Methadone Maintenance Treatment: The Stable User

2015

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 to describe both drug use and social circumstances:

She’s twenty-three, and she is what we would call stable. She is on a massive dose, I think a hundred and fifteen, well that’s not massive, that’s what she needs. She, um, other indicators are there. She’s got a relationship, an intimate relationship that’s really going well for her, she’s got stable affordable safe housing, she has reconnected back with her family […] she’s swallowing her methadone every day.

(Beverley, Melbourne, Victoria, nurse/case worker, 50s)

Danny, a client, uses the same term to describe approval in the eyes of his doctor, while Jenny, also a client, has a more specific use of the term: she was judged to be stable because she behaved appropriately, but in reality she was not.

I like [the] respect of the doctor giving it to me quicker, it means that he thinks that I’m stable, sure but the bottom line is I actually have got the takeaway.

(Danny, Sydney, NSW, client, 46)

I was deemed to be, you know, like a stable client, for want of a better word, which I wasn’t but, I mean I did pay and I didn’t cause a fuss.

(Jenny, Sydney, NSW, client, 46)

Graham uses the term to describe the absence of diversion or unwarranted drug use, Kara in terms of managing withdrawal:

I’d say definitely the first six months you should be going five days a week to the chemist and you should have to go weekends if they’re open. I honestly believe that, when you start. ‘Cause you are most likely to do the wrong thing, and you need to get that stability. Once you’ve got the stability […] then we should progress, we really should.

(Graham, regional Victoria, client, 39)

It actually stabilises me so I don’t actually want to go out and get a hit. Um, it makes me feel normal, so I don’t feel like I’m hanging out, or I’m sick, or wanting to have a taste really. […] Because once I’ve got that I’ve got that stability and then I can start working on getting back to work.

(Kate, Melbourne, Victoria, client, 27)

‘Stable’ can refer to the client in a holistic sense, or to levels of drug use, or to demeanour in clinics, or to employment. It can have more or less precise meanings; have a narrower or a broader sense. In contrast, while ‘chaotic’ describes what stability is not, it also commonly evokes more dimensions than drug use or behaviour in drug treatment. This is revealed in comments from clients:

[M]y own chaotic drug use um that meant that yeah I didn’t really know what was going on.

(Sue, Sydney, NSW, client, 40)

[W]hen we go onto methadone, our life is just chaotic, you know. It’s not like ‘hey, oh, I’ll go on methadone, you know, it’s trendy’. It’s not trendy at all, it’s just, you know, your, your life becomes unmanageable.

(Brendan, Melbourne, Victoria, client, 37)

Descriptions of chaos are more commonly evoked from health care workers than clients, however. The uses of the term are illustrated by the following quotes from Rosemary, Beverley and Tom.

I think the level of chaos is the [issue] […] they’re getting people from gaol, they’re getting people who are homeless who are living on the streets.

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

You’ve got access, transport wise, you’ve got poverty, you’ve got homelessness, transience, in and out of jail, domestic violence. You know, there’s just so many factors that contribute to this person’s chaos.

(Beverley, Melbourne, Victoria, nurse/case worker, 50s)

So if they stay in the treatment, they settle down, they stop using, they stop doing crime, their kids start getting looked after, they pay their bills, and they change pretty drastically within, you know, weeks, months, days sometimes. Um, you know, so people go from being very messed up and distressed and chaotic, to being pretty, pretty reasonable sort of folks.

(Tom, Melbourne, Victoria, pharmacist, 56)

Whereas ‘stability’ can be used to refer specifically to drug use, ‘chaotic’ is almost always about things other than drugs, such as housing, employment, family, crime and poverty. In the context of this ‘chaos’ that describes drug use but is always about more than drugs, methadone is often discussed as a means of addressing these non-drug problems. ‘Chaotic’ and ‘stable’, then, are not simply synonyms for addicted and not-addicted, and use of these terms highlights two connected points. First, drug addiction can be about more than drugs and, second, methadone addresses things other than other drugs. This recognition of the not-drugs dimensions of drug addiction has, in turn, another implication, which is that methadone use can coincide with illicit drug use and, further, that illicit drug use does not erase the effects of methadone in addressing addiction.

‘Chaotic’ and ‘stable’ are among a range of binary oppositions common in discussions of drug use. Probably the most simplistic is that between drug use (bad) and abstinence (good). Others distinguish between different kinds of use and different kinds of users (). In these typologies the key question is often that of addiction, or dependent use. The distinction between chaos and stability is different. In many respects, this distinction is problematic (as indeed are distinctions between use and addiction). It can conceal assumptions and disguise moral values as clinical. However, the vagueness and flexibility of the terms ‘stable’ and ‘chaotic’ also give rise to the possibility of a new identity: the methadone client who is a stable user.

[E]ven if they’re still casual users they still, they still become a lot more stable, you know they’re not out running around stealing and ripping people off and things like that, you know it does stabilise people up even though they might still be using. It’s not a bad thing like that.

(Darren, Sydney, NSW, client, 47)

[T]he general attitude is that if people are using they’re not stable. But the truth is that some people can be stable and still using. They may be, they just may happen to be using at the time that they had the urine done, and that may be once a month. We do have recreational heroin users who, who were using a lot and now just use as a treat every fortnight when they get paid.

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

Any opposition between illicit drug use and abstinence due to treatment is undermined by an identity particular to methadone maintenance treatment: the stable client-user. For this identity, whatever methadone is doing it is not substituting (completely) for heroin and it is not blockading heroin. In other words it is not acting in either of the two roles prescribed for methadone. Yet this is not to say it is doing nothing. If methadone ― as our data and other research indicate () ― effects change to ‘chaotic’ drug use and can be used alongside illicit drugs, then this has the potential to unpack some complacent assumptions. For example, when methadone is used alongside illicit drugs in a strategy to correct or change behaviours defined as chaotic, one-dimensional arguments about drugs causing chaos do not make sense.

Equally, the category of ‘stable use’ may unpack distinctions between use and addiction, in that use of heroin, usually understood as inherently unmanageable, addicted and chaotic, can coincide with stability and broad compliance with the rules of treatment. Moira, a client from Melbourne, is explicit in her refusal of both the notion that her use of heroin was chaotic and the idea that methadone caused huge changes to her, or her use:

I suppose I would be on methadone if I wasn’t working, but if I had the access to the money that I do from working, then I would prefer just to use rather than be on methadone. But because I do have to work to get that money, and because, to get that money I have to turn up to work and be functional and do a job, I can’t really rely on an illicit supply. Um, it’s sort of putting the responsibility for my capacity to work on an illicit black market […] I sort of need to be on methadone, you know, in case there is a drought, or in case, um, you know, my dealer does stop or run out, or get busted or, you know, whatever.

(Moira, Melbourne, Victoria, client, 38)

Moira uses methadone maintenance treatment to ensure that the relationship between her heroin use and her capacity to work is predictable and continuous. Rather than methadone effecting changes to her level of ‘stability’, it effected other changes to her heroin use, namely that heroin is not the only drug available to her. Emilie Gomart’s (2002) analysis of the two clinical trials of methadone reveals that the question of whether heroin is the same as methadone or different is not resolved through reference to an inert, pre-given substance. Instead, ‘methadone’ is constituted through the event of the trial and the drug is one actor in a network that produces it. Similarly, the stable user reveals that methadone is not a given, preexisting substance with universal effects. Methadone is different from one context to another, and changes according to circumstance. It replaces heroin, complements it, provides backup in its absence. It differs between individuals, and may change over time for particular individuals.

The stable user, then, illustrates the importance of agency, negotiation and resistance to rules in methadone maintenance treatment. Clients who continue to use heroin figure in treatment guidelines and other texts, but usually, as Governing Treatment showed, in terms of risk. The stable user cannot be accommodated into narratives of risk or chaos and shows alternatives to both pessimistic accounts of liquid handcuffs and redemption narratives of socialisation and abstinence. Importantly, the substance of methadone does not have pre-determined effects, nor is it simply the product of social construction. As Substitution, Metaphor and Authenticity argued, the particularities of methadone lie in it being like heroin but also not heroin. Methadone is not the same as heroin; the client who is a stable user is different from both the client who only consumes methadone and the drug user who only consumes heroin. The drug methadone is co-constituted through regimes of governance and regulation, government subsidies, medical training, transnational pharmaceutical companies, randomised control trials, political arguments and the substance ‘itself. Its agential capacities are neither determined independently of its consumption, nor determining of its effects.

The stable user exemplifies making up people from ‘below’. Our next example considers an instance of people being made up from ‘above’.