This report is based on the processes of change an addict must pass through while healing. An overview of different recovery options will be addressed together with an
in-depth analysis of the strengths and limitations in relation to the methadone maintenance program.
The road to recovery from any form of addiction is multi faceted and from the perspective of the addict, often a dreaded journey. Frequently, a grim life event compels the addict to confront their addiction. The catalysts that prompts the initial consideration of recovery are often outside of the addict’s control and can range from a multitude of situations such as, an unplanned pregnancy, criminal charges and threat of incarceration to the loss of employment, disintegration of their family or an overdose death of a close friend or relative.
Regardless of the circumstances that cause an addict to seek recovery, the following key components facilitate the goal of recovery:
1. The addict must admit to himself that he has an addiction problem.
2. The addict must decide to distance himself from his previous addictive environment, lifestyle and friends who also engage in self-harming behaviour.
3. The addict must stop his addictive behaviour. (The Centre of Addiction and Mental Health in Toronto report that heroin addicts who relapse while on the
methadone maintenance program should be permitted to continue with the program. This theory will be later addressed in this report.)
4. The addict will need to engage in an interwoven and revolving psychological thought process that is referred to by Levinthal as the stages of rehabilitation.1
5. Ideally, a strong support system of family and friends will create a positive, safe, healthy, nurturing and protective environment for the individual.
6. The addict and his family will benefit from an effective and appropriate treatment program.
Admitting to his addiction or addictions is the first key component or the foundation to which recovery will be built upon as the individual begins his journey of recovery. It is not unusual for an addict, especially an alcoholic to deny that his drinking is affecting his life or the life of his family. Until the addict wholly accepts and sincerely believes that he has an addiction, the recovery process cannot begin. A drug screening survey is a useful tool in determining whether an individual has or shows a potential addiction problem.
The next key component associated to recovery, requires that the individual makes life style changes that will not only support his decision to stop his self-harming behaviour, but will reinforce his process of recovery. Therefore it is essential that wherever possible, the addict remove himself from any environment associated with his abusive behaviour. For instance, gambling addicts should not frequent betting or lottery
establishments, ecstasy addicts must discontinue attending at raves, heroin or cocaine addicts must consciously choose places where drugs are not condoned and avoid frequenting known locations where drugs are used. The addict must isolate himself from all former friends who otherwise would encourage the addictive behaviour or participate themselves in self-abusing or destructive behaviour. An addict who independently adopts this attitude and is determined to avoid high-risk environments and people has a better chance to avoid relapsing.
The third key component of recovery involves abstinence from all self-harming behaviours and substances. For example where a cocaine addict is in the process of recovery, he must not only abstain from his drug of choice, but from all psychotropic drugs including alcohol.
The stages of change as described by Levinthal is another component of recovery and include the following stages:
1. Pre-contemplation stage. The individual in this stage has the desire to recovery, however they have failed to adopt the serious attitude necessary to make changes.
2. Contemplation stage. The individual at this stage continues to think about recovery but is unable to give a serious commitment to a recovery program.
3. Preparation stage. The addict at this stage is seriously considering starting a recovery program.
4. Action stage. The individual has refrained from drug use at this stage.
5. Maintenance stage. The individual has been free of substances for at least a six-month time frame.
Levinthal references the spiral model of the stages to clearly illustrate that a patient may pass through these stages several times throughout the recovery process. 2
The fifth key component that facilitates successful recovery includes a strong support system of family and friends. Addiction is quite an insidious disease that has a very harmful rippling effect that impacts all members of the addict’s family. Counselling for family members is a necessity and will provide the forum for the venting of their frustrations and will also afford the family members the opportunity to recognize their own behaviours that inadvertently contribute to the addiction. Typically, family members will adopt characteristics in order to cope with the chaos, unpredictability and possible violence in their dysfunctional home environment. Levinthal identifies the following five different types of enablers:
1. Controlling - In an extreme desperate effort and often underlying manipulative manner, a family member may engage in self-harmful behaviour or attempt suicide in an effort to control the addict’s behaviour. Family members may attempt to control the addict’s behaviour by showering him with gifts or engaging in over achieving behaviours in an attempt to make the addict happy in the mistaken belief that this will prompt the addict into abstinence or recovery.
2. Avoiding and shielding - A family member will purposely avoid the family environment because of feelings of shame, fear and embarrassment. An alcoholic’s husband may bury himself in his work. The addict’s children may spent a lot of time at friends’ homes, hang out at shopping centres or other places. Children with an addicted family member will not reciprocate invitations to their friends because of their unpredictable home environment and possible humiliation. Family members will also try to cover up or make excuses for the addict in an effort to hide the addiction from the extended family, friends or employers.
3. Assuming responsibilities - Family members may need to compensate financially for the addict’s loss of employment or to pay drug debts by acquiring secondary employment. Children of the addict may assume the role and responsibilities of the addicted parent. Although the child may be age appropriate with respect to their emotional level, they are most likely mature in other areas far beyond their young years. These children usually have no other option but to care for their younger siblings, healthy parent, their addicted parent and their home. Usually these children are unaware of any other way of life.
4. Accepting/rationalizing - The family members may excuse or justify the addict’s behaviour by minimizing the incidents of drug abuse. For instance, a spouse may sympathize and rationalize the addict’s abuse of prescription pain medication because of a legitimate physical or emotional problem. A spouse of an alcoholic
may accept the multitude of excuses rhymed off by the alcoholic.
5. Cooperation – The family may foster the addict’s behaviour by purchasing their drug of choice because the addict is too ill or under the influence of the substance thereby creating a more dangerous situation.
The sixth key component that promotes addiction recovery is that the individual enter into an appropriate treatment program suited to the type of addiction and their specific needs. Treatment may include a combination of programs, facilities, services and therapies including pharmacologically based treatment. Depending on the nature of the addiction and personal needs, the medical community strongly suggest that an individual considered the following options and combination thereof:
1. a twelve-step program, such as Alcoholics Anonymous or Rational Recovery,
2. an outpatient treatment program offering individual or group therapy,
3. inpatient treatment at a facility, such as Homewood, The Donwood, The Centre for Addiction and Mental Health and Bellwood,
4. a pharmacological program such as antibuse or the methadone maintenance program.
The Methadone Maintenance Program was developed in the mid 1960s and has been recognized as the most successful treatments for opiate addiction. It offers hope to people
who due to life circumstances are addicted to opiates and are ill. This condition affects all strata of society, not just the stereotypical junkie portrayed by the movie industry.
It must be emphasized that the program is not a cure for opiate addiction, however it permits the individual to withdraw with less discomfort as it stops the individual’s cravings and prevents them from feeling sick.
The methadone maintenance program is considered an oral substitution therapy where a predetermined dosage of methadone is taken once daily to replace snorted, injected or ingested opiates. Many opiate dependent individuals who have repeatedly tried and failed other treatment programs such as Narcotics Anonymous and 30 day inpatient treatment programs turn to the methadone maintenance program.
This program is designed specifically for people who are dependent on morphine, Percocet, Percodan, codeine, heroin, oxycodone, etc. and offers them unlimited services including counselling and monitoring. This program provides its clients a new life free of the chaotic lifestyle of injecting opiates several times a day in order to avoid withdrawal. While on the program, the individual has time to focus on his life that has now been stabilized instead of constantly worrying about scoring his next hit. The individual can also begin to lead a healthier life style and reduce his chances of either contracting or spreading HIV or hepatitis B and C. The client who may have considered himself a forgotten human being with feelings of shame, disgrace and embarrassment is provided with hope.
When a client initially presents to the program, he undergoes a psychosocial assessment that explores his quality of life, the amount and type of opiate used and the timeframe of the addiction. Treatment options are outlined and an additional comprehensive health assessment is conducted. Government guidelines are addressed and a treatment agreement is contracted with the client.
In order to arrive at a proper methadone dosage, the client is started at a low dose of 20 – 30 ml and as tolerance increases, dosages are increased at rate of 5 – 10 ml intervals. The goal is to arrive at a methadone dosage where the client feels stable. A properly established therapeutic dose does not cause the client to feel high, nor does the patient feel the suffering effects of withdrawal although they may experience slight discomfort.
Regular supervised urine screens are conducted and monitored for substance abuse and to verify that the client is taking methadone and not diverting it. If the client successfully reaches benchmarks and meets safety criteria, he will be granted methadone preparations to take home or "carries" as they are referred to. It must first be established that it is safe for the patient and the public to allow carry medication. The individual must have reached a clinical stability threshold, demonstrate cognitive skills, social responsibilities and satisfy safety storage concerns, before permitting this privilege. Any violations of this program will result in this privilege being withdrawn.
The methadone maintenance program encourages its clients to abstain from other substances, however it is recognized that with this chronic condition, relapse is unfortunately a harsh reality. It is the belief by most methadone health professionals, that an individual who slips and uses opiates while on the program, should not be discharged if they are making significant effort to get back on track. A dirty urine should not sacrifice the individual’s progress made while on the methadone maintenance program. A more realistic goal of the program should be for the individual to reduce the number of dirty urines while trying to increase their quality of life such as maintaining employment, returning to school, staying out of jail, increasing the level of their overall health and being available to their children. The benefits to the individual and society to keep an otherwise productive member of society on the methadone maintenance program regardless of a slip outweighs discharging the individual from the program.
The program also provides its clients with regular and if necessary daily group meetings and counselling. Although the methadone maintenance program assists with the physical withdrawal, the client must personally work at continuing with the program which means paying close attention to their addiction. Often while on the program, the client is overwhelmed by feelings of past issues that for years were drowned by their addiction. With counselling, the client must now face these underlying problems or in some cases a mental illness.
Counselling services address such basic needs as housing, food and clothing, as well as other issues such as, social skills, recognizing relapsing triggers, skills on how to distance oneself from the drug environment, relationships and employment. Counselling will also be made available to the client’s family. The counselling program will strive to have the client search within their soul to find their own goodness that can then be contributed to society. This process may be considered a spiritual approach and is useful when there is no previous religion for the client to reunite with.
The methadone maintenance program is not a magic pill and may take approximately one month per the number of years of addiction to recover. It is important for society to accept that a client may need to continue on the program for the rest of his life.
One of the limitations associated with the methadone maintenance program is the lack of available spaces. High-risk persons for example, pregnant and HIV individuals are granted priority access to the program. Although the program has recently expanded to satellite clinics and registered physicians’ offices, the demand still outnumbers the supply. In the past, individuals who were unable to meet strict program expectations, such as immediate abstinence were also denied access, however this criteria is also undergoing progressive change.
A negative and serious aspect of the methadone maintenance program is the possibility that a client could relapse and mix the methadone with other drugs including alcohol, tranquilizers or painkillers that could lead to death.
The program is highly criticized with public outcry when a methadone carry is improperly stored and accidentally and usually fatally consumed by an innocent child. Diverted methadone sold and ingested by a drug seeker who would not have built up a tolerance is also usually fatal.
Another negative feature of the methadone maintenance program is the long-term effects that include constipation, sweating, menstrual cycle disruption and sexual dysfunction. The effects may be stabilized through dosage adjustments or as the person’s overall health begins to improve.
A very serious limitation with respect to the program is the ignorant attitude pervasive within society. This program will continue to be stigmatized and viewed with disdain until a compassionate attitude is adopted towards this group. Society must be educated in order to appreciate the cost effectiveness and positive benefits to society with respect to the reduction of crime and transmission of infectious diseases. Above all the public must appreciate that health care is a right to all people and that the human dignity and welfare is paramount.