Supervised humiliation?

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Alex Boyt – pic by Nigel Brunsdon

In the real world, methadone provision too often means diversion, using on top – and humiliating supervised consumption, says Alex Boyt.

Read the full article in DDN magazine.

Methadone can be a life saver, both metaphorically and literally. However, many heroin users do not welcome daily methadone consumption – it’s harder to get off than heroin and does not address trauma in the way that heroin does – it doesn’t hit the sweet spot. With methadone, withdrawals go on twice as long, it’s a nastier habit, it hooks you in deeper. Many users want methadone occasionally – it makes complete sense to them – but they must take it every day, or not at all. The treatment system demands it.

In contrast, I was diagnosed with ADHD some years back and after being prescribed Ritalin, I found that my daily dose of the long-acting time-release drug did not suit me, I didn’t want to be permanently medicated. My consultant told me that my prescription was appropriate for my condition and that I should continue with it. I told him that his job was to help me reach my desired outcomes, not have me comply with his regime. He relented, I received a mixture of short and long- acting pills of different strengths, and for many years I’ve used Ritalin at the dose I want and when I need it – I often have days off.

No substitutions

When I was a heroin user, there were times I received a methadone prescription. Like many of my peers, I did not want to substitute heroin for methadone – I wanted methadone for when I could not get heroin, so that I didn’t go into withdrawals. Heroin withdrawal generates a degree of physical and psychological distress that is all-consuming. I wanted methadone so that I did not do crazy things to get money, so that I did not inject other people’s old dried blood clots or crushed up pills, hoping for relief.

There was a time when I was prescribed methadone in a way that worked for me. I went to the chemist weekly to collect my take-home supply. Eighty ml a day was the prescription, and two or three times a week I took some. The unused methadone went into lemonade bottles and was kept under the sink. The dose was ‘a swig out of the bottle when needed’. Some methadone I gave to friends when they were stuck, some I sold to buy heroin or food, but that awful dread of withdrawal was gone – methadone was insurance.

My partner fell pregnant and, worried that her drug use may be reported to social services and risk having our baby taken into care, she disengaged from treatment. Her smaller methadone prescription was stopped. She cut down her heroin use and my methadone was sufficient to both keep her steady and give me an occasional emergency dose.

The service, however, grew increasingly concerned that my drug use was not reducing. My urine tests, when I gave them, were sometimes clean when I was able to manipulate the process – once or twice I would have shown up as pregnant myself – but too often heroin was detected. The service response was to increase my methadone dose to 90 then 100 up to 120ml a day. The service did not understand – and I was unable to say – that my prescription largely served a different purpose to my street drug use.

One day, collecting my script, I was called into a room and given the news that I was to be put on supervised consumption – my daily dose was to be consumed at the chemist watched by the pharmacist as I could not be trusted. Each day I was to consume 120ml of methadone that I did not want or need. My partner was now in trouble. I tried containers in the neck of my shirt to pour the methadone in while pretending to drink my dose, but it didn’t work and I left with methadone dripping down my clothes. The daily ritual humiliation did not last long – I disengaged with the service.

Using on top

Many years later, I was working as the service user coordinator for Camden Council in central London. The commissioners wanted to know why 30 per cent of those on methadone were using on top of their script. I took the question to the user forum, where 50 people with lived experience laughed. Taking a straw poll of raised hands, the majority thought the figure was more like 90 per cent. Reporting back to the commissioners, the issue was dropped – they could not be the first to reveal the emperor had no clothes.

The client wants to be well thought of and definitely doesn’t want to be punished with supervised consumption, so they under-report drug use. The worker wants to think they are doing well and to report success to their manager, so the under-reporting suits them. The service wants to report low drug use to the commissioners who in turn want to perform favourably compared to other areas. So, on one level, the worker says to the client ‘what’s the problem?’ and the client replies ‘I’m not going to tell you, and the worker says ‘great, I don’t want to know’. The therapeutic relationship is too often based on this agreement. I remember service users telling me that when asked for a urine sample, suggesting ‘next month might be better’ often worked.

Death is no deterrent

Methadone is a powerful drug. It is mentioned in significant numbers of drug-related deaths, but those numbers are lower than those mentioning heroin. Those not in treatment are more likely to die than those who are supported by a service, and methadone prescribing is the number one evidenced intervention in reducing drug-related deaths. Supervised consumption may be considered to increase safety, but it drives people out of treatment and prevents people from engaging. I remember a client who was cut off his script for missing three days methadone consumption at the pharmacy and was back on street drugs. He told me, ‘I can die, as long as I don’t die on their methadone.’

Supervised consumption may have a place in the treatment system, but it is over-used – a recent small study questioned how much safety it provides, and many more would consider engaging it if wasn’t a requirement. Methadone is diverted – it is not always the name on the prescription that gets the dose. It is not helpful to consider users as failing to comply with the regime, or showing they cannot be trusted, as too many workers and services do. It is traumatised people helping friends or coping as best they can with the daily emergency of battling withdrawals, anxiety, self-hatred, and the judgement of others.

A breathing space

Standing in the dock at court nearly 20 years ago, I feared the worst. The judge sentenced me to two years in prison, but before they could take me down, I swallowed the methadone from a bottle in my pocket that a friend had given me. I was not going into withdrawals alongside the shock of the sentence. It gave me breathing space before I was seen by prison healthcare the next day – methadone met my need perfectly.

There are some good services and drug workers. I like to think somewhere a user is saying to a drug service, ‘Your job is to help me meet my desired outcomes, not to get me to comply with your regime’, and the drug service saying, ‘Sure, how can we help?’

My son is happy and healthy and has just finished his first year at Bristol University. We rarely see his mother – she is still a chaotic drug user. Every now and then she engages with a drug service, but she cannot do the supervised consumption. Some days she is stuck in bed, some days she has enough drugs – she never lasts more than a week or two.