Ethical Treatment of a Methadone Client in a Public Detoxification Facility





In order for a clearer understanding of the content of this paper I will provide the reader with a very brief history of substance abuse treatment in the United States.

The policy of this country, surrounding substance abuse, has always focused on either the illegality of the substance or in the case of alcohol, moralizing the way the substance is used.

There are two basic approaches to treating substance abuse in the United States today. By far the most popular is that in which total abstinence is the primary goal. This approach could be summarized as a confrontational technique. The client is told that their life is out of control due to the abuse and use of a chemical substance. In a harm reduction approach the client would be supported hoping that they would come to the conclusion and realization that their life is out of control due to use of a substance. Secondly that the substance is the central organinizing principle of their lives, meaning that the individuals focus in life has become obtaining and using the substance of their choice.
(Brown p.27)
In the confrontational approach many tools are utilized: detoxification centers, inpatient substance abuse treatment, residential treatments facilities (half-way houses and therapeutic communities), individual and group counseling. Education is the keystone.
Most of these services focus on the Medical Model of addiction and the 12 Step Model of recovery, commonly referred to as Alcoholics Anonymous. The Medical Model encompasses the basic belief of the disease concept, that the alcoholic is biologically different from the non-alcoholic. The alcoholic, it is felt, can never safely drink any alcohol. In the disease concept, the person is viewed as unable to control drinking as opposed to being unwilling or weak. Although the individual is not blamed for his/her disease, he/she is thought to be responsible for behavior. We do not blame diabetics for


their diabetes but we expect them to control their diet and take medication. The alcoholic is seen to have responsibility for managing the disease on a day-to-day basis.

Again it must be emphasized that Alcoholics Anonymous is very closely linked to this model of treatment. Although these principles were first used to treat alcoholism, they have been widely accepted and used in the treatment of all individuals abusing substances.
But the larger question that is not addressed, especially in the United States is what happens to the estimated 90% of the substance abusing population that is not yet ready for the total abstinence approach?
(Wood, 1995)
For years now the Europeans have taken a different and less invasive approach. It is called Harm Reduction. The first priority of harm reduction is to decrease the negative consequences of drug use. Harm reduction establishes a hierarchy of goals, with the more immediate and realistic ones to be achieved as first steps toward risk-free use or, if appropriate, abstinence.
Drug-taking behaviors result in one of the three following categories; either beneficial (as in the case of life-saving medication), neutral or harmful. Assigning a positive or negative value - a benefit or a harm - to such effects is subjective and open to controversy, but a harm reduction framework at least offers a pragmatic means by which consequences can be objectively evaluated. It eliminates the anti-user bias when offering services.
These services include street outreach, education, health care services, access to treatment, and HIV risk reduction programs that focus on needle exchange and

methadone treatment of heroin addicts. All of these approaches build bridges between the actively addicted individual and providers of other health services. The hope is that the individual can be kept healthy until he or she is ready to deal with their addiction.

The two most controversial aspects of Harm Reduction are needle exchange programs (NEP’s) and treatment of heroin addicts with methadone. In an earlier paper I noted that the methadone treatment of addicts in a Relapse Prevention program I interned at, caused problems with peers in educational groups and staff members who were in recovery.

I would now like to address this issue from an ethical point of view.
Scenario:
A female client presents herself at a public detoxification facility for the express purpose of detoxifying herself from heroin. She is