Response to the heroin epidemic: 1. Methadone and harm reduction

The heroin “epidemic” is a major concern all over the world right now. What are the various philosophies for dealing with it? In today’s post I’ll share some impressions from my recent visit to a harm reduction/methadone clinic in Belgium. Then I’ll post a piece by Percy Menzes who is dedicated to the use of naltrexone and policies that minimize access. Then we’ll see what Sally Satel has to say about programs that use punishments and rewards to get people to quit — so called incentives. That should keep us busy.

Last Thursday I took a train to a town in Belgium called Diest. It was two or three days after the attack on Brussels…so there were quite a few military guys standing around in the train stations with machine guns in their hands, ready for action. Not exactly reassuring.

But with all the chaos and pain that seem to infest the world right now, I felt a warm, cocoon-like embrace when I entered the Wit Huis  (The White House), a harm reduction clinic that provides loungeprescriptions for methadone, counselling, and a place to hang out for a little while.

The waiting room was a pleasant lounge where people (mostly addicts) could relax with tea and cookies (and baked goods such as Easter cakes) and chat with their fellow travellers. It was clean, bright, and there was an air of positive energy: care, concern, and understanding. There were leaflets everywhere, outlining the dangers associated with different drugs. And there was always eating areaa staff person present, just being friendly, chatting, offering snacks. The staff consists of two social workers, two MA level psychologists, a criminologist (to help with charges, probation, as so forth), and the doctor, Carl, who wrote the methadone prescriptions. Carl was my host.

After being shown around — rooms for counselling, a play area for people with kids, a laundry room, showers, a medical area where wounds and infections were treated and clean needles and accessories were handed out laundry room(in exchange for used needles) — I mostly sat in a chair next to Carl in an office/interview room, while one client after another came for their methadone script. It was sort of fascinating.

Most were heroin addicts of course, but many also used meth and/or coke. Many of the heroin users balanced their methadone dose with heroin obtained on the street. And this was no secret. There wasn’t much lying or sneaking going on, according to Carl and the others. It was a tacit assumption that opioid addicts would fluctuate in when, whether, and how much heroin they used to spice up their diet. And there was no confrontation. There was no scolding, no pep talks, no condescension, no sense of a parent figure keeping tabs on the naughty children. Yet Carl was careful to balance the dosage of methadone against simultaneous heroin use: less methadone with more heroin, naturally, to minimize the odds of overdose. And overdose was rare with this population. So how did they manage that?

The clients seemed content to report honestly on what drugs they were taking, mostly because there was no censure or disapproval, either explicit or implicit, in the attitudes and behaviour of the staff — including Carl. But just to make sure, unanticipated urine tests were requested when people said they’d stopped using heroin and wanted to increase their dose of methadone to compensate. Again, it was the warmth and camaraderie that flowed between staff and clients that neutralized the temptation to lie. The smiles and hand-shakes, the invitations to chat about how things were going, the absence of demands. These people were leading lives that to some extent they were choosing and to some extent they were stuck in…and nobody was judging them. The purpose of the clinic was to keep users safe, healthy, and out of jail.

Nevertheless, despite all this sweetness and light, these folks were seriously addicted, both physically and psychologically, to a very powerful drug. They weren’t anywhere close to safe and stable in the big picture. About half were homeless, which generally meant they slept in different homes night by night, or in abandoned houses, or with relatives. They were not the happiest of campers.

And where I saw this most clearly wasn’t in the statistics — re homelessness, unemployment, co-occurring psychiatric disorders — but in the posture and facial expressions of the people sitting Untitledin the chair across from the doc. They often looked defeated and helpless. While some expressed enthusiasm, plans for the future, many looked dreamy or blank. Quite a few had the hunched over posture that expresses shame or remorse. Their eye contact might be sparse and fleeting, looking down a lot — the gaze pattern of people who live with a chronic level of shame or sense of inferiority. A sense of personal failure they’ve grown deeply accustomed to.

That part was sad. That aspect made me think that harm reduction and methadone provide a solution to the heroin epidemic, but it’s not a great solution. Something is still seriously wrong here, and this form of treatment, connection, and care can make it livable. But only just.

Clinics of this sort have sprung up in towns and cities throughout Belgium and other European countries. As always, I’d love to hear your opinions.

59 thoughts on “Response to the heroin epidemic: 1. Methadone and harm reduction

  1. Mark March 29, 2016 at 6:10 pm #

    Your description makes me think these are people with … a broken heart.
    Here’s a fascinating talk by Dr. Alan Watkins on some possibilities for actually repairing that organ …

  2. Gina March 29, 2016 at 10:52 pm #

    Really glad you brought this up, Marc. I’ve heard this argument from people vehemently opposed to methadone (and Suboxone), and I do think it’s a valid concern—for some.

    My daughter’s experience with it since last July, however, has been nothing short of miraculous. She also has serious anxiety issues and the methadone really seems to help with that, too, which no other medication had been able to do. She just started her second semester at school, just got a job, is taking care of her daughter, handling her own life and making plans for her future.

    I’ll also mention that I’m a member of a number of closed Facebook support groups for people on MAT and the people who love them. There are lots of success stories in those groups, too, including long-term and those who have successfully tapered.

    Still, I acknowledge that some people have negative experiences with it or that it isn’t terribly effective for them or it helps but not enough. Just goes to show there’s no one-size-fits-all solution, and what works may change over time.

    Sounds like there’s more going on with these folks you describe than meets the eye—more systemic issues that methadone alone won’t alleviate and address. Just my thought.

    I am curious to see others’ thoughts.

    • Marc March 30, 2016 at 4:24 am #

      I’m glad you brought up this side of the issue, Gina. I know that there are success stories — I mean real, meaningful, lasting success, and of course tapering can and does occur. I don’t know the stats myself, but your daughter’s story shows us exactly how methadone maintenance can work well for people.

      I don’t have a deep sense of what was distinct about this group of users, but it seemed to me they were a fairly typical cross-section of heroin addicts in a semi-urban environment. Some looked really down and out. Some gave the impression that they were not fully functional cognitively or socially…which of course made them vulnerable to addiction in the first place. (And perhaps their expressions of helplessness or shame preceded their addiction.) And then there were some, as I mentioned, who had jobs or were anticipating jobs, who were taking care of their partners and children, and who expressed optimism about their future. One guy was building a cabin in the woods and was very proud of his work. I’d say this up-beat group made up 20% or so of the 20 or 30 people I met.

      Indeed, one size does not fit all. Thanks for reminding us.

      • Gina March 30, 2016 at 10:53 am #

        Yeah, that percentage sounds about right. Seems consistent with my admittedly unscientific observations at the several methadone clinics my daughter has attended in the Chicago area, though inner city clinics seem to have a higher percentage of those “beaten” folks likely for reasons that are not hard to tease out.

        I want to also point out that I’ve encountered in some of these pro-MAT/pro-harm reduction FB groups people who are equally dogmatic in support of MAT as some 12-steppers are in support of AA as the only way to beat addiction. Many of these folks are grieving parents who didn’t know about MAT meds before their kids died of an OD (and their legions are unfortunately growing every day in the US). Once they find out that people on MAT increase their chances of survival by as much as 75% (according to the most credible data), they’re really pissed and they want every other parent with a child struggling with an opiate addiction to know that MAT could save their child’s life.

        Still, there is no question that some people do have real problems with methadone or Suboxone. So, to the extent these medications are contraindicated for folks who are still not ready to stop using, how do we keep them alive? To me, heroin-assisted treatment as the Swiss have implemented is one very effective way to do that.

        • Marc April 1, 2016 at 6:25 pm #

          These are really interesting, important observations, Gina. Dogma and desperation often go together.
          By the way, what exactly does MAT stand for?

          • Gina April 1, 2016 at 6:58 pm #

            MAT stands for medication-assisted treatment, which can include both methadone and buprenorphine (Suboxone/Subutex), not to be confused with MMT (methadone maintenance therapy) or OTP (opioid treatment program).

            Also, I should clarify that I mis-read the percentages in your first comment. My observations are closer to the converse—about 20%-30% of methadone patients I’ve seen at various clinics have that “beaten” look, but the percentage is closer to 50% or more at the one inner city clinic I’ve visited. I’d say the socioeconomic conditions and prospects of the folks at the suburban locations vs the inner city locations had a lot to do with that difference, along with the quality of care delivered (i.e., individualized attention, counseling, etc.) at various clinics.

            • Marc April 4, 2016 at 3:15 am #

              These proportions are interesting because they tell us something important about what’s going on people’s lives…the other 23.5 hours of the day. When I think back, the distribution was more nuanced than I may have suggested. Only about a quarter looked “beaten” in a serious way. Then there was the upbeat 20% or so. The rest, the majority, looked like they were hanging in, if not particularly happy.

              While the clinic glowed with warmth and goodwill, small towns in northern Belgium aren’t exactly embracing of their addict populations…and certainly this is the default in most societies. So these people made up a layer of their own, a layer between being “good citizens” and wanton criminals. There was a sort of allegiance to a subculture….we’re drug users and that’s who we are, and we’re not trying to hurt anyone, and we appreciate being tolerated, if not exactly loved. That goes with a certain degree of shame, I guess, but it may not be overwhelming shame. There’s a difference.

              That feeling of belongingness to a subculture, partly nurtured by the clinic itself, seems critical to preserve a sense of self in the shadowy world of drug use. And that, as well as the socioeconomic factors you mention, probably make a big difference.

    • Terry March 30, 2016 at 5:37 pm #

      Hi. My son was a street kid between ages of 15 and 25 in Sydney – he barely survived. Since 25 he has been on OTP (opioid Treatment program – methadone) – he is now 37 and has progressed to now have full time job & stable accommodation and uses no other drugs at all except nicotine. yet still he is stigmatised and has to undertake to shameful daily ritual of obtaining his “Done” from a chemist and satisfying a doctor each 3 months he is a good boy. He is now on a very small dose – he seemingly cannot totally get of it (there is in my view many drug addicts who cannot be abstinent such is the extent of the biological or psychological need). Why do we continue to treat drug users as scum, why not give them heroin, we give drugs just as powerful to many in society via prescription (benzodiazepines for one). it is the illegality and shame which affects the user just as much as any negative effects of the drug itself. treat them (who are no different to me and you – only in what they chose to use to feel more secure or normal’) like humans. more harm is caused by the attitude to drug users than anything else and we in the industry contribute to that by continued focus on the drug use as a problem when in fact users in their use are trying to be average Joe’s and live like the rest of us. legalise drugs, change the culture towards drug users, and we might be very surprised at how much of this so called drug problem would simply melt away. Drug addicts, different to recreational drug users, are complex and often sad individuals, because most of them have been through hell, a hell most of us would not survive. we call them weak but I would not have survived what my son has and I’m an ex alcoholic. often it seems this world is simply getting nowhere – in 2016 we still look down our noses at those less fortunate than ourselves. This has nothing to do with biology, or does it, because shame could fashion and affect neuro pathways in similar ways to drugs themselves, as all feelings can. I rambled a bit.

      • Marc April 1, 2016 at 6:34 pm #

        Terry, I agree in large part. So do others. Criminalization is clearly the greatest facilitator of stigma and the cascade of suffering that often goes with it. Probably the most important spokesperson for this view today is Johann Hari. Please see his book, Chasing the Scream: The First and Last Days of the War on Drugs:

        Many other experts are starting to advocate for connection and care, putting an end to alienation and dislocation, as rational approaches to addiction. And legalization (with strict controls) may well solve many of the problems that addicts have tried most of their lives to overcome.

        • Terry April 3, 2016 at 7:03 pm #

          Thanks Marc – I have read Hari’s book and it was the most enlightening and encouraging book I have read in years – finally some commons sense is starting to emerge. we treat other anxiety states and psychological conditions yet any notion that we actually allow drug users to use under controlled conditions is seemingly beyond our ability to conceptualise – but I believe a change of culture will radically change the problem and allowing drug dependent people to reduce drug use whilst concurrently addressing the trauma may likely result in them reducing and ceasing drug use themselves as they mature – lets keep people alive long enough or them to fix themselves, as happens anyway around 40 years of age for many addicts. I am currently reading Stanton Peele’s book Recover which you also have knowledge of. There are good people trying to change the harm being done and seeking more empowering ways to change than the morally based approaches which so far have little success for addicts.

          • Marc April 4, 2016 at 3:26 am #

            I agree 100%. Let’s keep drug users alive, allowing them to fix themselves, as most eventually do. This enlightened view is the credo in more and more societies, Switzerland, Germany, and even the Netherlands topping the charts. Hari describes the positive effects of decriminalization in Switzerland, as you know.

            So, change is in the wind. Let’s keep hoping and working. I love the way Hari ends his book with a passionate call to arms. We can help make this happen.

      • Shelley April 8, 2016 at 7:27 pm #

        Terry, I could not agree more. Personally, i think giving the heroin addict – and i dohate that word – heroin is preferable togiving them methadone. Methadone is much harder to kick and has other more undesirable effects than heroin. England has treated heroin addicts with heroin for many years now and it has worked well. Many of the addicts in the program enjoy normal lives, holding down jobs, etc. which is entirely doable with a guaranteed daily dose that the addict does not have spend conciderable time chasing down.
        That said, i dont see societal attitudes changing over night, at least not here in the U.S. which still has a very Calvinist and punitive attitude toward drug users. Drug users are the single largest target of of our post 911 anti-terrorism resources, are denied student loans, housing, and jobs post conviction.
        It is this attitude that must change, as drug users will always be amung us, regardless of the cause. All drugs should be legalized world wide, and i guaranty the problems as they are will, by and large, disapear.

        • Terry April 10, 2016 at 5:57 pm #

          Shelley – you are a very smart person. I am amazed that systems do not see the benefit of legalisation s opposed to the cost of treating a large, and I mean large, percentage of the population as underclass animals. if we treated all of the athletes at this years Olympic Games, which is after all a gathering of sport addicts who give their entire life to whatever sport the are obsessed with, the way we treat drug users and alcoholics there would be much hue and cry. why are some addictions and the people who undertake them perfectly OK and others result in a lifetime of discrimination, shame and hiding?. Most of all it is a culture of thought that can change very quickly once it reaches a tipping point. it is very important as to what the Untied Nations may soon do when they discuss the world drug “problem” – but like you I won’t hold my breath. I’m 60 and I doubt I will see the change. when the treatments are worse than the condition some thing is wrong.

  3. Gina March 29, 2016 at 11:06 pm #

    And then there’s the experience of Walter Ginter, as interviewed by recovery scholar, William White:

    • Signe April 3, 2016 at 11:33 am #

      Maybe this was an oasis for heroin addicts but unfortunately the ‘real’ world is not like that. Their defeated and shame based attitudes come from the larger society. The shame has been instilled over many years and in many ways (I know this) until it is internalized. We (addicts) live in a cruel and uncompromising world. It makes these oasis (oases?) like the one in Belgium so precious.

      • Marc April 7, 2016 at 11:14 pm #

        You are so right. Please see Shawn’s comment below…which I hope to post as the post for tomorrow.

  4. Richard Henry March 30, 2016 at 7:02 am #

    Good Morning Marc.
    We have a Methadone and Suboxone Clinic here in Ottawa Called Recovery Ottawa.
    There are two different Doctors there handing out scripts, one more concerned than the other about using other drugs with their methadone and suboxone. The concerned Doctor rewards clean use with carries, meaning they can come in once a week, up to,3 weeks at a time. However they must come in every week for a urine screen test to make sure they have not used. This I find many like, it helps them with choice, knowing if they use they won’t get their carries and have to come back in everyday. This gives them a chance at refocusing their time to other things eg: work, education, recreational, rehabilitation etc. This doctor also encourages a time of freedom, free from methadone or Suboxone. But I think he feels so overwhelmed with the system and the lack of rehabs and proper clinical diagnostic centre he is just maintaining his clients, I did go in to see him one time, not to get anything but just to talk hahaha I think that was a first for him. The other doctor seems more like what you just described, I don’t have first hand knowledge, because I am not on any medications at that clinic or any other one, I give clients rides and do a lot of poking around and asking questions. The second group of clients from the other doctor seem to be just walking around in a daze, high out of there mind, all what you and all what you described, hopeless, stuck to this routine, using whatever they can whenever they can. In my view still far from where we need to be in finding and addressing the true underlying issue and problems people have. Not just maintaining a lifestyle but a life change.
    Regards Richard

    • Marc April 1, 2016 at 6:41 pm #

      Hi Richard. Thanks for this insightful description of two distinct modes for handling methadone maintenance. It sounds like both these doctors mean well and have their patients’ best interests at heart. But it seems clear that the first one, who gives a minor “reward” for staying off street drugs, is helping people more thoroughly. This is particularly interesting because it’s not pure methadone maintenance/harm reduction. There are sanctions/incentives built in. So this approach may capture the best of both worlds, without being unduly authoritarian or moralistic.

      I love the idea that you’re driving these guys around and helping out. What a great way to express your own gratitude for being in the clear.

  5. John Whelan, PhD March 30, 2016 at 7:04 am #

    Marc: Thank you writing this insightful piece. Having worked in addictions for over 25 years, it is still disappointing to see that we have not moved past medical management strategies. I get it, it allows us to do something to help and possibly reduce other harms, including premature death. But, we miss the point that you raise at the end of your article. Namely, that many of them are defeated, disheartened, ashamed of themselves. We are all responsible for ourselves and our behaviour but having said this, the vast majority of people I have treated are casualties; casualties of abusive families, neglect, physical /emotional abandonment; casualties of failed expectations. If we are to address addiction (and the blunting role it serves for people) I don’t think that we can continue to exclude social and relational factors intimately interwoven into this thing that we call addiction.

    • matt March 30, 2016 at 11:29 am #

      What he said.
      Thank you, Dr Whelan

      • matt March 30, 2016 at 4:46 pm #

        Another part of this is the factionalization among programs and approaches about what the right way to do this is. The posts on this blog have equivocalities in this regard. Some things work for some, some things for others. People’s recoveries are going to be nuanced and complicated, just like their personalities and just like the circumstances under which they became habituated to drug use. If governments continue to try to legislate the problem away, for example, by restricting physician’s prescription writing privileges for pain medication, maybe we should legislate that if anyone wants to get a license to start a treatment center, they should be required to offer all remedies available. In Massachusetts, the Bureau of Substance Abuse Services under the Department of Public Health is funding places called recovery centers that are charged to embrace all recovery traditions. It’s a place for people to hang out, go to meetings, use a computer lab for job search, get referrals, get acupuncture, do yoga, play ping pong, have Narcan and other trainings, have a voice in the community, and hopefully feel more empowered. If addiction is a public health problem, it should be in the public eye, not in the shadows and church basments. Otherwise, it remains stigmatizing and marginalizing.

        The (broad strokes) conceptual models like AA are about inclusion of the indivdual into the group, of fellowship, of social responsibiltiy, of spirituality(the Steps, helping others). CBT approaches like SMART Recovery are more about personal reponsibility, are pragmatic, are about the individual evaluating themselves and their relationship to their addiction, and then reintegrating and reconnecting. The fact is humans need both: a sense of autonomy and identity, and of sense of relatedness to their tribe. That’s why many SMART members do both. Yet I gave a presentation about SMART as another option recently at a sober house, and the reaction was as if I had told them to murder their children. Today a woman told me she was deterred from SMART because it was “like Islamic terrorists trying to infiltrate and destroy AA and recovery.” This rancor occurs in SMART too, and is nothing but a distraction from the real work, in my opinion. When people fixate on dogma– any dogma– they aren’t focusing on their recovery in a felicitous, meaningful and regenerative way. We have to find away to pull back the curtain.

        • John March 31, 2016 at 12:48 pm #

          I would like to say I have worked in the field of addiction for 13 years now. I class myself as a recovered addict and work a 12 step program. The people in the fellowship that depose other forms of treatment do not understand the 12 step program at all its about open-mindedness honesty and willingness. Not control or dictatorship of how someone should chose to recovery. Autonomy is a spiritual foundation of that program. An individuals right to their own personal recovery. And I would never press my values on anybody else unless they were in meeting looking for help.
          I have sat in SMART recovery and think it is a great tool.
          These people that preach not go to the SMART meetings are the ones that sit and moan about how bad life is in meetings. We have no place for them people in 12 Step meetings.
          The message should be carried how we found hope and strength to recover working the 12 step program in meetings. Not dictating how someone should choose to live their life.
          So please do not tarnish all of us in the 12 Step program with the same brush as these close minded people.

          • matt April 2, 2016 at 10:25 am #

            Once again, thank you. And once again, what he said.

            I hope I wasn’t misunderstood. I am in total agreement with you on this. What’s the saying? Principles before personalities? That’s where the truth lies. The problem is the principles are being interpreted by personalities, by humans, some closed-minded, some not…and about a high stakes, life or death issue. A defensive, “fear biting” reactionary stance arises when the “principles” are being wielded doctrinally as fact, by anybody from any of these programs and approaches. The stigma just gets stronger, and understanding driven further into the shadows. Fear rules the day reinforced by these close-minded people, and forced on the newcomer. ALL these programs should educate people and help them discover their readiness and resolve to change their life. The only thing I’d hope to be tarnishing with the same brush is ignorance.

            • john April 2, 2016 at 12:50 pm #

              I agree totally and thank you for your response. Definitely principles before personalities. The spiritual experience says it all for me in the basic text of alcoholics anonymous.

              “There is a principle which is a bar against all information. which is proof against all arguments and which cannot fail to keep a man in everlasting ignorance – that principle is contempt prior to investigation.”

              Herbert Spencer

              • matt April 2, 2016 at 2:06 pm #

                Thanks again, John. I personally feel anybody who authentically embraces recovery becomes a more spiritual person, by doing the right thing for themselves and everyone around them, by closing in on becoming the best version of themselves that they can be.
                My Camus bookend to your Herbert Spencer quote: “All the evil in the world comes of ignorance, and good intentions can do as much harm as malevolence if they lack understanding.”

        • Marc April 1, 2016 at 6:50 pm #

          These recovery centers sound amazing, Matt. What a great initiative! And of course it’s sad that people are still duking it out between SMART and AA….but it seems as if the era of monolithic approaches battling each other to the death is finally approaching its finale….sort of like the extinction of the dinosaurs.

          • Reagan April 6, 2016 at 10:03 pm #


            In attending AA, CA, and NA meetings over the years I find the level of indifference that occurs regarding the other meetings to be quite intriguing. Addiction is addiction is addiction and why there is such lack of compassion or indifference regarding this matter baffles me. The battle as you mentioned is very real almost aggressive in some conversations that I have been a witness to. In my opinion this division of ones addiction over another and which program offers “real” results only furthers the sickness that keeps one in active addiction. Competition between rooms within one addiction type is also very common and I really do not understand this mentality because ultimately we all have come in these rooms to heal and find support. I seek out additional ways to assist my own recovery and I feel uncomfortable doing this around others in a program because to them I am working my own program which means ultimately that this kind of thinking is what caused my addiction and possible my next relapse. So, I have retreated to my metaphorical closet because I study addiction outside of the confines of dogma. Maybe I am over-reacting. Thank you for a great article.

            • Marc April 7, 2016 at 11:20 pm #

              Hi Reagan. Thanks for sharing these personal and revealing insights. When you say “rooms”…do you mean 12-step? Are you saying that they can amplify rather than reduce the stigmatization, shame, isolation, etc? I’m not an AA basher….but I have heard this from others. I think there’s huge variability between groups. Or are you talking about the broader societal moralistic stand? In any case, I feel badly that you have to crawl off and do this difficult job in private. That isn’t the way it should be.

              No, I don’t think you’re over-reacting. I wish you success.

              • Carlton April 8, 2016 at 11:46 am #

                Hi Reagan, to add to Marc’s comments;

                Often when a person feels they are becoming free of something that binds a group, they feel less and less of a bond with the group.

                The group can sense it too.

                For instance, Fans in a crowded Sports bar talk, bond, and share a mutual recognition.

                but if an individuals feelings change, they will tend to talk and bond less, and this can noticed by the group too.

                Even referring to “we” does not ring anymore.

                Since recovery is ultimately an individual realization not a group realization, it is very hard to study and research.

                But I think an important key to understanding addiction and recovery is there.

                • Dr. Ron April 9, 2016 at 6:58 pm #

                  Having recently endured a personal verbal attack from a strident dogmatist during a NA meeting when I suggested that Psychiatric evaluation and treatment does in fact have a role to play in addiction treatment I can attest that all the above mentioned phenomena do occur precisely as noted.

                • Reagan April 10, 2016 at 2:03 pm #


                  Yes, I completely understand what you are saying and, yes, I do feel that on some level. For me, spending twenty five years in alcohol and meth addiction has left many unanswered questions. I believe in Marc Lewis’s idea about finding a self that we can trust and that is what I am exploring outside of a group environment. Status quo does not suit me in my search for answers to my own addiction. I am a firm believer that the answers are everywhere but one must put forth their own effort to find them and yes, I can see many good attributes within those in the meetings but ultimately the driving force of my own motivation is the catalyst for change and recovery. Thanks Carlton

              • Reagan April 10, 2016 at 2:15 pm #


                Thank you for your response. Yes, twelve step programs is what I was referring to. At times it does feel like it amplifies ones own insecurities or not so much that but having to reiterate that I am an addict-to me feels defeating and that I will never see a cure or even an understanding of the dynamics that were at play. Chalk it up to a mental illness type mentality. I do not support the disease model and therefore, I have a hard time finding a balance in these meetings. Not accepting the “one way” idealism is why I do outside research and many, many people that I meet are not like that-that is why I tend to not share what I have learned.I am passionate about wanting to find better approaches to the treatment and understanding of addiction but it seems that one has to move through decades of theories in order to find that crack. I am not out to bash any Anonymous group, that is not my intention but only to recognize and understand the patterns that have been created within these paradigms so I can better adjust myself maybe. The voice of addiction is powerful and the voices of former addicts and even those in active addiction and what has served and worked for them collectively is the crux of finding new answers/meanings. Thank you for all that you do.

    • Marc April 1, 2016 at 6:45 pm #

      Nicely put, John Whelan. See Gina’s comment above and my response to it. The underlying issue is indeed that failure, shame, inferiority and helplessness can be a low-grade infection long before addiction sets in. Then, as you say, addiction buffers the person’s emotional world, so there isn’t much chance of a radical transformation.

      Many experts these days are focusing on social and relational factors, as you recommend. Bruce Alexander is perhaps the most strident, but most of us see that social support means far more than drug support.

  6. William Abbott March 30, 2016 at 7:17 am #

    Is there any attempt to get these sad people off the opioid and then the maintenance methadone ie help them get totally drug free

    • john April 1, 2016 at 11:51 am #

      I worked in a community detox/recovery centre for last 7 months. I have seen more people complete drug treatment substance misuse free ie opioid medications in that 7 months than my 11 years working in treatment else where. 9 completed off my caseload in those 7 months.

  7. April March 30, 2016 at 7:40 am #

    Sounds like their problem is their socioeconomic status. I bet if they had safe stable housing, a chance at a decent job, and some mental health care, they’d be a lot less depressed. So much of public health really comes down to socioeconomic status. Medical care is at the very end of a long chain of events.

    • Gina March 30, 2016 at 10:27 am #

      I tend to agree with you, April.

  8. cheryl March 30, 2016 at 7:49 am #

    It is a good first step and one that could lead to hope which could lead to some confidence in moving forward to another step.

  9. Tim Greenwood March 30, 2016 at 5:45 pm #

    Great to hear and read this conversation about Methadone. Been some great discussions about it on CBC radio both pro and con. One discussion related to the fact that success rates for individuals going through “Detox” for opioids is quite low and there is a great danger of them succumbing to overdose if they relapse because their tolerance has greatly declined. This commentator suggested that MAT is much more successful and that individuals have more likelihood of a higher quality of life. The other commentator felt that Methadone was being overused and that young people who might have just been dabbling are being now introduced to a treatment that might become lifetime addiction:
    Finally there are a number of powerful documentaries on the subject of Methadone treatment and provide critiques of what to some extent can be an industry. Here are a few: Detox or Die, Methadonia, and Liquid Handcuffs. I believe they are available online for free

    • Marc April 7, 2016 at 8:54 am #

      Hi Tim. Thanks for your thought and for these links and sources. I haven’t had time to look at them yet, but they seem to reflect my own ambivalence. I guess my preferred treatment for an “average” opiate addict (if there were such a thing) would be methadone or more likely buprenorphine for a few months till it gets good and boring and then slow tapering while building in other engaging activities, practices, etc. Exercise, Tai Chi, whatever, plus mindfulness training to ride out cravings.

      I’m also hopeful about programs that supply clinical heroin which also becomes boring and could eventually be destigmatized. That has been shown to lead to voluntary withdrawal and abstinence in Switzerland and other societies. The trick would be to remove ALL pressure and let the person’s internal engine of desire start to kick over to new path because it IS boring and there’s no more fight to fight. The next post from Percy Menzies will offer a very different solution.

  10. John March 31, 2016 at 12:54 pm #

    I am following studies from Kings College in London on the effectiveness of methadone treatment its been really interesting stuff. I worked within treatment for 11 years prescribing with GPS

    I have a saying

    Methadone Saved Lives But It Stopped People Living

    • Koen Paulissen April 1, 2016 at 10:51 am #

      good point John, it is more of a political response or treatment of the problem, reducing drug related crime and overdose but less of an individual response.

    • Marc April 1, 2016 at 6:56 pm #

      John, that saying will stay with me. Especially because a close friend of mine died after 2-3 years on high doses of methadone. His life had become so incredibly flat that he started using coke, then crack, to feel alive….and those drugs led to his death. I never talk about him on this blog, but maybe I should.

    • Shaun Shelly April 3, 2016 at 8:24 am #

      John, with respect, I think that to make a statement like yours: “Methadone Saved Lives But It Stopped People Living” is ill-informed and very dangerous. I have commented more in a separate comment lower down. I am not trying to be argumentative, and I understand why you may say this, and I think it is important we debate the issues.

      • john April 3, 2016 at 11:31 am #

        Show me evidence in the UK where we have got an ageing user group parked up on Methadone for 20 to 30 years. It’s saved lives in some areas it’s also cost many people there lives through overdose and been maintained in treatment with no real direction of moving on until the new recovery agenda that came into force by the conservative government. So someone like myself that has been involved in Service user involvement from a ground level and then listen to what they after say. My comment is more that justified. I have worked with Hundreds of people over the years of being a substance misuse practitioner. I just not someone who had come along and not seen the value you Methadone and also its disadvantages

  11. Koen Paulissen April 1, 2016 at 10:35 am #

    Thank you Marc for your review of our clinic. It was good to have you. We look forward to the books coming our way. Take care,


    • Marc April 1, 2016 at 6:53 pm #

      Give it three more days. Amazon shall provide.

  12. john April 2, 2016 at 3:45 am #

    I worked within the prescribing services in the UK for 12 years. When I first started we were prescribing young people as young as 14 methadone which thank god does not happen as much due to drug use trends . That I then saw filtering into Adult services.
    In the last 7 months I worked in a community detox programme and have seen successes. That I have never seen in the other services I have worked in . All I see in the UK is a revolving door of an aged heroin and crack cocaine community. Slowly dying due to be maintained for years by one government and now the new government wants a different approach while cutting funding for vital services. Mutual aid and other support networks are now so vital. This is because the government had created a huge problem of parking people up on substitute medication over the years. Treating the addiction not the Person

  13. Shaun Shelly April 3, 2016 at 9:36 am #

    Hi Marc, As you know this is a subject that really interests me, and may be one of the few places our thinking may differ, at least slightly!

    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 above, 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).

    • john April 4, 2016 at 5:59 am #

      I agree with many of your points and also the last sentence to look at decriminalisation.
      You took my words out of context when I mean that methadone stopped people living. I have worked too in this field extensively over the years always being person centred. I have been involved in out area in 2004 with 2 bits of research around service provision and delivery in all areas of drug using communities.
      So yes people’s quality of life does improve in some areas but not all.

    • Marc April 7, 2016 at 10:22 am #

      Hi Shawn,
      I finally read this. It is very very important. You’ve covered the pluses and you’ve shown that most of the minuses are not a product either of drug use or treatment efforts but of the larger societal matrix. You’ve separated the factors that lead to stigma and isolation. You’ve advocated for the services that go missing with a pure biomedical approach (which of course is my perspective too), and you’ve given us stats to support your words and directions for improvement. This has to be its own post. Any objections if I publish it as a new post in the next day or so? My fear is that many won’t read this 3/4 way down in a comment section.

      • Shaun Shelly April 8, 2016 at 3:24 am #

        With pleasure!

  14. China Krys Darrington April 4, 2016 at 7:32 pm #

    I really enjoyed this post Marc. “he gaze pattern of people who live with a chronic level of shame or sense of inferiority. A sense of personal failure they’ve grown deeply accustomed to.” — man, I can relate to that. I embrace SAMHSA’s “10 Guiding Principles of Recovery”, one of which is “Many pathways to recovery”. One of those many pathways is Harm Reduction and what you described in your visit to Belgium. I often in my work for recovery support services find myself between agencies/families, even strongly-voiced and well-placed individuals who find only total abstinence acceptable. And those who utilize MAT or harm reduction to move, more slowly to a place of stability. I’ve watched too many people die who weren’t, for whatever reason, able to achieve total abstinence. My idea is that I’m glad abstinence works for me. But I’d rather keep people breathing (and hopefully working and parenting) long enough for them to find out where the roots (bio-psycho-neuro-social) of those addictions lie and can find pathways out of that addicted world.

    • Marc April 7, 2016 at 8:44 am #

      Hi China. I think a lot about why abstinence is so hard for many. It may be that I’m wrong and there really is a disease-like component in addiction. I don’t usually discuss this but changes in dopamine receptors can be long-lasting, and they consist in part of a reduction of engagement of attraction, what they call blunting, to other sources of pleasure over time. Yet I think, even if the DA system takes time to recover, it’s the psychological part that is most unforgiving. This drug has meant so much to someone for so long. Like a life partner, it is just feels too empty to go on without it.

      That feels like failure, but should it? We romanticize protagonists who fall in love for enuring periods of time, even with lovers who remain partly out of reach. Is it really so different?

  15. Marcus April 7, 2016 at 11:39 am #

    Personally, I have attempted probably every method known to man to get & stay clean, methadone, subutex, URODs, Ibogaine, MJ maintenance, detox’s, rehabs & half way houses and on & on. Yesterday, a report came out that concluded hydromorphone is indistinguishable from diacetylmorphine as a substitute & is widely available. To me, it all should be an option. I can only wonder how my life could have been different if HAT (heroin assisted treatment) were to have been an option. I know I had to put myself together a version of HAT here in the US before I came close to stabilizing, then like is not uncommon, I was able to transition to drug free over time. It took many nights in hell & almost 2 decades. Access to harm reduction shouldn’t be so hard to acess.

    • Gina April 7, 2016 at 11:04 pm #

      Glad you were able to do that for yourself. That is exactly why I wholeheartedly support heroin-assisted treatment (HAT) as an option. Curious what your opiate of choice was for your version of HAT?

  16. Marcus April 7, 2016 at 11:39 am #

    access ***

  17. Vivek April 11, 2016 at 2:29 am #

    The most widely self-medicated substances are over-the-counter drugs and dietary supplements. The psychology of self-medicating with psychoactive drugs is typically within the specific context of using recreational drugs, alcohol, comfort food, and other forms of behavior to alleviate symptoms of mental distress, stress and anxiety. I have seen such a great video for self medication, guys please have a look, hope this is useful for you.

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

    While the clinic glowed with warmth and goodwill, small towns in northern Belgium aren’t exactly embracing of their addict populations…and certainly this is the default in most societies.Many experts these days are focusing on social and relational factors, as you recommend. Bruce Alexander is perhaps the most strident, but most of us see that social support means far more than drug support.

Leave a Reply

Your email address will not be published.