the real dilemmas and restrictions placed on clients, and distort the power relations at work. In producing an identity position of dissatisfied customer, methadone maintenance treatment puts the lie to any idea that clients are zombies or too passive to talk back to power. However, the transformative possibilities of customer dissatisfaction are pretty evident in any context, let alone a drug treatment one. Moreover, the positioning of clients as customers distorts their obligations and the consequences of failing to meet them.

Third, the identity of clients is not an unhappy combination of the identities of ‘patient’ and ‘customer’ but, in the context of methadone maintenance treatment, has very particular meanings and effects. Some of these are transplanted from customer service, some are from patient-doctor relationships and some produce clients as analogous to client states, bound by contracts and agreements that belie inequalities (). All of these work together to produce an identity of methadone client that cannot be reduced to either patient or customer. The identity of drug treatment service consumer, however, is one instance where this irreducibility is giving rise to new categories. Rose and Novas (2005) argue that biosocial groupings include new forms of activism (‘rights bio-citizenship’), new forms of knowledge, especially about health and medical status (‘informational bio-citizenship’) and new forms of collectivity and organising, mediated by information technologies such as websites and email lists (‘digital bio-citizenship’). Each of these is evident in the work of user groups such as the Australian Injecting & Illicit Drug Users League (AIVL). Using mental health and disability services as analogues, these groups act in a number of ways for the inclusion of user views and experience: developing policy position statements, conducting peer research, publishing policy and user magazines and representation on government committees (Australian Injecting & Illicit Drug Users League, 2006; Bryant et al., forthcoming[b]). This model of advocacy shares similarities with other patient support groups and social movements, and also departs from them in important ways. It argues that consumers of services have specific expertise as well as experiential perspectives, and that specific resources should be dedicated to ensuring their active involvement in policies and program. In particular, it argues, the discrimination and stigma imposed on drug users lends particular urgency to the need for consumer representation. This relatively new identity construction of the drug user as treatment service consumer suggests possibilities for the biological citizenship of clients.

Finally, while any treatment or service relationship is bound by explicit and implicit rules of conduct, the client’s position in treatment is especially precarious, and felt to be so. Dishonesty and violence are not tolerated anywhere, and anyone who threatens the person behind the counter can expect to be told to leave at the very least. However, the expectation of dishonesty or antagonism, combined with the lack of real choice of doctor or dosing point in many cases, effects limitations on client complaints and dissent that are probably unique within medical treatment. Access to methadone has an enormous impact on clients’ lives, and the fragility of that access, its felt instability and the constant danger of its being lost, is unlike either customer service or other kinds of treatment.

The enactment of the client as dissatisfied customer reveals much then about treatment relationships, power and what is known about drugs and users. The next identity to be considered also illuminates new categories and new possibilities for understanding what and who methadone maintenance treatment produces.