Drug denial adds to costs and concerns

By SALLY JACKMAN*

The cost of treating someone for dependence on opioid drugs such as morphine, "homebake" and heroin is about $4400 a year. That sum is recouped many times over in reduced crime and prison expenses alone.

It makes no sense, therefore, that hundreds of people are on waiting lists for treatment, typically waiting several months and in some areas more than a year before a place becomes available in a methadone treatment programme.

The costs of this false economy do not stop there. The health and wellbeing of many of the country's 13,000 to 26,000 dependent users - and their families - are severely affected by the delay.

Physical and psychological dependence on opioid drugs can develop quickly. The illegality and high cost of the drugs frequently lead dependent users into lives of crime.

Their addiction focuses them on securing and using drugs, which may affect their ability to hold down a job and look after children.

It also leads some to neglect of self-care, eating poorly or engaging in risky behaviour like prostitution or use of unsterile injecting equipment. This leads to transmission of blood-borne viruses that have no vaccine, like hepatitis C. Involvement in a criminal sub-culture may also expose users to violence.

Methadone treatment programmes are the most effective treatment available for management of opioid dependence. They provide the patient with a daily dose of the legally prescribed opioid methadone which does not give the user a high but prevents withdrawal symptoms.

Freeing users from the daily search for drugs allows them to stabilise their life, pursue work or training, and take part in psychological or other treatment.

Dependent users may have underlying social and mental health problems that cannot be addressed by methadone alone and most treatment programmes provide access to a range of psychological and social services.

Research shows those receiving methadone treatment are less likely to use illegal opioid drugs and, therefore, less likely to be involved in criminal behaviour, and are more likely to be employed than people receiving no treatment or only assisted withdrawal.

According to a 1996 Christchurch study, people on waiting lists for a methadone programme yielded on average $1079 a week from crime to support their habit. Evidence suggests that provision of methadone treatment leads to around a 70 per cent reduction in crime among clients. The rate of imprisonment among opioid users is high and the cost of keeping a user in prison is $52,780 a year.

Despite a wealth of evidence supporting methadone programmes, there is still controversy about their use. One criticism is that methadone programmes simply replace one addictive substance with another and that the aim of treatment should be for the user to stop using drugs. To this end, some feel the starting point of rehabilitation should be an attempt to help the person give up "cold turkey".

In fact, treatment that forces the user to withdraw from drug use at the outset has a very low success rate. The longer people remain in methadone treatment the better their outcomes generally, and the better their chances of eventually withdrawing from all opioid use, including methadone.

Withdrawal may be an appropriate starting point for a small number of people but most need to receive methadone treatment for several years and some throughout their life.

The Blueprint for Mental Health Services in New Zealand set a Government target of 5666 methadone treatment places. Last financial year only 3896 places were provided. Before the election, the Labour Party said it would meet the methadone targets set out in the blueprint in the new term. It recognised that these targets may need to be reviewed and investment increased accordingly. An expansion of services requires both increased funding and changes in how services are delivered.

Health spending on methadone treatment has increased in recent years, in line with increased spending on mental health services generally. Increasing funding for methadone ahead of other mental health services would be a hard decision to take, but there are strong arguments for other sectors to fund the treatment given its demonstrated effectiveness in reducing crime.

The Ministry of Justice would be a natural ally of those seeking better services. One would think that organisations like the Insurance Council would advocate adequate treatment because they want to reduce burglary and theft.

Heavy reliance on specialist clinics may be a barrier to improving access to methadone. At the moment, some specialist clinics retain stable patients whose needs could be met by primary services (GPs and community pharmacies). This ties up specialist services and prevents others from getting treatment. Primary services would also have the advantage of normalising treatment for opioid dependence and reducing the stigma attached to it.

Moves to increase the involvement of GPs in the ongoing care of stable patients have met with resistance from some GPs and patients.

Some GPs have been reluctant to take on this treatment because of a stereotypical perception of methadone patients as high maintenance, involving extra paperwork, time and patience. In other cases they may view these patients as undeserving of treatment.

Cost is also a barrier for patients, who have to pay for treatment through a general practice whereas specialist clinics are free. Judgmental attitudes, prejudice and discrimination also make some reluctant to receive treatment through primary health services.

Some pharmacies dispensing methadone, for example, require clients to sign a contract saying they will eventually give it up. In some areas people must travel to another town to receive their prescription because local pharmacies are unwilling to dispense it.

Drug users have the same rights to health services as other patients. Their access to treatment, however, is limited in a way that would not be accepted for other lifestyle-related conditions, such as heart disease or diabetes.

Continuing to tolerate a situation where hundreds of dependent users are denied treatment is both unjust and costly.

* Sally Jackman is executive director of the Drug Foundation.