Safeguarding a life-long addiction

The opiate substitute methadone is implicated in 60 percent of drug poisonings. A safer alternative has long been available, so why are eight in ten recovering opiate addicts still using it?

After stepping behind a locked security door, I’m told to be as quiet as possible. We walk slowly through the room, passing booths divided by frosted glass and steel tables littered with syringe wrappers and alcohol wipes. Nervous faces look up at me, one after the other as I pass by.

“Noise sensitivity is a strong side effect when you’ve just injected,” whispers Ivan Christensen, head of Mændenes Hjem (The Men’s Home). The shelter, one of the largest drug user assistance facilities in Copenhagen, is located in Copenhagen’s iconic red-light district on Istedgade.

At the end of the hall is the smoking area, a small room behind a glass wall where about eight people are huddled. Plumes of smoke rise from a group deep in conversation; a few stand with eyes glazed, while others are hunched over fiddling with spoons and lighters. My eyes fall on a man in a red sweater, who puffs on a joint dipped into a piece of foil that he holds cupped in his hands – he looks like he’s only in his early twenties.

“These people are the most stigmatised in society and often we’re all they have,” says Christensen. “This isn’t where they start, this is where they end up.”

Christensen has been involved with Mændenes Hjem for almost 16 years and has worked in social justice since his teens. The shelter is one of the city’s facilities that accommodates people dependent on opiates – both users of substitutes such as methadone and those who continue to use illicit drugs.

The ingestion clinic I just toured is one of only a few in the world. It is open 23 hours a day and can receive up to 700 visitors every day. The shelter also provides food, shelter, medical care, assistance with entering rehab programmes and help with finding employment where possible.

“Given the lives some of these people have lived, it’s almost inevitable that they became involved with drugs,” Christensen explains as we walk down the corridor to his office, the smell of a strong sanitizer permeating the air. “And for many, it’s a life-long thing.”

Substitute high
Injection rooms in Odense and Copenhagen are credited with saving 93 lives in the first year they opened, as medical staff were able to step in and reverse potentially fatal overdoses.

Overdosing isn’t the only issue that injecting drug users have to contend with, however. Street bought drugs can contain a range of dangerous impurities, needle sharing risks the transmission of diseases such as hepatitis and HIV, while needle use can damage blood vessels and increase the risk of blood clots.

Heroin addicts in treatment are therefore given oral replacement drugs that minimise these risks. The two main opiate substitutes legally prescribed in Denmark are buprenorphine and methadone. But while buprenorphine is considered the safer and less addictive, 80 percent of addicts in treatment use methadone, according to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Health professionals have expressed concern that methadone remains the replacement of choice, especially given the government’s target to treat half of addicts with buprenorphine.

“Few will admit to discouraging the use of buprenorphine because of the cost,” Dr Inger Birkemose from the Odense City Council drug rehabilitation programme told Politiken newspaper recently. “Giving methadone is cheaper and you also get a patient who is happier.”

Unlike buprenorphine, methadone can be abused to achieve a high. Many heroin users also supplement their addiction with methadone. However, methadone is highly toxic and played a role in 60 percent of the 166 drug poisoning deaths registered by the police in 2012.

“[In 2012 there] was a decline in the number of deaths where heroin/morphine is reported and an increase in the proportion of deaths where methadone is assumed to be the most significant cause of death,” according to the EMCDDA’s latest report on the situation in Denmark.

Irene Mills, a general practitioner with over 15 years experience working with drug addiction at KABS – a Danish drug user treatment organization – says methadone overdoses normally occur when other drugs or alcohol are also ingested.

“For methadone to cause an overdose alone, it would require a much bigger dose than what is provided,” Mills adds.

Christensen says that while users of opiates are dying at least 20 years early, he has not found that substitutes are a major cause of death.

“People generally die from decades of drug use, which burns their body out,” he explains.  “They also tend to die from other illnesses. Some of our visitors have four to five conditions, both somatic and psychological.”

Mills and Christensen acknowledge that dependence on substitutes like methadone are not ideal, but few addicts can cope with transferring to white-knuckle sobriety. Mills says while it may be disheartening to hear, opiate addiction is commonly a life sentence, so providing a legal and safer substance is the best treatment.

“Of course getting off methadone is possible, but your life must be very stable outside of your addiction,” she says.

A rare recovery
Mads Nordheim, a musician and recovered addict, is one of the few who managed to escape the grip of heroin. A long-time drug user, his recovery was only made possible through the Danish rehabilitation system.

At just 13, Nordheim ran away from home in Norway to Christiania. He started smoking marijuana, eventually moving to amphetamines, followed by heroin. He used heroin for around 12 years before entering a treatment programme using methadone and has now been clean for over 10 years. He says the biggest motivator for his recovery wasn’t the state of his physical health, but the crushing isolation.

“The first time I injected, I knew my addiction had taken on another form,” he explains. “There weren’t any injection rooms in those days, it was all out in the open. Society wants nothing to do with you, and slowly you see less and less of those you love.”

Nordheim believes his recovery was only possible due to his stable background, including his support network of friends and his passion for music. But he says there is virtually no incentive for most users to get clean.

“Most people who are using have had and still have horrible lives. I would never blame them for wanting to escape, nor for not wanting to return to reality,” he says.

“When you inject, you get surrounded with this warm blanket – physically and mentally. You don’t need a thing – no family or friends, a roof over your head, or even food. The heroin is your trust and security.”

Nordheim did however note that rehab can be problematic in Denmark, as the system allows people to come and go as they please, meaning there is little motivation to stay clean.

“In many other countries, you’ve only got one shot at a programme,” he adds.

Revising rehab
Despite being carefully distributed, methadone often finds its way out of the hands out recovering addicts and on to the streets. Near Copenhagen Central Station, at a site known locally as the Pill Centre, dealers sell these prescription drugs .

“Some people enrolled in the programme sell their supply, either because they don’t need the entire dosage or because they have tried to save it,” Nordheim explains.

“GPs aren’t supposed to prescribe it, but some will if they have a history or good rapport with their patients. There are also robberies at pharmacies, all resulting in a steady flow under the table.”

Regardless of where drugs are coming from, Nordheim says harsher policies or a crack down on distribution won’t curb drug use.

“The simple fact is that people are always going to take drugs. The best a system can do is try to make it as safe as possible,” he says.

Christensen agrees, arguing that regardless of whether we approve of drug use, it will remain a part of our society.

“Of course we want people to be ‘clean’ and we will help them any way we can, but we don’t judge people’s choice to continue taking drugs, legal or illegal,” he says, adding that the same users have been visiting the shelter for decades and he doesn’t expect this to change.

“It’s hard to say whether the Danish system is successful. But if we can help people avoid getting involved with crime or putting their health at further risk, then it is worth it. We have to try to integrate people back into society. Often it’s one step forward, two steps back. But we’ll keep trying.” M

Features, News

By Lesley Price

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