‘Tony’ talks here about his reasons for coming into methadone treatment for the first time.
As a smoker of heroin and crack to start with, he discovered the feeling of injecting heroin while already on methadone. Although offered to him, he never wanted to go on a dose higher than 60 mg daily. This was because he didn’t want to stop using heroin yet, but did want to set some boundaries around his use. This happened back in 1992, so methadone for safer drug use rather than abstinence isn’t a new idea.
And the methadone helped him: He managed to keep his injecting to less than daily, and did no harm to his veins other than on his left arm in 12 years! At 47, when he felt like ‘growing out of drug use’, he was still in good physical health and easily stopped using both heroin and crack with no adjustment to his methadone dose.
I’m wondering what would have happened to Tony if treatment services had withdrawn his methadone because of his continuous on-top use, or if needle exchange services had refused to give him clean works because he was on methadone. It was good for him and it’s good for many others that ‘harm reduction’ and ‘structured treatment’ services are not exclusive, but I think we could do even better than this for those who continue using drugs by choice.
In my experience the safer use talk in structured treatment is easier forgotten than the motivation-to-treatment talk in the needle exchange: When I engage with someone coming to collect their methadone prescription, it’s much easier to talk about reasons, triggers, cravings and ways of managing them, than to talk about the use itself. But when I see someone in the needle exchange, the brief 2 minutes motivational talk around how their health could look like in the future and how treatment could prevent this comes naturally after talking about the use.
Tony’s story highlighted this bias in my practice. I think that we need to encourage an honest conversation about peoples’ reasons to come to treatment, to embrace the idea of methadone or other substitution medication as another helpful intervention for safer drug use, and to make space in each of our sessions to also talk about how people use drugs and how they could use safer.
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