Summary

  • Treatment should aim to reduce drug-related harm.

  • The client's motivation to change the component behaviours of their drug taking as well as their desire to achieve abstinence must inform the treatment choices made.

  • Appropriate treatment duration is a key factor in achieving positive outcomes.

  • The indications for treatment should be carefully considered following a thorough assessment.

  • Methadone shall only be used in the treatment of people who are opium dependent

  • Prescribing medication other than oral methadone mixture for the treatment of opiate dependence is controversial and should normally be undertaken only by a specialist service.

    The decision about what treatment to offer is based on:

    • What is available
    • The client's previous history
    • The client's current circumstances

    and the clinician's judgement of the required degree of:

    • Structure
    • Monitoring and
    • Support.

Introduction
Assessment allows us to formulate ideas about what the client needs so we can begin to look at the viability of the treatment options available. The treatment options that can be offered will probably depend largely on what facilities exist in your area as, with the exception of residential rehabilitation, funders are unlikely to buy treatment from outside their area.

Treatment choice must be guided by detailed assessment and clear treatment goals.

This section looks in broad terms at two of the principles underlying methadone prescribing:

  • Motivation and change
  • Harm reduction.

It then outlines:

  • Treatment options that are available
  • Criteria for choosing the optimum methadone treatment duration.

Motivation and change
A model of understanding drug-using behaviour and the process of changing it that is used by many clinicians in the field to inform their practice is 'the stages of change' model proposed by Prochaska and DiClimente.85

'Motivational interviewing' is the name given to the use of interventions, designed using this model, to help people achieve change in the component behaviours of their drug dependence and/or abstinence. Many clinicians use other psycho-social and counselling approaches to help clients resolve problems in all areas of their life while using the stages of change model to understand the processes the client is going through in terms of their drug use.

Most people who achieve lasting change in any ingrained behaviour do not achieve it at their first attempt. This is equally true for opiate use; most people who become lastingly opiate free have been through a series of detoxifications and relapses which finally result in a lasting abstinence.

It is possible to learn from each unsuccessful attempt, and to use the lessons learned to achieve better results in the future. The chances of success are higher if someone has been through the process of stopping and starting again than if they are stopping for the first time. For this reason it may be more helpful to view the process as progressing along an upward spiral rather than going round in circles.

Precontemplation: 'Problem, what problem?'
In this stage the drug user has no concerns about their drug use. Other people may have concerns and indeed the drug user may suffer all sorts of problems as a result of the drug use - but not identify drugs as the cause.

This perception can be reinforced by spending a lot of time with other drug users, thus rendering the problems they experience as 'normal' or by rationalising 'everybody takes something' or 'the people with a problem are the ones who are worse than me'.

People in precontemplation often benefit from the opportunity to get their drug use in perspective, to understand which of their problems are drug-related and to understand the reasons why they are using drugs.

If, to improve health or to achieve other goals, we wish to change the drug-using behaviour of a precontemplator, the initial aim is to enable them to weigh up the pros and cons of their drug use and to recognise problems and to attribute them accurately.

Contemplation: 'I'm not happy, but I'm not sure what to do'
People in the contemplation stage are concerned about their drug use but are often not sure what they can do - and may be ambivalent about whether or not they want to do anything. This may result in huge changes in what someone wants to do (and in their behaviour) from day to day.

It is in this stage, as much as in relapse, that contemplators frustrate helpers with urgent requests for help that are then not followed through. People may ask for a detox one day, relapse only a few days into the programme and come back a week later demanding an in-patient detox, but then fail to attend the assessment interview.

At this stage clients will benefit from help in understanding their predicament, coming to a stable decision about what they want, and identifying strategies to achieve it.

Action: 'I'm making changes'
It is at this stage that people implement the strategies and make the changes in their behaviour that they identified while contemplating change.

People spend the least time in action: the strategies either fail and they go back to thinking about change or they move on to maintenance. At this stage they need support, encouragement and help to develop a sense of perspective: it can be an emotionally fragile time.

Maintenance of behaviour change
This is an active state of holding on to the changes made. Complacency is the main enemy of maintenance.

The (ex)drug user may feel as if they have made it and fail to consider ways of holding on to the changes they have made - or look for danger signs. The helping services are often inclined to discharge the people in maintenance and go back to dealing with the more demanding contemplators.

When in maintenance people may benefit from help in identifying things that may go wrong, access to help in dealing with problems before they get out of hand and peer support from other people who are maintaining the same changes.

Relapse
This is a common successor to maintenance. The following cues often precipitate relapse:86

Negative mood states:

  • Boredom
  • Depression
  • Anxiety
  • Anger

Social situations:

  • Other people using drugs
  • Offers of drugs
  • Partners relapsing
  • Unexpected problems

Associations:

  • Flu
  • Media mentioning drugs
  • People
  • Places
  • Money.

It can be useful to work with clients to plan strategies for coping with relapse should it occur, but this has to be done carefully to avoid discouraging the client from attempting change.

Relapse need not be an entirely negative event. Indeed since most people who sustain maintenance have relapsed several times on their way, it is an important part of the process. Worker and client should be clear that an attempt to withdraw from drug use which ends in relapse is ultimately worthwhile as a step towards lasting change.

The value of this model is in reminding us that it is too simplistic to think of people as motivated or unmotivated. People are at different stages of motivation for different behaviours. It also puts into perspective (especially when compared to dieting or smoking) the attempts to achieve huge changes such as going from dependent drug use to abstinence.

Harm reduction

Adjuncts or alternatives to methadone treatment
A full menu of services to support methadone treatment would include:

  • In-patient detoxification
  • In-patient assessment
  • Out-patient lofexidine detoxification
  • Out-patient dihydrocodeine or buprenorphine treatment
  • Prescribing injectable drugs
  • Prescribing diamorphine (heroin)
  • Breathalysing facilities
  • Supervised Antabuse
  • HIV testing and counselling
  • Mental health services
  • Counselling
  • Psychotherapy
  • Alternative therapies
  • Employment advice
  • Skills training
  • Recreational activities
  • Residential rehabilitation
  • Supervised naltrexone

Important as all of these can be in supporting and enhancing the outcome of methadone treatment, many of them are, unfortunately, beyond the scope of this briefing and so cannot be described in detail.

Treatment aims
Before 1986 very often the only treatment aim on offer was abstinence. Even today many members of the helping professions are ambivalent about their role in working with drug users and feel (like some ex drug users) that the only 'real' treatment goal is abstinence.

Proponents of harm reduction are aiming at abstinence, as an ultimate goal, for most of their clients. The key to effective treatment is in the time scale that is envisaged before this goal can be reached, and the services that are offered to the drug user in the period before they are ready and/or able to achieve abstinence.

Methadone can be used in a number of ways to help people reduce their drug-related harm and to help them towards abstinence.

Justifiable aims for a methadone prescription would include achieving sustained contact with services that can offer the following:

  • Advice and information on HIV and hepatitis
  • Safer drug-using advice
  • Safer injecting advice
  • Counselling
  • Support, etc.

and:

  • Cessation of injecting
  • Significant reduction in illicit drug use
  • Reduction of high risk behaviour to acquire/take drugs
  • Increased stability in drug use
  • Reduced crime
  • Improvement of relationships
  • Cessation of heroin use
  • Cessation of other drug use
  • Ability to maintain or gain employment
  • Ability to maintain or start a college course
  • Reduction in drug use
  • Detoxification and abstinence.

Is prescribing methadone appropriate?
Methadone treatment may be justified if the following criteria are met:

  • The client is a non-injector who has been opiate dependent for more than 6 months
  • The client is opiate dependent and injecting opiates

and methadone:

  • Is not going to increase drug-related harm
  • Will help achieve appropriately set short and long-term aims from the list above.

However methadone is not an innocuous treatment and inappropriate methadone prescribing can:

  • Cause fatal overdose
  • Simply increase a person's total drug consumption
  • Increase the drug-related chaos in a person's life
  • Supply the illicit market
  • Demoralise prescribing and other staff
  • Reduce respect for the prescribing agency among both drug users and other helping agencies
  • Reduce the client's motivation and ability to achieve abstinence
  • Create opiate dependence.

Other reasons why someone might ask for a methadone prescription
Treatment of opiate use does not begin and end with methadone. Where people are not using opiates daily, or if they are using very low doses, medical treatments may be of very low priority. Not everyone who presents requesting a methadone prescription is a bona fide opiate dependent looking for help in changing their drug use. Other reasons might include their wanting the following:

  • A 'status symbol' - a methadone prescription is certification of being a 'junkie'
  • A source of income to buy heroin
  • Something to exchange for heroin
  • A way of keeping a partner with a more serious heroin problem stable
  • Help with their drug problem, believing that having a methadone prescription is the only way to get help.

Or they may be seeking a methadone prescription because they have been coerced by a:

  • Relative
  • Friend
  • Partner
  • Employer
  • Court.

Determining optimum treatment duration
The initial care plan should outline the anticipated duration of treatment. Clearly this can be modified over time but an agreement should be reached at the outset which outlines either the:

  • Planned treatment duration, or
  • Intervals at which it will be reviewed.

In 1990 the World Health Organisation convened a special meeting of international experts on methadone treatment and this group suggested a standard terminology for methadone treatment using these terms:

  • Short-term detoxification: decreasing doses over one month or less
  • Long-term detoxification: decreasing doses over more than one month
  • Short-term maintenance: stable prescribing over 6 months or less
  • Long-term maintenance: stable prescribing over more than 6 months.

The indications and contra-indications for these four categories are set out below.

Short-term detoxification
See also Section 9: Methadone detoxification.

Decreasing doses over one month or less
If methadone treatment is justified a minimum definition of successful short-term detox would be:

  • Contact with helping services during the treatment period
  • No illicit opiate/depressant drug use during the detoxification period
  • No opiate use for 1 month following detox.
Factors that would indicate that short-term detox may be a successful treatment option Factors that would indicate that short-term detox may not be a successful intervention
Strong motivation to become drug-free Little motivation to become drug-free
Strong social support network Poor social support network
Short history of opiate use Long history of continuous opiate use
Low daily opiate use High daily opiate use
High degree of control in opiate use Low degree of control in opiate use
No other drugs being used Poly drug use e.g. opiates, alcohol, benzodiazepines, etc.
Client requesting this treatment option of their own free will Pressure from others to undergo treatment despite reluctance and anxiety
Client has a clear vision of what they are aiming for and of the benefits of being drug-free Client only wants to be 'off opiates' and has not considered how to stay off
Availability of in-patient detox facility Early or late pregnancy
Detox is part of a care plan which includes residential rehabilitation Unavailability of in-patient detox facility
Client is smoking rather than injecting opiates Compulsory detox following breach of prescribing contract


Long-term detoxification

Long-term detox regimes are seldom the optimum treatment option, to read an additional piece on long-term detox written for this online edition of the book, please click here.

See also Section 9: Methadone detoxification.

Decreasing doses over more than one month
If methadone treatment is justified, and short-term detox has been excluded, a minimum definition of successful long-term detox would be:

  • Contact with helping services during the treatment period
  • No illicit opiate/depressant drug use during the detoxification period
  • No opiate use for 1 month following detox.
Factors that would indicate that long-term detox may be a successful treatment option Factors that would indicate that long-term detox may not be a successful intervention
Client determination to become drug-free with a recognition that other factors (physical, social, psychological) need working on as a pre-condition to successful outcome of the detox Client requests to become drug-free without recognition of the factors which may cause relapse
Failure of short-term detox: particularly if withdrawal symptoms precipitate relapse Long-standing chaotic, drug-using lifestyle
Client request for long-term detox Little motivation to become drug-free
Desire to address psychological issues during the detox period No desire to address psychological issues that may contribute to relapse
Social support system in place or that can be rebuilt by the end of the detox No prospect of a social support network developing during the detox
Need and desire to stop injecting behaviour in addition to detoxing Desire to use injected drugs in a controlled way following detox
Support available from a specialist and/or counselling drug service No support available from a specialist drug and/or counselling service

 

Short-term maintenance

Stable prescribing over 6 months or less
If methadone treatment is justified, and short and long-term detox have been excluded as options, a minimum definition of successful short-term maintenance would be:

  • Contact with helping services during the treatment period
  • Maintenance of contact with services
  • Cessation of high-risk injecting behaviour
  • Reduction/cessation of other opiate and depressant drug use.
Factors that would indicate that short-term maintenance may be a successful treatment option Factors that would indicate that short-term maintenance may not be a successful intervention
Continued opiate use following past short and/or long-term detoxes Long-term, chaotic drug-using history
Client request for short-term maintenance Long-term injecting drug use
Opiate use following or during detox Previous failure of detox following short-term maintenance
Prospect of social, physical and psychological factors improving given a period of drug-using stability Client cannot envisage an end to their drug use
Client desire to work at creating pre-conditions to successful detox Client feels dependent on injecting
Client has no dependence on injecting Intravenous drug use which has, in the past, proved difficult to stop
Support available from a specialist drug service No support available from a specialist drug service

 

Long-term maintenance

Stable doses over more than 6 months
If methadone treatment is justified, and short and long-term detox and short-term maintenance have been excluded as options, a minimum definition of successful long-term maintenance would be:

  • Contact with helping services during the treatment period
  • Maintenance of contact with services
  • Cessation of high-risk injecting behaviour
  • Reduction/cessation of other opiate and depressant drug use.
Factors that would indicate that long-term maintenance may be an appropriate intervention Factors that would indicate that long-term maintenance may not be a appropriate intervention
Long-term history of drug use (particularly if injecting) Short-term history of opiate use
Successful outcome of short-term maintenance but client still not ready to detox Client has no desire to stabilise drug taking and poly drug use is continuing
Poor social support network No previous histroy of methadone prescribing/detox
Client needs time to make considerable social or psychological changes in order to be able to successfully detox Client is apparently able and willing to reduce methadone consumption
Support available from a specialist drug service No support available from a specialist drug service

 

Treatment setting

For more information on the services available see Section 1: The history of methadone prescribing - Services available in the UK today. This section looks at the areas to which each treatment setting is best and least suited in the context of making appropriate treatment choices.

Specialist centre prescribing
Specialist centres are usually most suited to managing:

  • Large numbers of clients who could overwhelm smaller services
  • Chaotic drug users who need high levels of supervision and support
  • Difficult to manage clients who require treatment from specialised staff - such as clients with multiple drug use or concurrent mental health problems.

They are usually less suited to helping:

  • People who work full time (if they are only open Monday-Friday, 9am-5pm)
  • Rural areas with poor public transport
  • Opiate users not part of the subculture
  • People who are ambivalent about receiving help (they often have long waiting lists).

GPs prescribing alone
General practitioners working without the support of a consultant with a special interest in drugs or a community drug team are usually most suited to managing people who:

  • They know
  • Require short or medium-term detoxification
  • Have no concurrent benzodiazepine or other drug dependence
  • Are able to attend appointments and are otherwise stable.

They are less suited to prescribing for people who:

  • Are temporary residents
  • Are chaotic in their drug use and lifestyle
  • Require maintenance prescribing
  • Have a dependence on other drugs in addition to opiates.

GPs working with a community drug team
With specialist support from clinicians who can have regular contact with the client over and above their 5-10 minute weekly or fortnightly consultation, GPs can take on and treat a much wider range of clients who have drug problems. They are usually best suited for clients who:

  • Are stable enough to deal with attending appointments on time
  • Would find attending a specialist centre difficult
  • Are on a stable methadone programme - either detoxing or maintenance.

They are usually less suited for people who:

  • Are chaotic and find attending appointments difficult
  • Require supervised consumption of their methadone.

Private practice
Standards in private practice probably vary more than in other types of service for opiate users. Although all the questions below are legitimate questions to ask of any service if you are referring to, or receiving a client from, a private practice the following questions will help you ascertain the type and quality of the service on offer:

  • Is it a group or single-handed practice?
  • Have the staff recieved training in drug dependence?
  • Are there written prescribing policies?
  • What are the methadone collection regimes?
  • What is the degree of contact and supervision of clients?
  • Are counsellors and psychological support available and part of the treatment?
  • Is there any liaison with the local statutory service and contact with the drug unit consultants?
  • Are there limits on dosage and formulation?
  • How is dosage calculated?
  • What is the referral procedure?
  • Is there a waiting list?
  • What is the assessment procedure?
  • What is the average case load per clinician?
  • Are Home Office guidelines followed, such as requesting proof of a client's ability to fund their consultation and pharmacy fees?
  • What is the catchment area of the practice?
  • What are the fees and do they include, urinalysis as well as the consultation, and counselling?
  • Are general practitioners kept informed?
  • What information is given on treatment issues such as HIV and AIDS?

In general, responsible, well-supported and informed private practitioners are best suited for prescribing to people who:

  • Are in full-time, well-paid employment
  • Have legitimate access to funds to pay for treatment
  • Are stable
  • Will benefit from treatment not normally available on the NHS, such as injectables.

They are less suited to prescribing for people who:

  • Have no legitimate access to funds
  • Are chaotic and seeking maximum possible prescribed medication for least contact with helping services.

Prescribing injectable methadone
There are strong arguments for and against the principle of prescribing injectable methadone which are set out below.

Arguments used for prescribing injectable methadone Arguments used against prescribing injectable methadone
It is an incentive for people who may not attend a service offering only oral methadone It is difficult to determine who will benefit from prescribed injectables as there is no clear research or guidelines
It is an opportunity to work on a harm reduction basis with people who might not otherwise be in treatment People may have stabilised well (and with less harm) on oral medication
It is a realistic prescribing response to people who cannot stop injecting If decisions are made on prescribers’ preferences – in the absence of guidelines – it will be a constant source of conflict
It may attract users into treatment earlier in their career Clinicians can feel more like legal dealers and could attract more people than they could cope with into services
Giving clients a menu of drug choices can be empowering Giving clients more choice can reduce the therapeutic value of services and leave clinicians feeling de-skilled
It can provide a way of stopping using intravenous heroin It can cultivate or perpetuate injecting behaviour
It is a useful addition to an oral methadone prescription if occasional injecting behaviour persists It can be seen as doctors approving of, and colluding with, dangerous behaviour
It could be cost effective if it prevents people from catching HIV It may be seen by politicians and the media as 'being soft' on drugs and provide the springboard for a backlash that could threaten all prescribing
Injectables on the illicit market would be even more dangerous than methadone mixture

If, having considered the pros and cons of prescribing injectables, a service has decided to offer injectable methadone as a treatment option, the indications and contra-indications are set out below.

Factors that would indicate that prescribing injectable methadone may be an appropriate intervention Factors that would indicate that prescribing injectable methadone may not be an appropriate intervention
Client continuing to inject illicit opiate drugs despite 6 months or more on over 80mg oral methadone daily Client has no experience of oral methadone treatment
Long history of injecting Short history of injecting
Client only injecting opiates in addition to their methadone Client injecting many drugs in addition to taking their oral methadone
Client has long-term contact with the drug service Client is a new referral or temporary resident

 

Diamorphine prescribing
As with the prescription of injectables there are strong arguments for and against the principle of prescribing the user's drug of choice which are set out below.

Arguments used for prescribing diamorphine (heroin) Arguments used against prescribing diamorphine (heroin)
Heroin, especially if smoked, is less likely to cause accidental overdose than methadone As opiate users who are more chaotic are attracted into services there is more likelihood that the prescribed drugs will just increase the total drug consumption
It would attract many of the people who are most at risk of HIV and other drug-related harm into contact with drug services The number of people who would request treatment with heroin could overwhelm services
This is a catch 22 situation: while ‘the establishment’ opposes heroin prescribing, research funding is not available to prove the improved efficacy its proponents expect There is little research to demonstrate that it would be an effective intervention
It is for clinicians to inform policy makers of the most effective forms of health care: reduced crime and HIV spread are easy positive outcomes to ‘sell’ to opponents of prescribing As with prescribing injectables, prescribing heroin could provide the basis for a reactionary backlash against all prescribing and services for drug users

The prescribing of diamorphine in the treatment of dependence is restricted to those doctors who have a Home Office licence to do so. If, having considered the pros and cons of prescribing diamorphine, a service has decided to offer it as a treatment option, the indications and contra-indications are set out below.

Arguments used for prescribing diamorphine (heroin) Arguments used against prescribing diamorphine (heroin)
Factors that may indicate that prescribing diamorphine would be an appropriate intervention Factors that may indicate that prescribing diamorphine may not be an appropriate intervention
Heroin has been the drug of choice over a long period of time Client also injects drugs other than heroin on a regular basis
Client has a long history of injecting Client has a short history of injecting
Client has continued to inject heroin regularly in addition to taking oral methadone Client occasionally injects opiates in addition to taking oral methadone
Client has continued injecting despite receiving 80mg or more of methadone for more than 6 months Client has continued injecting on a low dose of oral methadone
Client has long-term contact with the service Client is new to the service or a temporary resident
Additional risk from injecting practice due to HIV-positive status Client is reluctant to engage with the service and a diamorphine prescription is unlikely to improve this
Client is already on a diamorphine prescription