Methadone Maintenance Treatment: The Lay Carer

2015

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 one day’s dose happens in some cases so people can remain on the program.

Another disruption to conventional understandings of diversion as pathological commerce is the program’s informal networks of sharing and exchange. Clients and service providers report that diversion takes the form not only of selling but sharing methadone with friends and partners who are withdrawing from methadone or from other drugs. Sharing is identified in the Victorian guidelines as a type of diversion:

One characteristic of substance misuse is the phenomenon of sharing with other drug users. Pharmacotherapies are no exception, and patients may share their prescribed drugs with non-tolerant associates, with serious adverse consequences. Deaths have occurred as a result of patients sharing their takeaway doses of pharmacotherapies with friends or partners.

(Drugs and Poisons Regulations Group, 2006: 22)

This appearance of sharing in the Victorian guidelines seems to be a recognition of the unremunerated circulation of drugs through social networks and suggests the range of practices that are normally grouped into categories like ‘misuse’. Our reports from interviews, however, emphasise that sharing most often occurs between opioid users, to assist during periods of withdrawal (often described as sickness), not between users and ‘non-tolerant associates’:

Yes, I was just helping out friends that aren’t on programs, that use. And, before I went on the program, I had a friend that would help me, you know, like, I had to go to hospital, and um, she was a legend, she brought me methadone down and, and stuff. And I was in there five days before the drug and alcohol worker came to see me.

(Alina, Melbourne, Victoria, client, 39)

I’ve given [my partner] some of mine to get him through and things like that. And we’ve had friends that have been um ahh have been really sick and um we’ve given them some to get them through. I don’t mean physically sick, I wouldn’t give someone, I mean sick hanging out sick.

(Renee, Sydney, NSW, client, 37)

But I, I’ve seen, like people before, like, you know their mate’s hanging out, and they’ll go ‘oh, here, have a sip of this’, you know, ‘and it’ll help you out a bit’. That sort of thing, where there’s not money exchanged, but ‘just have a sip of my methadone, and you know, you’ll feel a bit better’.

(Kate, Melbourne, Victoria, client, 27)

Sharing with non-tolerant friends, and taking methadone without permission, the examples described in the new Victorian guidelines, were not discussed by clients or service providers in this way. (Theft of takeaways in share houses and other communal spaces was discussed, but as theft, not as sharing.) In some cases people describe sharing between treatment clients, in some cases between a treatment client and an opioid user who is not a treatment client.

Like, it’s a bit hard if, you know, your boyfriend or partner is, like, hanging out in withdrawal, and obviously if you’re on methadone you know what that’s like […] Depending on the relationship of course, but, like, you know, ‘glug glug glug, oh, I’m fine, oh well, we’ve got no money bad luck, you hang’. It’s, you know, it’s like, if you love someone, you’re going to, and even, um, you know, if someone turns up on your doorstep and they’re just desperate and sick and fucked, you’re going to give them some of your take-away

(Moira, Melbourne, Victoria, client, 38)

As these examples show, and service providers and policy workers acknowledge, sharing is a form of sociality and care. Rose and Novas () describe biological citizenship as involving ‘a set of techniques for managing everyday life in relation to a condition, and in relation to expert knowledge’, and while sharing of methadone is utterly at odds with most orthodox notions of normative citizenship, sharing of methadone can involve, to cite Rose and Novas again, ‘ethical seriousness’.

It’s a generous thing to do, ah, a generous thing for an opioid dependent to give an opiate away. You know, there are, these things are valued.

(Colin, Sydney, NSW, policy, 46)

This then is our final example of new identities created by methadone maintenance treatment: the lay methadone carer. Concerns about methadone diversion circulate around the program’s sustainability in general and access to takeaways in particular, so it is important to clarify the range of activities that are grouped under the rubric of diversion (). From another perspective, criticisms of drug treatment on ethical and political principles could also benefit from this knowledge. These activities and the new categories of client to which they give rise operate in the dimensions of care and self-care. Drug treatment has been criticised as regulation and surveillance masked as care. Drug treatment itself is linked to the control of deviance, the making docile of unruly bodies. Helen Keane points out the pessimism, if not quietism, that can result from this:

[A]n overarching suspicion of regulation can lead to a situation where all health programs and medical care are diagnosed as inherently oppressive. This stance can bring about a conceptual and practical impasse in which attempts to care for others and oneself can only be diagnosed as paternalism, surveillance or co-option into a disciplinary regime.

(Keane, 2003)

She writes that there are ‘other ways to envisage the demands of care’ (). The production of the new identity of methadone carer is an example of alternative means of understanding caring than capitulation into an oppressive social order. It suggests negotiations of the field of medical regulation and care that are largely unrecognised. Moreover, it also suggests a means of addressing the gloomy assessments of treatment that circulate. Recognition of the nuances of diversion has the potential to add a new dimension to knowledge of treatment. Of course, sharing of drugs is not peculiar to treatment; people who are not opioid dependent also share illicit and prescription drugs. However, the sharing of methadone is distinct from this and adds weight to arguments that diversion of methadone has more dimensions than reckless incompetence or greed. Diversion of methadone is often considered in a calculus of risks and advantages in methadone programs: on the one hand, access to takeaways makes programs much easier for clients to handle and so is associated with retention; on the other, takeaways allow criminal behaviours such as diversion. Equally, a great deal of policy anxiety is generated, as it should be, around rare and catastrophic incidents of diversion that result in the death of a child, or an opioid naive adult. Recognition of the nuances of diversion is therefore essential for effective policy responses; grouping all irregular use of doses under the rubric of reckless and dangerous diversion misreads those instances of diversion as informal care. The sharing of methadone, as with selling and buying among small social networks, also raises different policy questions from zero-sum arguments about diversion. Methadone gets sold among peers because of difficulties in getting access to treatment, because the operations of treatment regimes are such that clients cannot stay on them, and because agreements on appropriate dose can’t be reached between clients and health care workers. The lay carer is produced not only by the practices of illicit drug users around care and sociality, but also by the resource deficits and rules of the program.

Sharing also undermines critiques of drug treatments as necessarily paternalistic and debilitating. The sharing of methadone demonstrates that people do things in response to the drug and treatment rules that they would not otherwise do, that the program provokes new forms of activity. It is not necessary to celebrate methadone lay caring in order to recognise that clients can behave outside prescribed rules while being scrupulously careful about following different, informal codes of responsible treatment: looking after others and themselves, keeping doses safe. These behaviours can only occur within treatment and construct an identity peculiar to it. Analysis of methadone programs outside Australia emphasise client passivity and capitulation to dehumanising rules (). The possibility of occupying a space of care may be a point of differentiation between Australian and other programs. This could have implications not only for policy and assessments of treatment retention, but also for other, political considerations of drug treatment as suppressing deviance and producing docile, obedient bodies. Once again, easy distinctions between addicted and not, stable and chaotic, compliant and disobedient are troubled by this new identity. Conforming to neither stereotypes of degraded, reckless criminality nor functional subjects perfectly reinstated to work and consumption, the lay methadone carer suggests new ways to understand the program’s imperfections and possibilities.