Long-term methadone maintenance treatment: Stigma and social isolation
Paula Mayock is an Assistant Professor at the School of Social Work and Social Policy, Trinity College Dublin. Her research focuses primarily on marginalised youth and adult populations, covering areas such as homelessness, drug use and drug treatment. She is the founder and Co-director of the Women’s Homelessness in Europe Network (WHEN www.womenshomelessness.org) and author of numerous articles, book chapters and commissioned research reports.
Mirroring trends throughout Europe, there has been a distinct rise in the age of Ireland’s opiate users who are in treatment. In 2015, 42.5% of treated opiate users nationally were over the age of 35 years compared to 27% in 2009. In the Dublin region, this trend is more pronounced: while 31.5% of individuals treated for opiate use in 2009 were over the age of 35, this proportion increased to 54% by 2015. Yet, very little is known about the lives of individuals who have been accessing methadone maintenance treatment (MMT) for a prolonged period of time and their experiences remain largely invisible.
A recently published Irish study of long-term participants in MMT (Mayock, Butler & Hoey, 2018) revealed the high levels of stigma in the lives of ‘older’ clients of MMT. We conducted in-depth interviews with 25 clients (16 men and 9 women) of MMT in the Dun Laoghaire Rathdown area: all had accessed treatment for the first time at least 10 years before the interview, with two-thirds having been first prescribed methadone more than 20 years previously. The average age for the sample was 43 years. Over half had experienced homelessness at some point during their lives, many for lengthy periods, and seven participants were currently living in transitional homeless accommodation. At the time of interview, only three participants were employed full-time.
“But yeah, there is a dirty stigma to being on methadone. I don’t care what everyone says, ‘Oh they’re not using, they’re not a drug addict’. But there is a stigma out there, you know” (Female, age 50).
Stigma was experienced on multiple levels by a majority of the study’s participants. A large number described ways in which they felt stereotyped as methadone treatment client by medical and other professionals in the clinics they attended. For example, one participant – a female, who like a large number of others expressed that the requirement to provide supervised urine samples felt dehumanising – described the practice as reinforcing “that junkie mentality”. Many others described feeling humiliated during pharmacy visits: “You go into the chemist or whatever to get your phy (methadone) and you’re left standing in the corner like a leper”. Stigma was also experienced in everyday interactions in their neighbourhoods, which one male participant said he had to “fight all the time”.
“There’s a lot of prejudice to drug addiction … It’s just the stigma sometimes, you know, that I have to fight all the time … Like growing a thick skin because people aren’t just going to accept you for it” (Male, age 35-39).
A majority of the MMT clients interviewed were managing stigma on a constant basis. Accounts of self-stigma – which refers to negative thoughts arising from being part of a stigmatised group – were common, with participants often describing ways in which they had internalised public attitudes to drug users and drug addiction. These narratives of self-stigma were particularly apparent among female participants, who frequently discussed changes in their physical appearance and an absence of trusted people in their lives: “I look like a junkie now and people judge. I certainly get judged a lot because of my appearance”.
There are many consequences of stigma, including a reluctance to engage with services because it was feared that attendance could serve to further expose and reinforce their status as a client of MMT. Concealing their ongoing engagement with methadone treatment from others, including family members and friends, was an imperative for a significant number: “I’ve often missed the clinic from hiding down the road”.
Growing older as a methadone patient exacerbated feelings of stigma, shame and stigma-related stress. A large number described their daily lives as secluded and lonely, because of a lack or absence of social relationships.
“I find the older I get the more different I feel … I’m finding it really hard to mix with people …” (Female, age 40-44).
Despite its efficacy and widespread use, MMT continues to be largely stigmatised and stigmatising, with patients often experiencing stigma and discrimination associated with their treatment. The findings of this research suggest that stigma negatively shaped participants’ lives, both socially and emotionally; it diminished quality of life , perpetuated feeling of ‘otherness’ and negatively impacted mental health. A frequently silenced and unspoken experience, addiction and drug treatment stigma made participants feel unwelcome and unable to participate and belong in their communities.
The stigmatisation of people who seek treatment for drug problems has serious implications for policy since it clearly undermines the goal of re-integration. More than ten years after accessing treatment for heroin dependency – and close to twenty years for a majority – this study’s participants were not socially integrated, and a large number had multiple and sometimes complex needs in relation to housing, education, employment and mental health. If the goals of ‘rehabilitation’ and ‘recovery’ are to be attained, the aim of tackling and reducing stigma towards people with a history of drug problems must be taken seriously.
Mayock, P., Butler, S. & Hoey, D. (2018) “Just Maintaining the Status Quo”? The Experiences of Long-term Participants in Methadone Maintenance Treatment. Dublin: Dun Laoghaire Rathdown Drug and Alcohol Task Force.
This research was funded by the Dun Laoghaire Rathdown Drug and Alcohol Task Force. The full research report can be downloaded at: https://www.dlrdrugtaskforce.ie/web-version-of-report.pdf