A Dutch Addict's View of Methadone Maintenance

Introduction: The Interview Setting

During a recent "Harm Reduction" conference in the Netherlands, the authors had an opportunity to visit local drug treatment programmes, detention facilities and other agencies dealing with drug abusers. In the course of visiting a methadone programme in Utrecht, a lengthy and informative interview with one of the clients was undertaken to ascertain clients' knowledge and expectations about drug abuse treatment. The resulting discussion highlighted differences between Dutch and American methadone programmes. These observations have particular relevance to contemporary research and policy issues pertaining to the expansion of methadone maintenance treatment in Europe and America.

The interview with "Jan" was more of a focused conversation about clients' drug-taking lifestyles and attitudes about methadone maintenance than a structured face-to-face interview. This was because Jan and another client joined in the director's discussion about his programme of some 210 clients, which was being conducted with the authors and two other visitors. As our discussion of the methadone programme and its clients progressed, Jan began to dominate the conversation because of his fluency in English and his willingness to describe local addicts' daily life and programme participation.

Interview with "Jan"

In response to questions, Jan described the difference between various drug combinations: heroin and cocaine was a cocktail; heroin and speed was a speedball; and coke and speed was a snowball. From Jan's discussion of the drug scene and his current use of illegal drugs, it was apparent that there was a widespread and active illegal market in drugs in this city as well as in others in Holland. Jan said that "all clients are still involved continually in taking illegal drugs." These drugs included heroin, cocaine and stimulants; for the most part, hash and marihuana use were taken for granted as these are openly and "legally" available for purchase at designated bars.

After a considerable discussion of how cocaine is used by addicts, Jan stated that "everyone uses cocaine; mostly it's smoked." The visitors tended neither to contradict nor ask for corroboration of statements made by Jan as, for example, when he said that "everyone" at the programme uses cocaine. It was deemed best to let this most knowledgeable addict report his experiences and opinions freely.

Discussion returned to the methadone programme. Jan said that clients were in the programme because it made life easier for them. This occurred when they had a regular supply of methadone as well as group support from other clients as to maintaining their drug-taking way of life. Jan said that he was now trying to get off methadone and that he was down to 12.5 mg per day. He was still, however, using other drugs intravenously. This occurred on a more or less daily basis, depending on his finances. He said that he was still stealing every day and using alcohol every day. He described his theft of radios and bicycles in some detail; his attitude about such thefts was casual--as though this is what addicts do and are expected to do to get money for drugs. He mentioned that 50 guilders (about $30) was the minimum amount of money required for a drug purchase (again, excluding marihuana and hash). An extended discussion ensued next about the procedure used by clients at this programme to inject the liquid methadone they received as take-homes at weekends or on other occasions. As we sat around the large table (two addicts, the programme director, the two authors and two other visitors), Jan complained to the director that they needed a larger syringe than the small ones provided by the programme to facilitate their front-loading and other group injecting practices. The programme director did not give him encouragement in this regard, and said that only a few clients shoot methadone. His response to Jan was cordial rather than contradictory or defensive.

Jan said that he currently attended the clinic six days a week. He rolled up his sleeve to show us scars and incisions on his left arm when asked about his current IV use.

Next, Jan discussed his preference for drugs. He said that cocaine IV was best, but that pervitine (Pervertin) was also great. This drug, however, was an expensive amphetamine which was difficult to obtain--but "excellent" in its effect, Jan assured us.

Talk then turned to big dealers. Jan said that these were mostly foreigners: Turks, Moroccans and people from Surinam. In discussing his offences, Jan said that the police mostly did nothing ("just took down names") about petty crimes committed by addicts. In his case, it was only after he was caught stealing car radios 10 or more times that he was arrested (jailed for six hours). As to common types of petty crime: store theft, car radio theft and bicycle theft were mentioned. But Jan noted that "most serious criminals are not in methadone programmes."

Jan said that he only uses illegal drugs now for pleasure; this was in contra-distinction to using drugs to prevent withdrawal. Methadone has, he said, reduced his compulsive need for opiates; consequently, he can now use other drugs more selectively for pleasure.

But Jan now wants to stop using methadone. He is 38 years old, has two children whom he would like to see more often and, in general, wants to stop using drugs and reorientate his life; but he has tried to detoxify 15 times before (he was quite definite about this figure) without success. Therefore, he is dubious-yet vaguely hopeful-about his present effort at detoxification. At 10.45 a.m. we interrupted our conversation to visit the methadone bus which was parked in front of the programme building. We discussed the operation of this bus, which visited three sites in the city on a daily basis to dispense oral methadone to some 200 clients. A driver and three assistants constituted the operational staff. The principal function of the bus was to dispense methadone at designated sites. I asked (JB) what was the reason for dispensing from the bus as it appeared that dispensing could easily be done from the programme office. I was told by the director that this off-site dispensing prevented an accumulation of clients at one place which would create local problems.

Shortly after our inspection of the bus, the driver and dispensing staff arrived and the bus left for its first site. Later, after leaving the programme offices, and on our way to the House of Detention in the town, we passed the bus parked near to a park. It was dispensing methadone to some 20 addicts who were around the vehicle. As we passed, an expensive car pulled up and a passenger got out to obtain her methadone. We continued driving through this area without stopping in order not to compromise clients' confidentiality.

When we returned to the conference room, I thought it appropriate to ask Jan his opinion of more structured methadone programmes such as exist in the United States, for it seemed apparent that his present effort at detoxification would prove as unsuccessful as those in the past since he did not seem to understand the pharmacology of methadone maintenance treatment. Both his vaguely expressed desire to stop using methadone and the programme environment were not conducive to rehabilitation. In this latter regard, Jan had mentioned that it was difficult to ignore or surmount the pro-drug influence of clients around the methadone bus.

Consequently, I mentioned that in better US methadone programmes patients were both encouraged to stop using illicit drugs and monitored in this regard. Furthermore, that counsellors, physicians and other staff were continually involved in assisting patients to change their drug orientated way of life and to become involved in more productive endeavours. Specifically, I mentioned that programmes tried to create a rehabilitation environment in which there was group support for rehabilitation and the provision of comprehensive services. Jan asked what would happen if he used drugs (e.g. IV use) while at such a programme? Or was absent? Would he be "kicked out?" (his tone in asking these questions was somewhat accusatory, as though this would infringe on his rights). I said that he would not necessarily be discharged for one or a few infractions, but that these programmes were designed to provide a basis for rehabilitation; that we expected patients to stop, or at least control and reduce, their illicit drug use; to seek employment; to give up crime; and generally to change their illegal way of life.

Jan said that he could not go along with these rehabilitation plans; that he did not want to be so controlled; that it would be difficult to seek and maintain employment; that he would relapse to drug use and that this should not be punished. I replied that our programmes were not involved in punishing addicts. We were, however, dedicated to rehabilitation. Jan said again that he would not like these programmes. At this point, it was clear that he was ambivalent about rehabilitation: he wanted a better life, but he did not want to make the required changes. In particular, he had not decided to give up illicit drugs, nor was he committed to establishing a stable way of life. He seems, at this time, destined to continue his addiction career with its focus upon daily drug-taking and its concomitant support from his addict friends.

Since our conference in Rotterdam had addressed various policy issues pertaining to drug abuse in the Netherlands and America, I decided to ask Jan about his views. Specifically, I asked: "What should Holland do now about the drug abuse problem? What would you recommend?"

Jan thought briefly and then said that what the Netherlands' Government should do is to make heroin freely available; this, he thought, would improve the situation for drug users. When asked about cocaine, he hesitated. "Cocaine mixes you up. It leads to aggressive behaviour. So, I don't know about cocaine."

Two Appraisals

An American Appraisal
John C. Ball

Jan was an able conversationalist who seemed to enjoy talking about the local drug scene. Indeed, he became quite animated when describing his own and other addicts' preferences for particular drugs. With respect to treatment and rehabilitation, Jan is ambivalent: he desires certain aspects of rehabilitation (such as closer ties with his children) but seems unwilling to forgo the pleasures associated with drug abuse. Somewhat surprisingly, he seems uninformed about the pharmacology of methadone maintenance and the need for long-term treatment. Thus, his present effort at detoxification seems doomed to failure.

Whether Jan is coping better with his addiction while in methadone "care" than he would on the street is an open question. Jan said that this programme is helping him. Whether this confirmed addict would profit from a more rehabilitation- orientated programme is doubtful. It seems unlikely, as long as he remains preoccupied with the pleasures of drug abuse and misinformed about the effectiveness of long-term methadone maintenance treatment.

A Dutch Appraisal
Govert F. Van de Wijngaart

Jan is a typical Dutch methadone client. He has been taking drugs since the late 1960s when the drug scene consisted primarily of high school and university students, artists and young labourers. The drug of choice was amphetamines (speed) and sometimes there also was opium on the market. Heroin only came to the Netherlands in 1972 and the speed users were among the first to try this drug. These early heroin users were mostly male (80%) and for the most part they had not completed their education and never obtained regular employment. Over the years, it became difficult for these drug users to obtain employment (even if they really wanted steady jobs) because the job market in the Netherlands is quite inflexible and, to be honest, which employers want to hire them?

In the Netherlands people without jobs receive social security payments which are enough for "normal" living. Most drug users, however, need additional ftmds so they resort to petty crime (as described by Jan). As a consequence, most regular drug users have been in jail as well as detoxification programmes. With regard to the latter, they seek detoxification to regain their health temporarily or because they really want to stop their drug dependence. During an average career of 20 to 25 years, these drug users commonly make numerous attempts to reduce or stop their use of illicit drugs and methadone. With regard to methadone, this medication has been dispensed to drug users for some 15 years or longer.

The methadone programme Jan attends is an example of a "care" programme. In this programme the client is maintained on methadone, but the additional use of other substances is tolerated. Thus the addict stays "in sight" as contact with him is maintained and an opportunity for education or prevention efforts is possible. With respect to education and prevention, the following harm reduction measures are advocated for clients:

• Restrict your use of numerous illegal drugs.
• If you do use various drugs, do not shoot your drugs.
• If you do shoot, do not share your works, and use "fresh" needles from an exchange programme.
• Stay as healthy as possible, try to have decent meals (at least once in a while), practice safe sex, and see your physician on a regular basis.

Acknowledgement

We wish to acknowledge the outstanding cooperation of Rolf jaarsma at the Methadone Program, which is part of the Consultation Center for Alcohol and other Drugs "Centrum Maliebaan" in Utrecht.

Note

For a comprehensive review of methadone treatment in the United States see: J. C. Ball & A. Ross (1991) The Effectiveness of Methadone Maintenance Treatment (New York, Springer- Verlag). For a comprehensive review of drug abuse treatment in the Netherlands see: G. F. VAN DE WIJNGAART (1991) Competing Perspectives on Drug Use (The Dutch Experience) (Amsterdam, Swets & Zeitlinger).

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