Keynote paper presented at the
1996 National Methadone Conference
November 23rd

Nick Stafford
Project Officer
Gold Coast AIDS Association and Injectors Newsline
(GAIN)
PO Box 65
Nobby Beach 4218
Queensland

Methadone maintenance is widely regarded as the most successful treatment for heroin dependence. It has been accepted by the general public, policy makers, drug and alcohol workers, and opiate users.

However, methadone maintenance has been accepted by these various groups for very different reasons. Today I would like to explore these different beliefs and tell you about my experience of methadone: how it has affected my life and how as a heroin user, I understand these changes.

In doing this I hope to demonstrate three things.

That methadone maintenance has become a place within our society where two antagonistic belief systems come into contact and conflict. Put very simply these two beliefs are

A. non-medical opiate use is not acceptable. This is held by the majority of the general public, policy makers and drug and alcohol workers.

and B. non-medical opiate use is acceptable. This view being held by the majority of opiate users.

Secondly, the legal prescription of an opiate, not methadone itself is responsible for most of the benefits I have experienced while on the program.

Thirdly that opiate prescription, whether the opiate be methadone, heroin or anything else, is not a form of treatment, but a form of acceptance and respect.

I want to begin by saying that going on methadone has had a really positive effect on my life. It has allowed me to improve my financial status and my physical and psychological health. It has had these effects without any fundamental changes in my beliefs about drug use.

This is one of the reasons methadone maintenance has been so readily accepted by opiate users like myself. Because it respects our right to be opiate dependent and secondly because it does not have as a pre-condition of treatment that we change our beliefs.

What are these beliefs am I talking about?

they are:

That I believe it is my human right to use opiates or any other drug I feel like using, for whatever reasons I may have.

I feel my life has been enriched by the use of heroin, marijuana, speed, acid, and other drugs.

I believe these drugs should all be legally available.

And I will continue to use these drugs, if I so desire, for the rest of my life.

These beliefs are shared by many people on methadone as well as hundreds of thousands of other Australians. Even so, it is clear that these views are held by only a small minority. A household survey by the national campaign against drug abuse found that the vast majority people do not believe that non-medical use of opiates should be legalised. This non-acceptance of non-medical opiate use is supported by a common perception of opiate users.

To use opiates is to be seen as sick and therefore in need of treatment, not acceptance. Until the combining of harm minimisation and methadone maintenance all treatment had one main objective: adherence to abstinence on a moral and a behavioural level.

This insistence on abstinence clearly contradicts my beliefs and those of many other people seeking help from treatment services.

Methadone maintenance based on harm minimisation and needle exchange are the first two services offered to people like me that do not insist on abstinence as a pre-condition for help.

This does not mean however that the methadone program has become client centred. It is still clearly based upon the beliefs of the majority of the general public for whom opiate and other illegal drug use is not acceptable. This creates a situation for me, as an opiate user, that is full of conflict.

These two conflicting beliefs: opiate use is acceptable, opiate use is not acceptable, come in contact when heroin users like myself walk into a methadone clinic. I can best describe what I think happens by way of analogy:

Before the advent of government funded social services for the poor all we had in Australia was the church based charity groups. Heroin users walking into methadone programs are like the poor people accessing these charity organisations.

The poor person walks in and says,

"I would like some help, my life is little out of control at the moment."

The person behind the counter says, "we would love to help you, come this way, we will provide you with a meal and some clothes. But first we would like you to come in to our chapel. We would like you to pray with us to demonstrate that you share our beliefs, then we will see to your needs."

So the poor person goes in, sings some hymns, listens to a sermon, drinks from the holy cup and pretends he or she is a believer and finally gets the goodies and leaves.

Heroin users walk in to methadone clinics and say,

"Hello, my life is a little out of control, I would like some help."

The clinic worker says,

"We would love to help, but first you must prove you share our belief that heroin use is unacceptable. "

Of course you agree with the person, you want the goodies, so you look them in the eye and you say, "Using heroin is wrong, I'll never do it again, I want to be saved," But the person is not so sure, so they hand you the little plastic holy cup and say,

"See that room down the end of the corridor, go in there and pray and prove to us you do believe."

So you go in to the little prayer room. You drop your pants to you ankles and you pray.

"Please god I never asked for much before but right now I need some urine. I have to be at work in half an hour. Not just any urine either god, it has to be pure, I know I used some heroin yesterday but could you just leave that out?"

I failed every single prayer test during the first 6 months. My little offerings were not pure enough. This told the staff that I was an unbeliever. There were no smiles for me. Instead I got pursed lips and unspoken disgust. And no take aways.

I then moved interstate to a new job and away from the things that were stimulating what was to me too much heroin use. In a new state over the last 12 months I have cut my heroin use down to once a month and have slowly been reducing my methadone dose. I plan to detox just after Christmas.

I feel methadone has worked really well for me. Firstly it reduced or eliminated a number of physical and psychological stresses that being heroin dependent created in my life.

Most of these stresses can be traced back to the issue of money. Going on methadone removed all of these. I have always supported my heroin use with money earned from legal jobs and I was working full-time while dependent on heroin. Despite earning a good wage however, it wasn't enough to comfortably support a heroin habit.

Methadone removed the constant worry of how I was going to get enough money to score. It meant I could wake up each day and know I would be well enough to work and function in my social and home life.

I was able to pay my rent and bills removing the fear of eviction. I was able to spend more money on food and begin to regain the weight and physical strength I had lost.

It also meant I would no longer have to go through the constant mini detox's due to lack of money and it removed the fear of being busted or even worse worrying about my dealer getting busted.

In summary going on methadone ended 18 months of fairly constant stress. Before methadone the only way out was detoxing and recovering. Besides the constant mini detox's due to lack of money I tried to detox seriously about 5 times. Each time I managed to get through the first horrible week. However trying to work full-time while still seriously weakened and physically traumatised proved too much for me. Even after a month I would still be feeling unwell. To add to this, each detox attempt left me feeling weaker physically and emotionally and even less confident about coping with the whole process again.

So I went on methadone because I could not afford heroin, and I was sick from all the stress this entailed. From my point of view I would have been happy regardless of which particular opiate was on offer. Morphine, pethidine, opium, methadone or heroin, I would have accepted any of them.

If methadone was my drug of choice and cost as much as heroin on the black market and I had been offered heroin or morphine maintenance it seems clear to me I would have received the same benefits. The money stress and everything associated with that would still have been removed. So would the fear and trauma of constant mini detox's. The legal hassles would have been solved and all this would have allowed me to replenish myself physically and emotionally.

I can summarise this by saying I had three main objectives in going on methadone:

To stop my money hassles.

To put off the detox recovery process so I could continue working.

And to regain my physical, emotional and spiritual strength so I could detox and recover successfully at a later date.

I have been able to meet these three objectives and in this sense opiate maintenance has worked well for me. Many places including the Northern Territory do not have any opiate maintenance programs. I realise that I have been lucky and I am grateful for that.

I don't feel I have been treated though. These benefits are due to the program neutralising, reducing or removing the negative impact created by the laws of our society and attitudes of those people who do not accept my use of opiates. I am legally being given opiates. The concept of treatment does not accurately describe what I experience. To me it is a label used to convince the general public into allowing something they don't agree with to occur: namely the legal selling of opiates to people.

To be honest I think treating opiate dependence by prescribing opiates is one of the best medical cons of the century. We have managed to swap one opiate for another and call it treatment and have the public believe us. And people say heroin users are good scammers.

Methadone is acceptable because it is said to be different for three reasons. It has a half life of 24 hours, it can be taken orally and it doesn't give the person any enjoyment. The 24 hour half life is mainly an administrative and economic bonus. And other opiates can be taken orally. It is also possible to get pleasure from methadone you just have to know the right way to administer it. Personally I don't inject my methadone although I understand exactly why people do it.

Put it this way, imagine if you went to see a doctor and said, "Doc, I have got this problem can you help me?"

He says, "Yep we have a really successful, safe treatment for that."

"Great," you reply, "are there any side effects?"

"Not really, nothing too serious, you just have to take this drug once a day. You will become physically dependent and experience constipation, sleep disturbances, lower sexual drive, maybe increased sweating. At the end of the treatment we bung you in hospital for about 10 days, just a slight flu like thing, nothing to worry about."

I mean it's a hell of a treatment. If I am going to have to suffer all these side effects of opiate dependence you would think the doctor could at least give me an opiate that gave me a little pleasure as compensation. But no he has to prescribe, what is for me anyway, the least enjoyable opiate of all. There are all sorts of reasons and justifications for this but they mean nothing to me. I just feel I am being punished.

To go back to the analogy of the religious group, methadone maintenance is like having our rituals accepted in a very controlling way. "We will let you practice your ritual of using opiates every day but only if you accept certain conditions. You have to administer the drug in our setting not your own and you must accept the opiate we provide." It is an effective way of robbing my ritual of pleasure and the cultural meanings I would like it to have.

Because heroin use is one of our beliefs, I feel as a group, we have been vilified, demonised, marginalised. And this to me explains the huge ambivalence I feel towards the methadone program and the people who work within it.

On the one hand I am really grateful that you all support and operate this opiate maintenance program. As I have told you, it has really helped me in my battle to live with dignity within a society that will not accept my beliefs and practices. I hate to think what state my life would be in now if it wasn't for the program.

On the other hand I am still angry and always will be as long as my society refuses to accept my practices as legitimate and legal. The methadone clinic happens to be the place where my practices are accepted and yet tightly controlled at the same time. It is where I am most keenly aware of the this non-acceptance and yet also where I am offered help. The program is both my helper and my jailer.

This is why the attitudes and beliefs of clinic workers have such a big effect on how smoothly or not things run in individual clinics. Research by Dr Caplehorn in Sydney recently articulated what many of us consumers have always known and in some cases experience daily. There are people working in methadone who believe that opiate use is not only unacceptable but that people who use opiates should be punished. That abstinence is the only acceptable goal and maintenance is a temporary compromise.

While I am comfortable in my beliefs about drug use I am not a machine. Disapproval, non-acceptance, and negative moral judgements affect me. They effect my self esteem and my feeling of worth. I find it very difficult to develop real or honest relationships under these conditions.

Not all workers I have dealt with have expressed disapproval towards me. In my current clinic I feel respected by both my counsellor and the doctors. Yet I do wonder whether this respect is based on us not telling each other what we really believe but only, what we think, the other wants to hear.

My clinic recently asked the consumers whether we would like to attend a meeting and have a say in how the program is run. It was part of their accreditation process that required them to become more client centred.

I thought about going along but didn't. I don't think many, if any, of us attended. I thought to myself I bet the staff feel pretty disappointed in us. I can imagine them saying, "Here we are giving them the opportunity to have some input and they can't even be bothered turning up."

But it wasn't lack of interest that stopped me going. It was because the current guidelines mean that what I would like from the clinic is not possible. To me a client centred opiate maintenance program is very simple. It is a program that:

- Offers heroin, methadone and other opiates in combinations chosen by the client in consultation with staff

- It will allow clients to vary their doses so they can get stoned either at night or on weekends.

- It will provide general medical care

- and will provide counselling based upon an acceptance of the right to use opiates and other drugs and aimed at helping clients achieve their aims and goals.

- Finally it will advocate for the rights and needs of opiate users on a local, state and national level.

When we have clinics offering these services then we can truly say we are being client centred; that we are providing a service that is centred on the beliefs and needs of opiate users. Until then I wont turn up to the meetings called by my clinic. Not because I don't appreciate what they do for me, because I do, but because I feel there is no point. My beliefs and opinions are not acceptable.

It may sound like a contradiction but I while I can accept a person wanting to live opiate dependently for as long as they want, personally I don't enjoy it. Well that's not entirely true I usually enjoy the first month but after that it becomes a drag. I can not wait to get off methadone. I really dislike having my life controlled and restricted by the requirements of the program. But even if I was given 6 take aways a week I would still feel this way, which is not to say that I would not enjoy and benefit from 6 take aways a week. Rather it is the side effects of dependence that bore me. I enjoy taking drugs to change my consciousness, being maintained on a set dose defeats the purpose.

Being prescribed an opiate, being allowed to be legally dependent, has in the end only done one thing for me; it has put off the inevitable: detoxing and recovering. I went on methadone because I didn't feel able to detox and recover from opiate dependence given my level of stress and physical and emotional depletion.

Has being prescribed an opiate made me more ready and able to deal with this challenge? Clearly yes. You don't know what a relief that is. I really appreciate the program for this. 18 months after beginning I feel ready to begin the detox and recovery process. I have booked my annual leave for just after Christmas. I feel scared and apprehensive but also confident and excited.

That I have been able to reach this stage of preparedness is because I have been legally allowed to be dependent. This acceptance of my desire to use opiates, not any treatment is what has helped me get here. The program has not addressed the reasons why I became opiate dependent. I have been offered no relapse prevention education. I have read and been told so many conflicting stories about what to expect from a methadone detox and recovery, from both health professionals and opiate users, that it is impossible to know who or what to believe.

Fortunately I had the resources to take things into my own hands. I sought out a counsellor and during this year I have learnt a lot about what makes me tick and the emotional processes that made remaining an occasional opiate user difficult for me. It is very clear from my experience that it is a gross generalisation to say that dependent opiate users are dependent because of emotional problems . With me however there is some truth in this statement.

I really respect the counsellor I have at my current clinic. He is a nurse and is compassionate, respectful and helpful. Psychotherapy is beyond his training and skills however. I think no less of him for that but recognise it as a limitation inherent in the program.

The majority of people on methadone do not have access to a counsellor with the kinds of experience and skills needed. The media hysteria we have had for nearly a century means that many people including counsellors have real difficulties accepting the belief systems of opiate users. This is very problematic because many people would agree that acceptance and respect are basic requirements of successful therapeutic or helping relationships.

This brings me to something that really worries me about the way we are practicing opiate maintenance. If people like myself, go on methadone because we find it too difficult to detox and recover from heroin dependence, why do people imagine we are going to find it any easier to recover from methadone dependence?

The label 'treatment' very neatly hides the fact that when a person leaves the methadone program they are still opiate dependent just as they were when they entered 'treatment' .

I have gone through the ways in which having a legal opiate dependence enables you to regain your health and well-being and how this creates a much better position to deal with the detox recovery process. However the absence of acceptable client centred support on a psychological level for most methadone clients suggests to me that we are going to see the following scenario:

Over the next 5 to 10 years the number of people who are on methadone for the 2nd or 3rd time is going to continue to increase. It brings us back to the problem that opiate maintenance was introduced for in the first place. The problem being our inability to devise ways of supporting people to successfully detox and recover from opiate dependence.

What can we learn from this; the legal prescribing of an opiate? That legally accepting a person's desire to use opiates dependently improves their health, well-being and chances of moving successfully to a non-dependent lifestyle if they choose.

It requires that we treat people who use opiates as a group who are different, not ill or sick. And that we listen to what they believe, need and want to do with their lives. It is not an easy thing to have happen. Opiate use is not acceptable to the majority of our community.

Yet one of things I really want to know as I approach the end of my treatment is how do I make sure in future that I remain an occasional user?

How do I avoid another habit? No one working within methadone seems to either want to or be able to help me with this question.

It highlights the difficult position people working in methadone are in. Society has asked you to help these "sick" people. But these people do not believe they are sick. We think we are just different and the "sick" label is used to both control us and negate the validity of our beliefs and practices. It is a difficult challenge: how to help people some of whose beliefs you either can not accept or are unable to respect.

It leads to an ambivalence that is impossible to remove without a change in the drug laws and attitudes within our community. Clinic staff are both our helpers and our jailers.

If you get confused about why some of us seem to be trying to get around the rules at times the reason is because, like all other humans we like to act in a way that is consistent with our beliefs. Like all groups of people whose practices are suppressed we will try and find a way around. Again it is not sickness, it is human ingenuity.
I would like to suggest that the confusion and ambiguity between helper and jailer is because society, not heroin users, have placed you in a very difficult position. They are paying you to help us but not respect our beliefs and desires.

We are like some primitive urban subculture whose practices mainstream Australia will not accept. Our practices are unacceptable in the way the aboriginal practice of spearing people through the leg as a form of punishment is not acceptable. You have been asked not just to help us but to civilise us. To convince us that our customs are barbaric and harmful. That we should abandon our beliefs, desires, customs and practices and accept another set of beliefs and customs in their place.

As with aboriginal communities, years of discrimination, marginalisation and disrespect have meant that at times we can be a pretty wild, out of control bunch. Some of us will go to extraordinary lengths to defend our rights and customs. The effects of this non-acceptance, discrimination and suppression mean that many of us, like myself, need help every now and then. Like the aboriginal's appreciation of white people who help them, we are grateful for your help.

But please, do not forget, it is self determination we would like, not assimilation into another belief system. Acceptance, choice and respect not treatment and control.

Thank you

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