Strong support for opiate substitution treatment…and fixing the bigger picture

…by Shaun Shelly…

I just pulled into a lodge in Banff, Canada at 2 AM (roughly noon for me) after a flight delay and missed shuttle. I’m way too tired to introduce this intelligently. All I can say is that I have huge respect for Shaun’s understanding of what goes on in opiate addiction, both above and below the surface we call treatment. See for yourself:


Firstly, I think that the most important thing to remember is that OST (either agonists such as methadone or partial-agonists such as Buprenorphine, with or without naloxone) saves lives. There is up to 75% reduction in mortality for those in these programmes as opposed to those who do not have access. That alone should sweep away almost any argument against the utility/ethics/need for OST programmes. OST is well researched and has been shown to work and save lives over many years. (*1 for examples -there are many)

Secondly, low threshold programmes, such as the one you describe [see last post], that do not insist on abstinence or accessing other services, are a vital part of the continuum of care. The data tells us that psychosocial interventions such as CBT add nothing to the outcomes of these programmes in terms of drug use, retention, other health issues etc. Personally I have some issues with the design of some of these studies, and as with most “addiction” research they are too limited to draw absolute conclusions from, but certainly the lack of availability or the lack of willingness to engage in psychosocial services should NEVER prevent the supply of OST.

Thirdly; there is plenty of evidence that these programmes improve access to health services; improve compliance on ARVs and TB meds; reduce criminal activity; improve quality of life in some people; can help people become employed; lead to people choosing to engage in other “addiction” treatment programmes, including abstinence based programmes (but this increases risk of mortality in the short-term!) etc etc

So, it is clear, in my opinion, that we should be offering low-threshold OST programmes. I think it is also very important to note that this type of programme, along with needle and syringe programmes, offers a unique opportunity for drug users who are highly stigmatised to engage with health and other services, and, perhaps vitally, to engage with people who are part of a wider community without stigma or judgement. This interaction can, and sometime does, provide the “scaffolding to construct a vision of future self” (to paraphrase one of my favourite quotes from Marc).

For some people the simple move from a street opioid to a pharmaceutical opioid with a longer half-life is all that is needed to find some stability and start “living” again. If they have the correct support structures, mental faculties, education, family or alternative family structure, the right lucky break or a guardian angel individually or in any combination, they will be able to build a productive life. I know many such people. They are still dependent on an opioid, but are not addicted – so what! Just the structure of attending the clinic and not having heroin be their all-consuming vocation, can give them the space and the belief  to start making changes, and these are often self-accelerating. Some of these people will eventually down-titrate to zero or close to zero dose, some may not. Their choice. Some may have, as Dr Mark Willenbring has suggested to me, a hypoactive endogenous opioid system that requires a life-long agonist to function optimally.  Either way, they, and many of the rest of the world, except the abstinence Nazis, are happy.

However, there are many exceptions. While many of the people you saw “weren’t anywhere close to safe and stable in the big picture” I would argue that this has little to do with their drug use. I certainly do not want to paint all street dwelling dependent heroin users as victims – they are often the most resourceful and resilient people I have ever met – but many of them (but not all as Gabor Mate would have us believe) are sufferers of serial trauma and most have been highly stigmatised, ciminalised and ostracised. In this case, they may not have the resources, intrinsic and extrinsic, to build on the new-found structure of methadone or buprenorphine and create a “new life” or find “recovery”. Indeed, for many that may not even be desirable.

For many of these people heroin is a form of vocation and indeed the thing that binds them to their street family (see the video I have linked at the end of this post). I have worked extensively with these populations, and I find that for many drug use is a supremely logical choice in the face of little chance of finding meaning in what others would call “normal” pursuits. As I stated earlier, this is not a problem of pharmacology, this is a problem that lies beyond the individual and in the structural and systemic issues of modern society – the work of Alexander (his FULL BODY of work!) is very relevant. To expect methadone programs to address these issues is unrealistic!

This leads me to the one area where I do have a problem with methadone programmes and the reductionist approach that reduces harm reduction to a set of bio-medical interventions. Just because people are being kept alive does not mean we have solved the problem. The other issues that need attention are criminalisation, stigma, inability to address the needs of those with mental health and other issues. These are not (only) drug issues, but societal issues.

One of the steps towards addressing these wrongs lies in the fact that agonist therapies work – they are the only consistent therapies to work with “addiction” when it comes to health issues. The logical conclusion is that we should make pharmaceutical agonists easily available to all drug users – allow these street users the same benefits that many of us “functional due to privilege” users enjoy – access pharmaceutical quality drugs with the minimum of barriers. That is decriminalise, legalise and regulate all drugs. This will not solve all the problems, but will go a long way to prioritising who does and doesn’t need “treatment”!

Video on “street families”:

*1 EG :Caplehorn, J. R., Dalton, M. S., Haldar, F., Petrenas, A. M., & Nisbet, J. G. (1996). Methadone maintenance and addicts’ risk of fatal heroin overdose. Substance Use & Misuse, 31(2), 177–196.
Connock, M., Juarez-Garcia, a., Jowett, S., Frew, E., Liu, Z., Taylor, R. J., … Taylor, R. S. (2007). Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation. Health Technology Assessment (Winchester, England), 11(9).

29 thoughts on “Strong support for opiate substitution treatment…and fixing the bigger picture

  1. john April 9, 2016 at 5:25 am #

    I enjoyed this really did. I know how important this is as I have worked in treatment

    • Mark April 9, 2016 at 6:09 am #

      I’m pretty convinced that addiction in all forms is a Wicked Problem.
      Wicked Problems study comes out of Social Policy research.
      As a Wicked Problem addiction then needs Wicked Solutions.

      For a cogent, clear understanding of what differentiates a Wicked Problem
      from a really complex problem, and how we might begin to address them,
      I highly recommend this book by a neuroscientist and an integral psychologist:

      Wicked and Wise by Alan Watkins and Ken Wilber

      Here’s a TED Talk by Alan. It’s the first TED Talk I’ve ever seen where the presenter has been allowed to go double-long:

  2. April April 9, 2016 at 6:05 am #

    Excellent post. Blaming people’s drug use is a great way of avoiding societal responsibility for extreme poverty. Now that white men are dying of alcohol and other drugs it’s not quite so criminalized. Functional due to privilege is so well said.

  3. William Abbott April 9, 2016 at 7:50 am #

    What are the ” legitimate” objections to appropriately applied harm reduction approaches?

    Seems most come from the ” Abstinence Nazis” as you call them– a corps of the Disease Modelist Army junta leading the War on Drugs

  4. Richard Henry April 9, 2016 at 11:02 am #

    When are we going to find help (Harm-Reduction) for stimulant users? amphetamine user like Crack cocaine need support for their problems as well. All the attention is given to opiate users, I think primarily because it’s withdrawn is not only of the mind but of the body. I wrote about this problem in my memoir “Life in the game of Addictions” it’s of my battle with substance abuse, my indifferences on what should or could be done, and my ultimate redemption.Dr. Madeleine O’connor has had some success with MODAFINIL in supporting people with amphetamine addictions. I believe my life would have turned around a lot quick if I had had this kind of help

    • Shaun Shelly April 9, 2016 at 1:36 pm #

      Richard, you are 100% and this is something I am working on as it is of interest to me. Modafinil is something that has certainly helped me at times but is very expensive – Carl Hart has also done some research on it. A friend is busy finalising the UN’s first guide to stimulant harm reduction, which has been written by former stimulant users. Will keep you updated – more later.

      • John April 10, 2016 at 10:18 pm #

        I’ve been getting mileage out of Vyvanse as a substitute. It’s resistant to tampering and doesn’t feel great if you take too much. It doesn’t have the rush of Adderall or Ritalin. Unfortunately its so expensive my health insurance doesn’t want to cover it any longer.

        Any thoughts on it?

        • Shaun Shelly April 11, 2016 at 7:40 am #

          It is not available in SA, although I have heard that it can be useful

      • Richard Henry April 9, 2017 at 8:50 am #

        I have finally been perscribed Vyvanse for my Amphetamine Use Disorder and it is working fantastic. Thanks to getting a referral to an addiction specialist at the University of Ottawa Dr Ramin. It has been 20 years fighting this disorder will so many road blocks along the way. Today I feel Blessed and am also involved in an upcoming event called PASSION Projects T.V interview in sharing my story please share and send friends request to my Facebook to get involved… It will be on this Tuesday @ 7:33 is something I am hoping will touch many viewers. Please share and in helping others get the help they deserve… Respect Richard Henry

  5. Terry April 10, 2016 at 6:09 pm #

    why use a substitute?? – why not use less harmful forms of the drugs people have unconsciously chosen as the best for their set of “wounds” – we see straight over the obvious solution because we are always seeing illicit drug use as a problem – how much harm and how many lives has drug use saved ?? of course we have only ever really researched one side of this argument. and yes Ice is only very strong coffee – the reason it is causing trouble is there is no less harmful affordable option for people who use drugs (cannabis is the obvious choice but is far more expensive than Ice)

    • Shaun Shelly April 11, 2016 at 2:50 am #

      Terry, I agree that the obvious conclusion is the legalistion and regulation of all drugs, thereby restoring the basic right to use whatever drug we want in a way that makes it as safe as possible.

  6. Jeffrey W Skinner April 10, 2016 at 7:28 pm #

    This looks really good, except for one really big issue. I find no fault in discussions pitched at professionals and the thoughtful addict base. But this far too dry, technical and cautious for a general audience. The ground is shifting under our feetand there is a real opening for policy change.

    What is the take home for a receptive GENERAL audience?

    • Reagan April 11, 2016 at 8:21 pm #


      The ground is shifting as one can see this within these blogs, books, and other areas but addicts on some level are non-conformists and that doesn’t make for a good campaign. But, this is just my opinion. To many times they (addicts) are viewed as the stuff on the bottom of ones shoes and I wonder to myself can former addicts really be taken seriously? There is such a divide within the collective mind of society, government, justice systems, and the domesticated mentality that may be too big of a wall to penetrate. Former addicts and even those in active addiction willing to do the footwork to gather research, penetrate areas otherwise deemed dangerous territory, and rising up with what they have learned post recovery and afterwards can be a potentially deadly wave turned toward the multi-billion dollar organizations that fund any drug war, because this can take money out of their fists, expose the insanity, and overthrow a dying paradigm. Are we really up for the challenge? Forcing a larger opening into real policy change that is truly for the people? Thanks for letting me share.

      • Jeffrey Skinner April 12, 2016 at 2:30 pm #

        Thanks for sharing your ideas. As someone with a long history of dealing with the wreckage of addicts lives I know the territory pretty well. Funny thing is the only full blown addiction I ever knew first hand is tobacco, something I escaped finally 28 years ago. Tobacco doesn’t hurt that much until it kills you, but one thing that makes it especially binding is that you can’t escape except by strong will and determination, because your drug of choice is affordable and always there 24/7 within 2 blocks. You don’t get temporarily free of it because you lose your supply.

        I played with opiates as a young dude, but I recognized that it was something to avoid because, as a friend of mine says “life shouldn’t be that good.” In fact CAN’T be that good beyond the very very short term.

        I hear in what you say a piece of something that binds addicts to their drugs. The strange belief that they are special, different and the rules that apply to the rest are not for them. The romantic temprament if you like. It can be deadly too.

        Many years ago I saw a film documentary about a heroin addict in a maintenance program in Amsterdam. He told the interviewer something like this: “There’s nothing romantic in my situation. My life is BORING, from the outside. I am 20 years married, I have a wife and two kids and a job. We live in an OK apartment. I inject heroin everyday because I haven’t been able to stop. But other than that I’m just like you.”

        Addicts generally need to believe that they are special and would often rather be dead than boring. Fairly often they get what they want.

        Don’t despair. Have the courage to live in the big ordinary.

        Yrs – JWS

        • Reagan April 12, 2016 at 7:10 pm #


          Thank you for the gentle reminder about the special thing. That was not my intention at least consciously but maybe subconsciously that is something my 25 stint with addiction has produced. It is interesting, challenging, and new for me after cleaning up to find a way to the surface or maybe what you stated…”the courage to live in the big ordinary” and that is something I strive for. I have smoked for almost 30 years and I often wonder if I can quit meth and drinking-what is it about a cigarette that seems far worse to fathom much less even attempt. I would shake your hand because constructive criticism or an insightful response is needed and welcomed. Yes, I am still working to unlearn and to relearn so thank you.

          • Jeffrey Skinner April 14, 2016 at 9:32 am #

            I hope you get it done, I know it’s not easy. This forum works, both as a symposium for ideas and a support for the struggle to get clean. I’ve never seen anything quite like it elsewhere.

        • Carlton April 14, 2016 at 7:35 am #

          Realizations that can occur during the struggle to regain ones freedom from an addiction can change the way one experiences the big ordinary.

          To be able to experience the vast spectrum of grief, excitement, boredom, etc, without fear or limitations, is a palatable, regained freedom.

  7. Vivek April 11, 2016 at 2:26 am #

    Self-medication is a human behavior in which an individual uses a substance or any exogenous influence to self-administer treatment for physical or psychological ailments.
    For more details please check out this video:-

  8. China Krys Darrington April 13, 2016 at 12:33 pm #

    Great…and I mean *GREAT*, post.

  9. Marcus April 15, 2016 at 1:02 pm #

    “Some may have, as Dr Mark Willenbring has suggested to me, a hypoactive endogenous opioid system that requires a life-long agonist to function optimally.”

    So, a “hypoactive endogenous opioid system,” why? Which came first, the chicken or the egg? Or is its neither as in the case with the chicken (bird that laid first chicken egg was not really a chicken)? I continue to believe as a result of an enormous amount of reading research over the past 2 decades or more, the genetics link is critically under-reported / minimized. And that addiction is a symptom for addicts of the hardcore variety of a hypoactive endogenous opioid system and not a disease itself. Either way, the pejorative drug war yields disastrous results, MAT (medication assisted treatment) and HAT (heroin assisted treatment) are vital to stabilization both individually and as a whole group. Harm reduction common sense approaches are desperately needed, still.

  10. Life Changes April 19, 2016 at 4:34 pm #

    This article creates interesting statements. Thank you for sharing, I really learned a lot.

  11. recoverycnt May 24, 2016 at 3:07 am #

    Excellent post. Blaming people’s drug use is a great way of avoiding societal responsibility for extreme poverty. Now that white men are dying of alcohol and other drugs it’s not quite so criminalized.
    you can see video of Drug Rehabs Experts opinoin

  12. Irene June 3, 2016 at 5:47 am #

    Thanks for sharing a well versed article, we need to work better for the people suffering from addiction, making a collaborative effort is the best way to save lives. I think blogs and good articles are very useful for the people looking for addiction recovery. Here I would recommend a very useful article for the people willing addiction recovery. In this article It is explained in a well manner How To Counter Addiction?

  13. Chris June 4, 2016 at 5:39 am #

    The courage to live in the big ordinary” and that is something I strive for.

  14. rachel yuri June 7, 2016 at 10:12 am #

    Addicts generally need to believe that they are special and would often rather be dead than boring. Fairly often they get what they want.. All the attention is given to opiate users, I think primarily because it’s withdrawn is not only of the mind but of the body.

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  16. zack smith May 6, 2021 at 4:42 am #

    could have just as good a time without it as with it. I think there is so much information out there that as in all things, moderation is key. This clearly doesn’t apply of course for those who have addictions.TORQ Physical Therapy

  17. emma January 9, 2022 at 1:22 am #

    I would shake your hand because constructive criticism or an insightful response is needed and welcomed. Yes, I am still working to unlearn and to relearn so thank you.essentialslimketo

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