Background

Approaches to addiction treatment remain a source of ongoing policy debate worldwide. Advocates for a recovery-focused approach have questioned the dominance of harm reduction strategies, particularly in regard to their record in social integration and other non-treatment outcomes, such as employment and education. Traditionally, some recovery advocates have argued that an abstinence-centred system best serves the social reintegration of its clients.1 Critics of this outlook have insisted that it is limited given the wide range of other personal and socioeconomic challenges faced by people who use drugs, and that it is grounded more in ideology than scientific evidence.2 Currently, there is an accommodation between the two perspectives, whereby most supporters of recovery do not view drug-based treatment as inimical to the goal of social reintegration and a fulfilling life.

In Ireland, the authors of a 2005 study assert that a covert implementation of harm reduction strategies occurred in response to the opiate epidemic and emergence of HIV in the 1980s.3 Irish drug policymaking has since given way to a more transparent process through the introduction of national drug strategies and has shifted towards an aspirational focus on ‘rehabilitation’. Although differing slightly in terminology, this rehabilitation framework largely reflects the recovery concept of other jurisdictions. The current drugs strategy is characterised by two main themes: integrated care pathways that provide a journey towards recovery and service provision that is respectful to clients and promotes their involvement as active partners in the planning and delivery of their care.4

A 2021 research paper, published in the International Journal of Drug Policy, examined how the lived experiences of service users on long-term methadone maintenance treatment (MMT) compare with Ireland’s current drug policy goals.5

Methods

In-depth qualitative interviews were recorded with 25 long-term clients who had been enrolled in MMT at least 10 years prior to participating in the study. Recruitment focused primarily on clients of specialist addiction clinics in the Dún Laoghaire-Rathdown area of South Dublin. The interviews were topic-centred but allowed flexibility to accurately capture service users’ personal experiences. Analysis was guided by a grounded theory approach and thematic analysis was used to identify patterns within the data collected between August 2017 and February 2018.

Results

Positive impacts

Most of the study participants reported that MMT had positively impacted one or more aspects of their lives, with the benefits concentrated on providing a sense of stability and normality. Clients reported such stability had resulted in better management of daily life and responsibilities, more positive engagement with children and family, and improved health and wellbeing. Male interviewees particularly recounted a reduction in criminal activity and contact with the criminal justice system.

Inability to progress

While MMT promoted daily stability, a journey to recovery was not reflected in the accounts of the study participants. Individuals generally described their circumstances as stagnant with a significant lack of progress or change. One respondent described treatment as ‘stalling’ rather than ‘fixing’ the problem and many expressed feelings of being trapped in a cycle, with references to ‘liquid handcuffs’ and being held ‘hostage’, highlighting the perception of an unending process rather than a pathway to recovery.

Lack of involvement and control

Negative viewpoints towards the treatment setting were also conveyed by respondents, with a perceived lack of caring or interest shown in the personal circumstances, issues or challenges faced by the service user. Study participants depicted a sense of passivity in their care and felt there was little opportunity to provide input or influence their treatment plan. One interviewee explained: ‘They’re giving out maintenance too quick [without] asking “What do you think?”.’ Participants drew attention to a particular unwillingness of prescribing doctors to lower the clients’ daily dose, with such requests viewed negatively or refused without detailed explanation or engagement in discussion. Several respondents described the difficulty in establishing trust with doctors in the clinic. Overall, the ability to exert agency over their treatment was largely absent in the experiences recorded for this research.

Obstacles to reintegration

Several barriers to social reintegration were expressed by participants, most of whom were unemployed at the time of interview. Many felt the labour market was generally out of reach due to low educational qualifications, stigmatisation, and concerns around balancing MMT with employment. Daily life for interviewees was often depicted by feelings of isolation and loneliness, with family relationships remaining tenuous, difficulty maintaining friendships, and lacking a sense of belonging in their communities. One interviewee explained how he found it ‘pretty hard to reintegrate into normal society’, with the same sentiments of marginality shared among the majority of study participants.

Conclusions

The authors conclude that there is a clear disparity between Irish drug policy aims of recovery and social reintegration and the lived experiences of those who are long-term MMT clients. Participants did not view themselves on a pathway to rehabilitation and that the current system did not facilitate client input or autonomy over their ongoing care, while reinforcing feelings of social exclusion and stigmatisation. This study indicates that the current rehabilitation framework has not yet delivered improved outcomes for opioid-dependent clients and practices of service-user involvement have not been meaningfully implemented. To improve the quality of life for service users, a more realistic policy approach is urgently needed.

2 Best D, Bamber S, Battersby A, et al. (2010) Recovery and straw men: an analysis of the objections raised to the transition to a recovery model in UK addiction services. J Groups Addict Recover, 5(3–4): 264–288.

3 Butler S and Mayock P (2005) ‘An Irish solution to an Irish problem’: harm reduction and ambiguity in the drug policy of the Republic of Ireland. Inter J Drug Policy, 16(6): 415–422.
https://www.drugsandalcohol.ie/6779/

4 Department of Health (2017) Reducing harm, supporting recovery: a health-led response to drug and alcohol use in Ireland 2017–2025. Dublin: Department of Health. https://www.drugsandalcohol.ie/27603/

5 Mayock P and Butler S (2021) Pathways to ‘recovery’ and social reintegration: the experiences of long-term clients of methadone maintenance treatment in an Irish drug treatment setting. Inter J Drug Policy, 90: 103092. https://www.drugsandalcohol.ie/33604/