Methadone treatment has become the most common form of opioid substitute treatment and, as such, is the most extensively researched intervention worldwide. Internationally, there is evidence to suggest that methadone treatment can reduce drug-related morbidity and mortality and improve a person’s health and social well-being.  There are a limited number of studies measuring aspects of the effectiveness of methadone as a treatment for problem opiate use in Ireland. Cox and Lawless (2004) undertook an evaluation of a methadone prescribing service in Dublin City ‘to examine the role which prescribed methadone plays within the lives of a cohort of opiate-dependent individuals in Dublin City.’ 

The study employed a mix of quantitative and qualitative methods.

 The quantitative study followed a cohort of individuals who entered a methadone maintenance programme in 1999 and continued in treatment for an 18-month period. A validated questionnaire, known as the opiate treatment index, was administered to 33 clients at some time following entry to methadone treatment at Merchants Quay Ireland in 1999 and to 17 clients who were still in treatment 18 months later. The questionnaire collected self-reported data on six domains: drug use, HIV risk-taking behaviours, social functioning, criminality, health status and psychological adjustment. Excluding social functioning, the data collected for all other outcomes was based on behaviours in the month prior to each interview. The data on social functioning pertained to behaviours in the six-month periods prior to each interview. Each domain had a number of questions, with a number of answer options. Each answer option had a score, with the lowest score indicating the lowest level of risk-taking or the best experience. The questionnaire collected some additional data on each client’s demographic and social situation.

The main findings between baseline and follow-up study were:

• The mean opiate treatment index scores for HIV-related risk behaviours increased (accounted for by an increase in reported sexual risk behaviours rather than in drug-using risk behaviours) in the month prior to the follow-up study, compared to respective risk behaviours reported at the time of the baseline study.
• Criminal behaviour decreased substantially, with only one client reporting committing one or more crimes during the month prior to the follow-up study, compared to six clients reporting similarly at the time of the baseline study.
• Social functioning scores decreased considerably, indicating an improvement in housing, employment and family relationships at the time of the follow-up study, compared to the baseline study.
• Health status remained similar.
• Psychological adjustment scores decreased, indicating that mental health outcomes had improved over the 18-month period.

  It is important to note that the sample size was small and that the improvements in mean scores were not tested statistically. Nevertheless, the findings suggest a number of positive outcomes associated with methadone maintenance therapy.

 The qualitative study consisted of three focus groups. These were undertaken to ascertain the experiences of clients and service providers with respect to methadone maintenance. Two focus groups were carried out to ascertain the experience of clients who attended the methadone prescribing service or the day programme at Merchants Quay Ireland. Those who attended the day programme were receiving methadone maintenance in a health board clinic or general practice setting. The clients were asked about methadone maintenance and continued risk behaviour, use of counselling and other auxiliary services, impact of methadone on their lives, and their relationship with service providers. The third focus group comprised staff working in the methadone prescribing service or the day programme at Merchants Quay Ireland. The service providers were asked about the positive and negative aspects of methadone maintenance, issues that positively and negatively affect treatment outcomes, and other pharmaceutical treatment options.

 Five themes were identified in the data transcribed from the focus groups:

• Theme 1 ‘Key players in methadone treatment’
  Clients welcomed the improvements in drug treatment services following the introduction of the methadone protocol, particularly the increase in the number of places available, the removal of all financial charges, the wide range of services available in the clinics for the less stable patients, and the transfer of stable patients to general practice settings. The clients’ experiences at pharmacies were both positive and negative. The negative experiences were long waiting periods, lack of privacy and poor communication between the general practitioner and the pharmacist. 

• Theme 2 ‘Methadone treatment and integration’
  The transition between active drug use and stabilising on methadone maintenance is a very vulnerable time for drug users. Clients reported that structured day programmes and formal training programmes provided them with a regular routine and the skills to gain future employment. Many who were employed reported that it was very difficult to meet the competing requirements of both a full-time job and the methadone treatment services. In general, those with full-time work feared that their employers would discover that they were on a methadone treatment programme and that they would lose their position. The majority of clients reported that methadone maintenance improved their relationships with their families and decreased their criminal activity. 

• Theme 3 ‘Responding to methadone’
  Clients reported that, initially, methadone maintenance was very important when moving from active drug use to no drug use, but that they now worried about the long-term dependence on methadone itself. Some clients who were stable on long-term methadone maintenance expressed a desire to detoxify but feared that they would find it difficult to tolerate the withdrawal symptoms, or that they would relapse into heroin use. They also reported that service providers did not encourage them to detoxify but to maintain status quo. Clients requested that a broader range of detoxification methods be provided for those wishing to detoxify from methadone maintenance and that service providers facilitate their provision.  

• Theme 4 ‘Managing methadone treatment’
  Most clients reported that the high turnover of counsellors at drug treatment centres was disruptive in maintaining a stable lifestyle or dealing with crises. The clients accepted that their drug use had to be monitored but asked for an alternative to urinalysis, as it was humiliating for both clients and service providers. 

• Theme 5 ‘Methadone and health’
  Many clients on methadone reported dental problems that they associated with their methadone therapy. Many also reported that opiates were not their only problem drugs, with some reporting dependence on other prescribed drugs, such as benzodiazepines, hypnotics and tranquillisers. The clients also reported interactions between antiviral therapy and methadone. 

 Overall, the two elements of the study suggest that methadone maintenance therapy was successful in stabilising heroin users and in assisting them to establish a positive lifestyle. The provision of services at primary care increased the number of places and removed some of the stigma associated with drug dependence. Clients reported that the monitoring of drug use by urinalysis was humiliating and recommended that other methods be introduced. The studies highlight some of the issues that inhibit successful treatment, such as polydrug use, mental illness and infection with HIV or hepatitis C, and recommend comprehensive services to deal with these issues. The clients requested that service planners and providers develop a wide-ranging approach to assist those who wish to detoxify from long-term methadone maintenance. 

Cox G and Lawless M (2004) Maintaining or enabling? Evaluation of a methadone prescribing service in Dublin City. In Pieces of the jigsaw: six reports addressing homelessness and drug use in Ireland. Dublin: Merchants Quay Ireland.