SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Post-its from Practice:
Remember what works and be prepared to fight for it (Sep 2010)

On my first day back at work from wild swimming in Scotland and feeling refreshed, a very anxious William greeted me. He was concerned about all the anti-methadone press and he feared that he would be forced to detox and lose his recovery.

William has been a patient of mine for over 14 years and he has been on 120mg of methadone mixture for 10 of those years. Before that he had undertaken numerous detoxes with other services and undertook 4 detoxes with us, 2 in the community and 2 followed up with several months in rehab. He was sure that he could be drug free and as the employment terms and conditions in his chosen profession do not allow him to be on OST (opioid substitution treatment), he felt he must detox.

With each attempt, the result was always the same. He would remain drug free, have counseling weekly and attend a 12-step meeting daily but after several months start to slip, usually with smoking a little heroin. Each time he knew what he was doing and would increase his attendance at meetings and contact with his sponsor. He would come and see the practice counselor and me and verbally beat himself up. Each time William would say that he felt "incomplete", "strange" or "deficient" and he struggled in life and work. He added that he felt "normal" when he began to smoke heroin again.

After the fourth detox with us, which was followed by a suicide attempt, the counselor and I suggested that William should consider a short period of maintenance before trying again. He very unwillingly agreed and even more reluctantly was titrated to an `optimal dose'. Every 2 weeks I reviewed the dose and how he was and after 3 months he declared he had never felt better and wanted to remain on maintenance! His local NA group supported his decision, however sadly his sponsor didn't, but then he was able to find one that did! He has remained well on the same dose since. William has defined and is living his own recovery. He was promoted last year and uses his own experience to support clients.

Because of his success with engaging problematic clients he had been asked to go to a meeting to discuss the future of drug treatment in his area - and what he had heard had scared him. To quote William "the talk was all about abstinence as the only way, rubbishing OST and time-limiting it and commissioning only detox services". He was particularly upset by some of the language in the meeting such as "stuck on methadone", "not supporting people to their full potential" and even "harm reduction is outdated"!

I assured him that we were going to continue at the surgery as before with supporting people in treatment to choose their own route to recovery and write their own recovery script, because sensible clinicians (and some politicians) view abstinence as being on the same spectrum as harm reduction and not in competition with each other.

We went over again how the evidence of the benefit of OST is overwhelming and how reliable and persistent research shows that substitute prescribing treatment substantially reduces deaths, crime, HIV infection and drug use while also assisting social functioning such as improved education, training, parenting and employment.

Methadone treatment has been endorsed by UN agencies, WHO and UNAIDS, as well as NICE and the Department of Health in the UK. On this background I am left wondering why are we allowing opinion and politics to lead the agenda on drug treatment? Those of us working in the field must stand by what we know works. Which of course is not handing out a prescription and sitting back.

I agree with the NTA's view that some rebalancing of the system is necessary, but please let's shout loudly about what is good and what we have gained over the past years because if we don't, we will lose it and there will be more good people like William out of work - and sadly, more deaths.

- Dr Chris Ford
GP Lonsdale and Clinical Lead for SMMGP