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 to the same degree, hold against the alcoholic or the smoker: that he cuts himself off from the world, in exile from reality … that he escapes into a world of simulacrum and fiction.

(Derrida, 1993)

Restitution to society includes incorporation of norms and the adoption of prescribed class and gender roles. Drug treatment is designed to facilitate these changes, although, as we saw in The Chronotope of the Queue, its specific operations often work against them. NSW’s treatment guidelines describe an instrumental socialisation process, access to services and so on. The ‘structure’ of treatment described by health care workers suggests something slightly different, which is that without the discipline of daily attendance clients may just hang around all day, in thrall to the pleasure principle:

[T]his chaotic group that I’m talking of are generally not employed, they’re generally not doing a lot. There doesn’t seem to be a lot of structure in their lives, so almost coming to the pharmacy every day is a point of structure.

(William, Sydney, NSW, pharmacist, 43)

You know, the client is working every day of the week, he needs takeaways. He can’t, you know, the pharmacy doesn’t open till nine, he’s got to be at work at seven. Um, things like that. So, I mean, that’s totally reasonable that the person has some, but, but then the guy who is just, you know, doing the me-too thing, it’s like ‘I want takeaways ’cause he’s got them, but I’m just basically in bed all day’.

(Tom, Melbourne, Victoria, pharmacist, 56)

Perhaps less evidently, methadone treatment also produced another figure who cannot be trusted, who requires regulation and structure: the unreliable health care worker. This figure is sometimes incompetent.

I think that private doctors need to be regulated […] I do tend to think that there are some doctors out there who don’t necessarily have an idea of what they’re doing, which is very unfortunate. Um and they can be seeing clients for many, many years um without really knowing what’s going on.

(Diane, Sydney, NSW, nurse, 30s)

Sometimes they are insufficiently scrutinised.

[T]here are guidelines for those doctors to follow, but they’re not always being followed. So who, who are they accountable to? […] When I work in the wards, and I still do, and when we give out, you know, schedule eight drugs, we have very strict guidelines that we have to abide by. But, ah, doctors, you know, can do what they like (both laugh). And they do, you know, they do.

(Pamela, regional NSW, nurse, 46)

Sometimes they are dishonest and exploitative.

Some doctors you can see are just there for the money and they’ll exploit the people and they couldn’t care less about them.

(Dominic, Sydney, NSW, pharmacist, 44)

And sometimes they have failed to do what was expected of them.

[W]hy would I want to jeopardise my program because a doctor either doesn’t know the guidelines or is too lazy to follow them? So [arguments with doctors] can often cause some angst, but only with guys that, as I say, are either lazy or, um, you know, just obnoxious, or, you know, sticks in the mud.

(Mario, Melbourne, Victoria, pharmacist, 40)

Health care workers, then, were seen as oddly similar to clients, as not only imperfect but imperfect in the same ways clients are. And just as clients were active in protesting their construction as childish, dishonest and irresponsible, so too service providers protested what they see as attacks on their autonomy. Otto, a doctor, describes treatment guidelines as not simply trying but punishing:

[I]t should ultimately be at the doctor’s discretion how things are done and the doctor should have guidelines, but I think they need to be, they need to be clear, unambiguous and uhm, and with less, with less of the kind of punitive aspect that’s been going around lately.

(Otto, Sydney, NSW, prescriber, 50s)

Again, methadone maintenance treatment enacts both clients and service providers, and in their resistance and reaction to these actions, both clients and service providers work to change both the treatment regime and themselves. This is another example of a new identity produced through treatment. In this case, it is the imperfect agent in need of guidance and structure which, in a neat circularity, treatment itself is said to provide.