Background
Methadone maintenance treatment (MMT) is considered a common treatment for opiate- dependent people across Europe and especially in Ireland. As MMT services cater for vulnerable populations, a human-rights-focused approach can assist in shaping and framing processes to provide more equality and access to services. A 2022 qualitative study1 looked at how to better understand the human-rights perspective in relation to people accessing MMT services in Ireland.

Method
In-depth qualitative interviews about the experiences of MMT were conducted with 40 current and recent service users. The majority of participants were from Dublin and included 17 women and 23 men. Data were collected between January and December 2019 and analysed using a narrative inquiry design.

Results
The authors found five interrelated themes from the narratives of the participants.

1. Giving away control and eroding personal autonomy
2. Coercive, restrictive, and disrespectful practice
3. A system predicated on reward and punishment
4. Disregarding best practice
5. Consequences of system failure. 

Narrative 1: Giving away control and eroding personal autonomy
This is characterised by power imbalances; restriction of personal agency; and fear of perceived authority. The narratives suggested an unequal power relationship between the participant and their service provider. One example was signing a consent form at the start of treatment, with many not understanding or recalling the content of these forms or the consequences of what they were signing.

I wouldn’t have a clue what they said [staff], but you’re hardly not going to sign them ... if that what it takes to get help. You’ve got to remember you’re usually in a heap [highly distressed] signing those forms. John (p. 3)

Some participants felt their privacy had been violated, especially when they became aware that the signing of these forms permitted their service provider to share personal information, manifesting the power of the service provider.

Many expressed living in fear or being ‘controlled’ or ‘chained’ and feeling like a ‘puppet’ due to the practices of some service providers. They reported that they felt doctors had powers that often impinged on their private lives, such as around childcare, and brought unnecessary difficulty to their lives.

I do feel under threat by the doctor. She’s never come straight out and said it but there are things she could do that would make my life more awkward. She could put me back on ‘dailys’ [daily supervision of consuming methadone] … and she uses this to control me. Joseph (p. 5)

As for dignity and respect, me bollix. One dirty urine, the takeaway is gone, even if you have months of clean urines. Really, with the amount of urines, clean urines that I’ve given, I should be on weekly takeaways. If I had these, maybe then I could get a job. Jason

Participants who were parents also expressed fear of social workers and considered them a threat to their role as parents.

Narrative 2: Coercive, restrictive, and disrespectful practice
This is characterised by unmet expectations of treatment; social opprobrium; and shame and hopelessness. Many service users spoke of becoming disillusioned with their expectations of MMT, which they had hoped would improve their lives, enable them to rehabilitate, to return to work, and to repair relationships, for example. Moreover, most participants felt they had received unequal treatment when compared with other health service users and sometimes felt treated like second-class citizens.

[At the GP practice] I mean you could have an appointment … but they just put people ahead of you [in order of arrival], looking down at you [staff]. It’s hard to explain but you feel like a second-class citizen. Aido (p. 5)

Some participants also felt ‘subhuman’ at the hands of MMT service providers, in particular in relation to the imposition of sanctions. Others provided examples of where their service provider expressed a lack of confidence in the ability of the service user to achieve positive outcomes. In addition, service-user narratives described a sense of hopelessness sometimes combined with feeling ‘belittled’ and having no ‘self-respect’ or ‘self-worth’, to the point where they felt they had no right to an acceptable standard of treatment.

…I can’t complain, anything I done was my own fault, dirty urines so I had to be punished. Anything I got punished for was my own fault. Emma (p. 5)

Narrative 3: A system predicated on reward and punishment
This is characterised by pejorative binaries and the lack of a robust complaints facility. Participant narratives often referred to being ‘dirty/clean’ (in relation to urine samples) and how this was internalised.

We’re calling ourselves clean and dirty, we shouldn’t be labelling ourselves like this, but it’s the clinics, they put that into [you], your urine is either clean or dirty, and that’s how you’re treated. Jenna (p. 6)

Some participants spoke of their reluctance to make a complaint about certain service providers because of the fear of any ensuing consequences.

I can’t complain about him [doctor/service provider], even it was anonymous, he would find out it was me .... I would be reluctant to make a complaint because I think he would make my life a living hell. Jason (p. 6) 
 
Narrative 4: Disregarding best practice
This is characterised by an observed lack of staff knowledge and experience and lack of choice. Narratives suggested some participants felt doctors in MMT services did not have enough experience and this hampered their recovery.

I don’t feel my doctor knows enough about addiction to be running my life. They don’t do much training, but we are expected to do all the work to get on methadone and stay on methadone .... They don’t realise there is more to it than the drug. Lisa (p. 6)

We get them stand-in doctors, they’re training. One would give you a sleeper [sleeping tablet], the other would take it off you. Louise (p. 6)

Some participants also felt that some doctors often overlooked their other medical problems, such as stress, anxiety, and pain.

I’ve always had anxiety and insomnia but as an addict, they won’t give me anything .... It’s like, ‘she’s a junkie, she’s only looking for tablets’. This really annoys me. Sinead (p. 6)

Several participants discussed that one of the consequences of the perceived power imbalance with MMT services and lack of choice was that they had no choice but to try to self-detox without medical supervision, despite knowing the dangers of doing so.

I feel like just a cheque to my doctor, a number; me and the fella, we had to detox ourselves because the doctor would have left us where we were. Emma (p. 6)

When I wanted to detox, I had to do it behind the doctor’s back. I was never even asked about detox, I think they had me down as someone who would be on methadone for life. They said I couldn’t do it when I asked, wouldn’t let me. So, I had to do it myself, without them knowing and that’s how I got off methadone. Unfortunately, I think this puts a lot of people off and keeps them on methadone. Louise (p. 6)

Narrative 5: Consequences of system failure
This is characterised by geographical restrictions; the stigma of MMT precluding social reintegration; being ‘back in the circle’; and a lack of follow-up care. Many participants, especially those from more rural areas, discussed the consequences of long waiting times – ranging from 2 months to 2 years – to access MMT services.

I went through the usual three urines and visits to counsellors and was waiting two months to get back on … I had relapsed .... I was living on the streets … it’s a long time to be waiting to get back on methadone, especially when you are living rough and tapping [begging] …. No other illness is treated like this. Aoife (p. 6)

Narratives frequently indicated that the set-up of MMT services hindered the attempts of many service users to get employment, which for some put them at risk of returning to criminal activities in order to alleviate financial pressures. The participants spoke of other external risks associated with MMT, for example, exposure to drug dealing in the environs of the clinics.

Going back into the clinics every day makes it impossible to stay clean, especially when you’re from the inner city. Zimovane, Valium, there would be everything, never mind heroin. And I’d be stable. I think that once you get stable there is no need for you to be going in there every day or even every few days .... I could get lay on [drugs first, money later], the lot, I wouldn’t even need money. Robbie (p. 7)

Other issues highlighted were the lack of support services when a person finishes MMT and then the subsequent problem of accessing services if they need to return to treatment. These factors encouraged participants to stay in MMT rather than to move on.

That’s one of the reasons why I don’t want to leave the methadone services, there’s nothing afterwards. It scares me that when I finish with the doctor there is nothing there for me afterwards …. It’s so hard to get back on the services that I don’t want to leave or come off them. Linda (p. 7)

Discussion and conclusion
The authors conclude that their study presents an over-arching narrative which does not support the position that Irish MMT services are ‘compliant with a human rights-based approach that incorporates principles such as fairness, respect, equality, dignity and autonomy’ (p. 7). As such, they point to possible ‘system failures’ in Irish MMT services. The response needs to be multidimensional and include adequate resources to move towards a more human-rights approach within the system.

1    Healy R, Goodwin J and Kelly P (2022) ‘As for dignity and respect…. me bollix’: A human rights-based exploration of service user narratives in Irish methadone maintenance treatment. Int J Drug Policy, 110: 103901. Available from: https://www.drugsandalcohol.ie/37442/