Is the methadone programme the best way of helping heroin-users to become drug-free? Or is it just a State-sponsored way of replacing one drug problem with another? Conor Lally reports
It's a cold January morning in Dublin's north inner city. Inside one of the capital's pharmacies, scores of servings of the heroin-replacement drug methadone are poured into tiny containers.
They are stacked neatly on shelves in the back room of the pharmacy. Each is placed alongside an identity card, each featuring the name and picture of a different drug addict.
These containers have formed the backbone of the State's fight against heroin addiction since the mid-1990s. Methadone is prescribed to addicts by GPs working under the methadone treatment protocol.
Throughout the morning, the faces on the cards appear in the shop. They come, drink their daily fix, and go. All over the capital the same scene is repeated, all day, every day. There are 6,423 addicts on the State's central treatment list receiving methadone. The State spends €49 million a year on all its drug-treatment services.
But many groups working with addicts are now questioning the effectiveness of the daily methadone march. Some argue that dispensing methadone amounts to State-sponsored drug addiction. They say the substance simply replaces heroin in the cycle of addiction, with the majority of drug-users no closer to leading a drug-free life even after years of methadone "stabilisation".
Critics of methadone use say that recovery facilities for chronic drug addicts are inadequate and that official Government policy should be tilted more towards drug-free recovery programmes and away from methadone maintenance.
Advocates say the drug stabilises heroin addicts in that they no longer have to steal to feed their habits and do not run the risk of taking an impure drug. Many also believe that once an addict gets into a routine of methadone use they can begin to rebuild their lives.
Jim Cumberton is chairman of the Drug Prevention Alliance (DPA), a voluntary group which promotes early intervention and drug free recovery. He is also the former head of the Coolmine Therapeutic Community in Co Dublin and is a past president of the European Federation of Therapeutic Communities. He believes the National Drug Strategy is so heavily dependent on methadone use that it is condemning drug users to a life of chronic addiction.
Methadone is a stronger, more addictive drug than heroin, he says. "In a lot of cases addicts are more sedated, even over the longer term, than they were on heroin.
"Most methadone users also use other drugs such as alcohol and tranquillisers. In maybe 5 per cent of cases addicts stabilise on methadone and they can do things like hold a job and function properly but the others never get the chance to live a full life again. People simply become trapped and a lot of addicts will tell you that methadone is a lot harder to come off than heroin."
Cumberton believes the estimated 30 detoxification beds in the Dublin area for addicts should be quadrupled. There's an estimated 14,000 heroin addicts in the Dublin area.
"There's no point in getting someone off drugs and then putting them back immediately into the very environment where their problem started.
"I think while methadone can have its uses for detoxification from heroin, those under 20 should never be put on methadone maintenance. And when the State, your GP and a health board is telling a child and parent that methadone is a way to recovery, it is very hard for a parent to turn that down."
At the Rutland Centre in Dublin, a drug-free treatment facility, director Stephen Rowan shares some of the DPA's reservations about methadone. He says while methadone can be used with success in the early stages of recovery for chronic drug users, it should not be used for those who have had a more short-term involvement with the drug. Health care providers need to place an emphasis on establishing a recovery path for an addict rather than viewing methadone maintenance as an end in itself. He believes once addicts show a willingness to progress beyond methadone they must be met with whatever resources they need.
"More often than not what they are told is that they are not ready, for whatever reason. You would just have to question, when is an addict ever ready for the next step? What do they have to do, or what do they have to say to prove that they are ready? That would be our concern."
While methadone maintenance has been concentrated in the Dublin area, Galway's first methadone clinic has just opened. However, not all health care workers in the west agree that the region needs a clinic.
Dr Greg Kelly has worked as a GP in Castlerea, Co Roscommon, for more than 20 years. He has also been the medical officer at Castlerea Prison for the last six years and is a former chairman of the Western Health Board. He opposes both methadone maintenance and the opening of the new Galway clinic which, he says, will bring a "tourist industry" of drug addicts to the west of Ireland.
According to Dr Kelly, the best way to help drug addicts kick their habits is to get them off drugs, including methadone. "Alcoholics don't give up drink by having a little bit of alcohol a day, gamblers don't give up by having just a quick fix each day and smokers are the same. So why do we think we are going to help heroin addicts by giving them methadone?" He believes residential detoxification backed up by counselling will cure a huge number of addicts and he refuses to dispense methadone to prisoners at Castlerea.
"When a person is in jail it is a golden opportunity to get them off drugs. I have had prisoners come to Castlerea from other jails just so they can leave drugs behind. And every single addict that I have had has come back to me within a week or two of being drug-free and is doing well. By giving someone methadone you are saying 'this person is never going to be able to do without drugs'. You are writing the person off, it's a negative approach and it is not working."
At the Merchants' Quay Project in Dublin, director Tony Geoghegan has a different perspective on methadone maintenance. He believes it is a very effective way of stabilising addicts and maintaining long-term contact with them before introducing them to next step treatment facilities.
Geoghegan is also chairman of the Voluntary Drug Treatment Network, a coalition of 15 Dublin agencies and sits on the National Drugs Advisory Committee on behalf of the Irish Association of Alcohol and Addiction Counsellors.
He says heroin addicts live a life steeped in chaos and crime. Methadone can restore some order and even if addicts are maintained for a number of years on the drug, their addiction very often subsides after two years.
He warns that just because an addict may be on methadone for a very long period that should not be interpreted as a failure of the system.
"If someone is on maintenance for 10 years it could be the case that they might have died during that time if they had been taking street heroin."
However, he agrees there is an acute lack of facilities for addicts who want to achieve a drug-free recovery away from methadone and that education and training is the best way to progress former addicts, but "because addicts don't get much sympathy in Ireland," spending on recovery-realted facilites has not been a priority for successive governments, he says.