It is also of much concern to politicians and those responsible for treatment services.
The Scottish policy document The Road to Recovery, published in 2008, enshrines the fundamental principles which appeal to all sectors of the debate about the aims and aspirations of treatment.
It was a tactical triumph, at least in its acceptability to the divergent views of MSPs, and the document embraces all aspects of treatment which might aid recovery for all individuals. The essential outcome aspired to is complete abstinence from addictive drugs.
Harm minimisation and methadone treatment are considered as a serious part of the treatment portfolio but, for many, the document and the strategy is about a version of recovery which transcends the philosophy of damage limitation and enshrines abstinence and renewal of lives blighted by drugs.
Since the publication of the current Scottish policy much has been made of the limitations of harm minimisation, otherwise known as risk reduction or damage limitation.
Rather than bringing harm reduction and abstinence-oriented treatments together, there remains the view that these are incompatible and even opposing options.
Regrettably sections of the press and some experts have chosen to characterise methadone and other opiate substitute treatment as a barrier to recovery, or worse still, a dangerous treatment full of such hazards as sudden death, addiction to a drug worse than heroin and a conspiracy to commit drug users to a perpetual sentence of addictive behaviour.
It is hard sometimes to follow the logic that methadone is a pervasive evil, especially in the presence of much evidence of its benefits and decades of experience of its efficacy in saving and transforming lives (for the better).
For those of us in clinical practice, the reliable experience of transformation of young people dependent on opiates, injecting in a damaging way, tormented by addiction and involved with a revolving door of crime, custody and further crime, to a state of calm and safety is very satisfactory.
It is a great pleasure and privilege to be involved with a therapy which reverses some of the damage and removes the individual from harm.
The real value of treatment must surely be in using a combination of all available treatments and opportunities for recovery – the correct application of the strategy document. Harm minimisation, methadone and other treatments are entirely complementary and an approach which combines pharmacological therapies, residential or abstinence-orientated treatments as well as any other intervention is not only possible but best practice.
Why people with drug problems should not receive and benefit from all therapies at the same time seems a mystery. It must be our responsibility as a profession charged with supporting people through an illness to apply all available interventions rather than one or another. Clearly no treatment option is perfect and combinations are likely to be better.
Harm minimisation is not a clearly defined treatment. It is a philosophical approach to treatment, a pragmatic response to a difficult situation without an immediate cure. Anyone who contemplates the urgency to prevent the transmission of a blood-borne infection or who has seen the trauma of reckless injecting behaviour with all its risks cannot fail to understand the urgency to divert these dangers.
For many drug-dependent people opiate substitute treatment is a life-saving intervention. Perhaps more controversial is the value of this treatment over a longer period.
Research has, however, convinced most clinicians and organisations such as the National Institute for Health and Clinical Excellence (NICE) and many western governments that longer term, and sometimes very long-term treatment has persisting value. The most long-running studies have proved beyond reasonable doubt that some people never stop using opiate drugs. Equally, these studies have demonstrated that a large percentage eventually stop taking opiates and are enabled to progress to a comparatively, drug-free state. All individuals with successful outcomes would claim that recovery was based on a combination of factors rather than a single intervention.
The time has come to integrate treatments, to call a truce on critical undermining of any single strand of treatment and to allow access to best practice for all who need it.
People with opiate addiction problems are in a difficult position. They are marginalised by their mental health problem sometimes made worse by social inequality. Further difficulties arise because of the illegality of their dependency needs and the stigma connected with drug dependency. Perhaps cruellest of all is the lack of adequate advocacy and help given to them by health services, the public and elements in the media who conspire to under-represent their needs and constantly minimise the true extent of their problems.
Roy Robertson has been a full-time Edinburgh GP since 1980 and is Senior Lecturer and Reader in the Department of Community Health Sciences at Edinburgh University. This article is also published today on the blog ScotfreeHIV, founded by Roy Kilpatrick, formerly of HIV Scotland. http://scotfreehiv.tumblr.com/
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