FOREWORD - Scottish Recovery Consortium · CHAPTER 10 38 KATE MEMOIR)(40 THE PUBLIC PERSPECTIVES)(CHAPTER 11 42 GILLIAN MEMOIR)(44 SRC PERSPECTIVES)(01. In my experience ... completely

F O R E W O R DThis book is a visual conversation about methadone (meth) and other opiate replacement therapies and their place in the treatment of heroin addiction in Scotland. Collected within the pages of this book are the considered thoughts and reflections of over 30 people in Scotland today. We have a collection of ‘memoirs’ – stories written by people in recovery today who have spent some time on methadone or are still on it. We have a collection of ‘perspectives’ – stories written by people directly involved in the delivery of the methadone programme or affected by it. Adding visual texture and more creative depth to the project, we have images from the methadone photography project. Funded by the Big Lottery’s small grants fund, a group of 10 individuals in recovery from all over Scotland came together in 2015 to make photographs for the book. Their images speak eloquently of conflicting feelings about methadone: hope, despair, confusion, and happiness. Adding another layer we have an editorial team, mostly in recovery from addiction themselves, reflecting on the truth of what is being said, the beauty of how we present the material and the balance of the final book. We do not direct you to have a particular opinion; we do not seek to debate with you. This book is part of an ongoing dialogue about a treatment that, at times, has had a controversial place in the range of options for treating heroin addiction. The Scottish Recovery Consortium (SRC) has spearheaded a campaign on Opiate Replacement Therapies (ORT) like methadone since the publication of the “Independent Expert Review of Opioid Replacement Therapies in Scotland” in late 2013. This book, the country wide ‘ORT, Recovery and Me’ live conversations and the new forms of mutual support emerging for people trying to come off methadone are all parts of that campaign. Our goal is to inspire, support and facilitate as full a recovery as is possible for every human caught in addiction in Scotland. We do that by connecting people and encouraging them to learn from each other in conversation. We invite you to take part in the conversation.

Enjoy the book!

The SRC editorial team

C O N T E N T SCHAPTER 1

0 2 RACHEL ( MEMOIR)0 4 THE PHARMACIST ( PERSPECTIVES)

CHAPTER 2

0 6 RAYMOND ( MEMOIR)0 9 THE GP ( PERSPECTIVES)

CHAPTER 3

1 0 STEPHEN ( MEMOIR)1 2 THE TREATMENT PROVIDER ( PERSPECTIVES)

CHAPTER 4

1 4 GARY ( MEMOIR)1 7 THE ACADEMIC ( PERSPECTIVES)

CHAPTER 5

1 8 ROBERT ( MEMOIR)2 0 THE FAMILY MEMBER ( PERSPECTIVES)

CHAPTER 6

2 2 JASON ( MEMOIR)2 5 THE CLINICIAN ( PERSPECTIVES)

CHAPTER 7

2 6 DAVID ( MEMOIR)2 8 THE ADDICTION WORKER

( PERSPECTIVES)

CHAPTER 8

3 0 MARIA ( MEMOIR)3 2 P O L I C Y ( PERSPECTIVES)

CHAPTER 9

3 4 FRANK ( MEMOIR)

3 6 THE MEDIA ( PERSPECTIVES)

CHAPTER 10

3 8 KATE ( MEMOIR)

4 0 THE PUBLIC ( PERSPECTIVES)

CHAPTER 11

4 2 GILLIAN ( MEMOIR)4 4 SRC ( PERSPECTIVES)

01

In my experience, addicts have a huge fear of becoming

‘stuck’ on a high dose of meth without the psychological support needed to become completely abstinent from all opiates (meth included). Nearly every addict or ex-addict I know has some experience of methadone. However most are unwilling or unable to make the transition to decrease heroin use, partly due to the fear that to do so would mean taking a much higher dose of meth, which they feel is a life sentence.

I do know some ex-addicts who are now completely abstinent and did use methadone in their recovery. However only one of these people actually used meth in the recommended way. That person had a fantastic safe support network, a job, a lovely flat, and a good level of emotional intelligence and awareness. I believe that without these supports he would never have found

people to gain the ability to come off ORT. Every addict I know is absolutely desperate for accessible psychological support, preferably from an ex-addict. This need will always precede any willingness or ability to be able to stop using heroin, to use methadone in the recommended way, or indeed to move on from ORT.

I have made it now to complete abstinence and have started to volunteer in my local recovery community. On my first day there I just thought “wow”. There are people who are further on in their recovery and their influence on me is huge. It’s really clear here that it’s possible to sustain your recovery, and I have found this type of support from other people really helpful in my own recovery.

I would like to encourage people that it is entirely possible to move on from ORT. It is something which can’t be rushed though, and your social support and understanding of yourself

A GREAT DEAL

OF WORK NEEDS

TO BE DONE TO

REDUCE THE

BELIEF THAT

METHADONE

IS A LIFE

SENTENCE

BROKEN LINES

– Chapter 01 Chapter 01 –

the ability and confidence to enable himself to move forward in this way.

I was extremely unwilling to start a meth script. I was in the middle of a college course at the time and felt that I couldn’t risk being sedated. I needed to focus and I was lucky that due to my circumstances and history of not injecting, I was allowed to use suboxone instead.

My use of suboxone lasted for about a year and a half and I found it really difficult to come off. I was determined and motivated but had to find coping mechanisms for cravings or relapse-likely situations. In my own personal experience this type of information and support isn’t readily offered, you really have to look for it on your own.

I think that a great deal of work needs to be done to educate both addiction staff and addicts, and to reduce the belief that methadone is a life sentence. We need more services that support

is key to being successful. Chase every opportunity you can find locally for positive support, activities, group work and counselling. Don’t wait for it to come to you because it is unlikely that this will happen. There is a lot of support out there, and the best chance of coming off ORT is to find and access that support. Be aware that you can direct your own recovery.

REBIRTH

M E T H A D O N E M E M O I R S

RA CHEL

M E M O I R

02 03

The supervised methadone programme that operates in Scotland

started in Glasgow in the 1990’s. This was long after I had qualified as a pharmacist. Not only was this new for the patients, it was a new experience for me too. I didn’t have any text books or training to fall back on. It was all about learning from experience as I went along. Most of my time was spent in a small local community pharmacy with occasional locum work in a variety of different pharmacies. The big advantage of a community based pharmacy is that you get to know people and their families, and methadone patients were no exception.

Methadone “user”, is a discriminatory term that I heard and read being used, often by other professionals. In the early days I very quickly realised that this group of patients had to face institutionalised discrimination on a regular basis from health and other

worked on the principle that anyone embarking on a supervised methadone prescription was taking a positive step forward in addressing a drug problem and that it was the role of the pharmacist and equally, if not more importantly, the pharmacy support staff to help them on this journey. I can honestly say that in over 20 years my experiences have been overwhelmingly positive. Some of the most clinically challenging but also rewarding interactions with patients have been with methadone patients.

Based on these experiences I firmly believe that methadone is a vital tool in helping patients to stabilise their life and to start on the road to recovery. This is never an easy journey but my role and experience as a pharmacist has been to help support patients and their families through this journey.

Our pharmacy also offered a needle exchange service and that meant that we could see at first hand the

COMMUNION

GREEN DOOR

T H E P H A R M A C I S T

BASED ON THESE

EXPERIENCES

I FIRMLY

BELIEVE THAT

METHADONE IS

A VITAL TOOL

IN HELPING

PATIENTS TO

STABILISE

THEIR LIFE

AND TO START

ON THE ROAD

TO RECOVERY



services designed to provide care and treatment. A simple example, we don’t use the term “user” for any other patients and their prescribed medicine and I soon came to realise that it was part of my responsibility to ensure that those accessing this service in a pharmacy were treated in the same way as any other patient with a legal prescription.

It’s inevitable that you build relationships with people that you see on a daily basis and become involved in the wider aspects of their lives and this became a common feature in our pharmacy. The pharmacist is an accessible health care professional but I found that relationships built on trust developed over time and I would be asked for advice and help on all aspects of a patient’s life across a whole range of good, bad and sometimes tragic times.

This is about memoirs and in the early days there were numerous myths and fears about dealing with this patient group. We actively

very real improvements in someone’s health when they embarked on a methadone programme. My view is that methadone and now buprenorphine has a vital role to play in helping people on the road to recovery. As a pharmacist it has been one of the most professionally satisfying aspects of my career and it’s been a privilege to share the journey with our patients, some of whom have a special place in my own memoirs.

P E R S P E C T I V E S

04 05

My experience of taking methadone was one of mixed fortune.

Initially I was prescribed methadone in my mid-twenties, a period in my life where my drug use was at its worst and best described as chaotic. I had lost everything. I was involved in crime, my family relationships had broken down and I had lost my job. I lost the ability to be a father to my daughter. I no longer had the skills and attributes to function in life.

In a desperate state, I thought my only option was to go on a methadone prescription. This was prescribed by my doctor with no other form of support or treatment offered at the time. For several months I still used heroin and other drugs on top of my prescription. I would have periods where I would manage to stick to just taking methadone but for most of the eight years I was on methadone, I could not manage to achieve this

and it became a dangerous period in my life with several overdoses.

During this time, I was offered no support apart from my methadone being upped in my cries for help. It was not until the last of these eight years that I became desperate and was offered help in the form of residential care in order to get off all drugs including methadone. This was something I took the opportunity to do as, by this time, I knew that methadone was not working for me, in fact it actually worsened my condition. On entering treatment, I was given a chance to detox from all drugs, including methadone, and given the right tools in order to stay drug free.

It helped reduce my criminal activity for a while as it prevented me from going in to full withdrawal, but it also added to the list or combination of drugs I was trying to find salvation in. I feel that my answers came in being offered a pathway to total abstinence, one that

RA Y MOND

WHAT I REALLY

NEEDED WAS

SOMEONE TO

TALK TO,

RATHER THAN

SOMEONE TO

GIVE ME

METHADONE

ALLOTED TIME

LOOKING DOWN

M E M O I R


I wanted for a long time but did not know how to achieve.I am glad that I found the strength and courage to find this way of life and am grateful for the people who supported me with this. All those years ago what I really needed was someone to talk to, rather than someone to give me methadone. Today I believe that if I had the opportunity to access residential treatment years ago, I might have done so with proper support. What I do know is that methadone was not my solution.


06 07

I believe that ORT can save lives because that is what I have been told,

that is what I have read and that is what I have seen.

I have had many different experiences of caring for people with addictions and prescribing for people in ORT. Through provision of ORT people have been given an opportunity to reduce and stop using illicit drugs and depend on something else, ORT. In doing so, the risks of health related complications of drug use, such as contracting a blood borne virus, are reduced. Drug-driven crime and the consequences of this for the perpetrator, their families and the community are also reduced.

Replacement therapy, maintenance therapy, substitution therapy and dependence are all names once given to the treatment of opiate addiction with methadone, buprenorphine and other prescribed opiates. I am under no

illusion that to be enrolled in an ORT programme is easy. It has been described to me as a ‘lesser evil’ and maybe that is so, a necessary evil even for some. ORT is one form of treatment available to people with opiate addiction but it is certainly not the only treatment.

After being stabilised in ORT, I have seen people regain the capacity to make impartial decisions and positive lifestyle choices, which are not influenced by illicit drugs. There is a sort of freedom in that I believe.

As a profession we must optimise ORT to afford our patients the best chance of success. Whilst in treatment patients have access to holistic care from a multidisciplinary team, specifically designed around their needs. Patients struggling with addiction often have complex needs that require complex solutions, which may take considerable time to achieve, and that is alright. The chemical addiction is just one part of each individual’s

T H E G P

HOPE

EXPIRY DATE



own puzzle, sometimes it is the smallest part and sometimes the largest.

We are starting to experience a paradigm shift from maintenance therapy to recovery in its many forms. This is a very positive direction of travel, which I wholeheartedly embrace. Recognition of recovery is key and I am a firm believer that there are a multitude of markers of recovery. Abstinence is of course important but does not necessarily constitute recovery for me. I do not believe that we should set the bar at that for all. I hope not to impose my idea of recovery on others but rather be guided by their own understanding of this. I am a medical professional in the business of caring and I aim to use my skills to keep people as safe as possible, with or without ORT, all the way along their recovery journey, even when they falter.


08 09

Twenty years or so ago I was on methadone. I used and abused it for

two years or so, then used heroin for sixteen years till I had had enough. I then went back on methadone. It still took four more years for me to get down to a stable amount and go into treatment. I have only been out of treatment two weeks and, following all the suggestions, life is working out really well for me. I’m forever grateful to the treatment centre for showing me I have a choice today not to use, and I don’t.

ST EPHEN

IT’S NOT

ABOUT THE

DRUGS, IT’S

ABOUT YOU

M E M O I R

PRESCRIPTION BLUES

SANCTUARY


My advice is that you have to want it. It’s a hard drug to drop. Try subutex then a treatment centre. Get to Narcotics Anonymous meetings and follow their suggestions. It’s simple and works. Just keep up with your meetings; the penny will drop. Or get into treatment if you can’t stop. It’s not about the drugs, it’s about you. Treatment is the best thing I have ever done for myself. It showed me I did not need to use or be on a methadone program. Freedom from using is a godsend.


10 11

I have been a treatment provider for opiate dependency

for over 10 years and have largely been involved in prescribing methadone for this. I work within a service that is more than a prescribing service and offers a package of care. Staff are recovery focused, trained in psychosocial therapies and have links with fellowships and residential rehab.

The popular press are very damning towards methadone and while there is an element of truth in what is written, it’s not as clear cut as that. Methadone is a controversial, addictive drug but it does exactly what it’s meant to and if used correctly and in combination with several other factors can contribute to recovery. I see this every working day.

Don’t get me wrong, it’s not the solution and I’ve seen plenty of cases where it’s made no difference and in

regular basis. Surely this is a good thing?

Methadone can be a vital part of a package to establish a degree of stability that allows engagement in the next phases of recovery. We know lifestyle changes are needed which medication cannot address and, as everyone’s circumstances differ, every recovery journey is individual to that person. Anyone who believes methadone “does not work” is mistaken. There is no magic cure or quick fix to this situation, and I will be happy to contribute towards recovery by prescribing methadone as I know it can make a difference to people’s lives.

I would advise anyone thinking about methadone as part of their recovery to discuss their options with their prescribing service. Changing over to suboxone can be a great step towards recovery though it can be difficult to transfer initially and the sudden clarity of suboxone can sometimes

CLEAR VIEW

T JUNCTION

T H E T R E A T M E N T P R O V I D E R

DON’T GET

ME WRONG,

IT’S NOT THE

SOLUTION AND

I’VE SEEN

PLENTY OF

CASES WHERE

IT’S MADE NO

DIFFERENCE

AND IN SOME

HAS ACTUALLY

MADE THINGS

WORSE


some has actually made things worse (as it’s added to the risk factors associated with an overdose). I don’t think any medication is the “answer” and so methadone is no different from anything else.

What I do see however is people entering services in chaos with a variety of physical and mental health problems and risks associated with heroin use. Once commenced on methadone (and suboxone) there can be significant reductions in risky behaviours: reduced illicit drug use; improvements in both physical, mental and social health.

People can be on methadone for over a decade and this can be viewed negatively, but how is success measured? If you adopt an approach of harm reduction you could argue that a person on methadone for this length of time is alive and engaged in services. People on long term methadone use are still seeing professionals on a

be alarming for clients. When reducing methadone go slow and steady and use other interventions to help you move on such as voluntary work. Remain in treatment until you have reduced to a very small dose e.g. under 5mg daily and until you are ready and confident to take the final steps towards total detoxification and discharge from services.

M E T H A D O N E M E M O I R S P E R S P E C T I V E S

12 13

SHADOW SIDE

HALF WAY

For all the years I used heroin I tried avoiding going into a

methadone programme because of all the horror stories I heard about withdrawal. I listened to other addicts talk about how it was worse than coming off heroin and that it soaked into your bones. I also noticed that anyone who was on methadone never, in my experience, managed to get off it.

I only ever witnessed people cut down then get the dosage put back up. After many years of doctors’ scripts of dihydra-codeine and diazepam I realised I was unable to get clean from heroin with substitutes. I contacted a treatment centre for help and they arranged for me to attend an assessment for entry. I listened to their advice as I was using as much heroin as I could get my hands on each day. I spoke to my drug worker and within one week he had arranged a daily pick up of 30ml methadone.

GARY

SU B STITUTING

PR E SCRIPTION

DR U GS FOR

IL L ICIT

DR U GS IS NOT

DE A LING WITH

TH E PROBLEM,

IT ’ S ONLY

DE L AYING IT

M E M O I R

The first thing I noticed about methadone was it took away my panic in the morning about how I was going to score. I never got any high from methadone, it only delayed my withdrawal. I would use heroin on top of it to try and get the feeling I was after, defeating the reason I was on a script. Going to the chemist every day felt degrading so I would leave it to later and later in the day when there were less people around. I found by using heroin before picking up my methadone that I could still get a buzz from the gear. I wasn’t content in being stabilised, I still wanted the rush from the heroin but I found I would need larger doses of gear to overpower the methadone.

I only stayed on methadone for two months until my entry into treatment. In treatment I had to be totally abstinent from all drugs and after the first day I went into withdrawal. The methadone gave me a rattle that I hadn’t experienced before unlike heroin withdrawal.



Not only did I go through a week of sleepless nights but I experienced a lot more hallucinations and terrible paranoia.

Substituting prescription drugs, like methadone, for illicit drugs for me is not dealing with the problem, it is only delaying it. Total abstinence and going through the withdrawal is the only way I can be totally free of drugs.

14 15

From an academic perspective there is a body of evidence

from high quality research, carried out in several countries across the world, that the provision of a stable daily dose of methadone to people with problems of dependence on opiate drugs, usually heroin, is highly effective in reducing drug related harm. These studies have shown that methadone is effective in:

• reducing the sharing of injecting equipment

• reducing the injecting of heroin

• reducing heroin use

• keeping people in treatment

Surprisingly, given its effectiveness, methadone treatment has been the subject of some considerable controversy. This, however, is somewhat misplaced. The World Health Organisation and the authors of the recent Review Independent Expert of Opioid Replacement

Therapies in Scotland have indicated such controversy is the result of seeing harm reduction as something which gets in the way of the successful treatment and prevention of drug use. In fact the two things are not opposed to each other but are complimentary; they are two sides of the same coin.

While it contributes greatly to the reduction of drug related harm, methadone is not a cure for problems of heroin use. It does, however, offer people the space, the stability and the sustained contact with treatment services to enable them to embark on and make progress in their recovery. Methadone is a means to an end. It can play a very important, albeit relatively small part, in facilitating a person’s recovery. Psychological, social and lifestyle factors are of greater importance in the long run and the sooner people can engage in effecting this personal, psychological and social change the better. Academic research has shown that

T H E A C A D E M I C

GREEN MAGIC

THE OTHER SIDE



methadone has given a lot of people the space to start making these changes and to recover from their dependence on opioid drugs.

There are still, however, areas where we need high quality research to be undertaken. For example, such research is necessary to inform us as how people can best be helped to successfully withdraw from their methadone treatment, when the time is right, while minimising the risk of relapse and sustaining ongoing recovery. Ongoing research into treatment services is also needed to ensure that methadone treatment and other similar treatments are delivered safely and effectively in high quality recovery oriented services.


16 17

My first experience with methadone was around

20 years ago, when I was around 20 years old. My friend and I found two 30ml bottles of methadone outside a local shop. We were both recreational drug users at the time taking alcohol, cannabis, speed, ecstasy and temazepam. We knew what it was, but were naïve to the dangers of taking it. I decided I was going to try and sell my bottle. My friend drank his 30ml that night and he was found dead the following morning having overdosed.

As my drug use progressed I became addicted to heroin. Due to the damage I was inflicting on myself and pressure from my partner and parents I went to my GP to seek help with my heroin addiction.

I was given a prescription of 30ml of methadone, no information of its purpose, what it does or how long I would need to be on it

RO BERT

M E M O I R

WE KNEW WHAT

IT WAS, BUT

WE R E NAÏVE

TO THE

DA N GERS OF

TA K ING IT

depressants. Suicide became an option, a serious option. I couldn’t go on the way I was living.

I went to the homeless addiction team and asked for help. I was given a drug worker and told him I wanted off methadone and other drugs. I went to a detox centre. I began to reduce from 120ml going down 5ml every 3 days. It was difficult, I never slept for weeks, suffered cramps, diarrhoea, and with no drugs in me was a shattered shell of the person I had been long ago.

By the grace of God, I was directed to a treatment centre who assessed and helped me address the core conditions of my addiction.

I have remained abstinent from all drugs for nearly 8 years and have become a responsible member of society. I only wish that I was given the choice of looking at the causes of my addiction and then maybe I wouldn’t have wasted 12 years of my life on methadone.

HEART SYMMETRY

REFLECTIONS


for. I was told to make an appointment for the methadone clinic in the surgery for the following week. I used heroin and other drugs, mainly benzos all that week. I told my GP, and the following week I was given 40ml. This pattern occurred each week until I found myself on 120ml of methadone. I continued using street drugs alongside the methadone.

This was my life for the next 12 years, attending the chemist daily, feeling demoralised as I trudged past people on their way to work, to Boots the Chemist, having to stand in a methadone queue away from shoppers, told I had to use the back entrance and had to sign a waiver that I was no longer a paying customer. The feeling of being different, uselessness and hopelessness followed me everywhere, every day.

Over the years, depression set in. My only journey out most days was the journey to collect my script of methadone and anti-


18 19

I am writing this as the mother of a heroin addict. From January

2011 – March 2015, my son was being prescribed initially suboxone (buprenorphine and naloxone) and latterly subutex (buprenorphine) to treat his opiate dependency.

I had put the dreadful stress of all that time out of my mind but in writing this and recalling things, I think that we all were living in a nightmare, an unreal world where we couldn’t see how things were going to improve.

I know that during all this time of being on medication my son still ‘lapsed’ into taking heroin or other drugs. Although it may seem ‘wrong’ he says now that taking other drugs gave him a ‘break’ from suboxone / subutex and he felt ‘better’. During the years my son was taking suboxone / subutex he had no appetite, was constipated and had trouble sleeping. However, the psychological side effects

grew increasingly worse. His personality diminished. He had no confidence, was depressed, anxious, unable to work and became a virtual recluse. He hated having to take medication every day in order to be able to ‘function’. He did try to stop the medication a few times but did not manage. In March 2015 he went into a Christian Rehabilitation Centre where within three weeks he was clear of all medication. He remained there for a year regaining his physical and emotional health.

If I am to listen to professionals, I am led to believe that the prescription of ORT is essential for harm reduction and to ensure that illegal drugs are not consumed. Perhaps in an ideal world, where the ‘perfect’ model of recovery is followed, and medication accompanied by psychological and psychosocial support this may be true. But I believe it is a dangerous and risky route to ‘sentence’ people to ORT. I have always been

keen to view local and national statistics which will show that people have managed to ‘come off’ ORT, e.g. for a month, six months, a year. But as yet I have not been able to access that information. No one has asked the right questions so no answers are available. Over the years there have been few stringent reviews / assessments of how the ‘Roads to Recovery’ are going. My perception is that local drug and alcohol units are not monitored or ‘inspected’ to ensure that they have been adhering to ‘National Guidelines’.

Unless there is a robust recovery model being followed in drug and alcohol units, including targets, assessments, monitoring, evaluation, etc. as outlined in the theory provided in the Road to Recovery Document, prescription of a synthetic opiate is not an adequate treatment of opiate dependency. I am not medically trained but common sense would indicate that the longer you are ‘addicted’ the harder

PERSISTENCE

BOUNDARIES


T H E F A M I L Y M E M B E R

it is to stop. This of course is ‘good news’ for the companies who are making the drugs. I am a great believer in ‘knowledge is power’ and ORT is prescribed to people at critical times in their lives who have little understanding or capability of understanding what the implications of the medication will be. It would appear that historically professionals in the field also have shown little understanding of the implications, leaving people on medication for years or a lifetime. If you are diminished physically and emotionally by the effects of ORT, it is very hard to see a different way of life free from medication. Without a strong support system of kind, compassionate people it may be impossible.


20 21

J A SON

I had issues around drug and specifically heroin addiction

going back 15 years. The first real issue I had with being on methadone was having to go to my local chemist every day to have my prescription dispensed. Living in a small town and knowing almost everyone that I would see caused me a great deal of embarrassment and shame. Inside the chemist itself there was no privacy or separate room to take the methadone. I had to take it in front of the full shop. The stigma of being on methadone and by extension a heroin addict on display for people to see, I believe, did a great deal of damage to my mental health, self-esteem and personal worth. I would often find myself in and out of the shop three or four times just to get my methadone as there would either be neighbours or other people that I knew in the chemist.

TH E STIGMA

OF BEING ON

ME T HADONE

DI D A GREAT

DE A L OF

DA M AGE TO

MY MENTAL

HE A LTH,

SE L F-ESTEEM

AN D PERSONAL

WO R TH

M E M O I R

physical decline consisted of me gaining a significant amount of weight. I didn’t wash, shave or get my hair cut for extended periods of time. I would go for months without getting a shower.

Being in this physical state just compounded the shame which I already felt going to a chemist every day. I would try my best to plan out my walk to the chemist so I would meet less people and avoid bumping into anyone that I knew.

Going to the chemist also contributed to a few dangerous situations where I was almost attacked by using addicts. Being in and around that world is always a dangerous situation, but I did find it incredibly difficult to break away from that when I would be going to the same chemist and waiting in the same room to see my drug worker.

I was on methadone for a period of just over three years and one day I decided that I had had enough. I was completely sick


of what I saw as the degradation and harm that methadone was causing me. Appreciable benefits such as not taking heroin any longer were also now not applicable as I was using with almost as much frequency as I had been before going on a prescription. While I do totally understand that the addiction service and chemist were trying to help me, what in fact happened was that I damaged myself more. Over that three years I was almost certainly not the same blight on society as I had been in the previous years, but I truly believe that the damage I did to my spirit and self-worth was at least equal to what I did to myself through my heroin addiction.

After tapering my dose down to beneath 30ml I made the switch to suboxone. I only stayed on this for a week as it seemed to me to be exactly the same. I attended a chemist with the same shame and feelings, but now only collected pills. Against the wishes of

I also found that going to the same chemist and drug worker as addicts who were still using illicit drugs, and being in forced socialisation with them (whether I tried to avoid them or not), would time and again drag me back into using heroin on top of my prescription. My interactions with my drug worker were very limited in terms of any actual workable solution to get me off drugs. While he was a very nice guy, he did not really offer any way out other than upping my dose of methadone.

Over a period of time on methadone I found there to be a growing lethargy and apathy within myself. I would struggle to motivate myself to do simple tasks like getting washed, tidying the house and even getting out of bed. The decline in my physical health and personal hygiene were probably the most noticeable things to other people, but the death of any motivation, positive thoughts and personal esteem were far more detrimental overall.The aforementioned

my worker I just stopped collecting my prescription altogether and willingly went into withdrawal. This is a testament to how determined I was despite what being on methadone had done to me. I was willing and happy to enter into the most brutal and intense rattle I had ever experienced.

Overall, I would say that while there are certain benefits to being on an ORT, my own personal experience of methadone was that I completely lost 3 years of my life. I was unemployable, socially retarded and emotionally bankrupt. I often feel that I could have gone into recovery earlier if I wasn’t on methadone. From my own personal experience, I would say that anyone currently using methadone should try to reduce their use and look for alternatives such as rehab or fellowship support.


22 23

I worked in a methadone clinic for 10 years and remember

it as an unhappy place of work. The job was difficult and it felt like you were managing chaos, scratching the surface rather than helping people to get better. People became stuck. It felt like the purpose of lots of services was to stop the chaos and workers generally became risk averse which then became a vicious circle. I do think the majority of people that worked in this field were really passionate but the lack of skills and knowledge about recovery meant that people weren’t really being helped. When I worked at the clinic there was no real focus on recovery and no drive to get people to move on from methadone. In my experience, few people got better. I think that this has changed now.

Before anyone begins a methadone programme they should be able to make an informed choice as to whether a methadone

T H E C L I N I C I A N

ROAD LESS TRAVELLED

ORACLE



programme would suit them best. Without exception the people that I worked with were unaware of what methadone actually does, the side effects they could experience and the possible duration of the programme. There was also a risk averse attitude on the part of specialist prescribers and GPs to detox clients, again I think due to the focus on stopping chaos rather than on moving people on. I think it’s important for someone working in services to be aware of this reluctance and to educate themselves on methadone detox.

My advice for anyone that wants to learn more about methadone is to focus on the facts. Learn about detox by speaking to someone who has successfully moved on from methadone use. Look at alternatives in your local area like fellowship meetings and recovery communities where you can access additional support. Learn coping strategies for those moments when you might be tempted. Overall, know that moving on from methadone use is possible.

M Y A D V I C E

F O R A N Y O N E

T H A T W A N T S

T O L E A R N

M O R E A B O U T

M E T H A D O N E I S

T O F O C U S O N

T H E F A C T S


24 25

I have been on methadone for more than 16 years of my life where I have

been in prison or residential treatment. The first time I was put on methadone I was told it would be for only a short space of time. At that point, my life was controlled by drugs i.e. heroin and cocaine. My local drug worker got me in contact with a chemist and at that time I thought that by taking methadone it would stop me using drugs. What I didn’t realise was that my life would be controlled round about a chemist. I got caught up with everyone waiting at the chemist door for it to open. I had lost the ability to cope with life, all prospects of work had left me and all I could think about was getting my dose in the morning and getting caught up in criminal behaviours.

DAVID

M E M O I R

SI N CE BEING

CL E AN AND

NO T ON

ME T HADONE MY

WO R LD HAS

OP E NED UP NEW STAR

DAY DREAMS


Since being in recovery and looking back on all my experiences of being on methadone, I have come to the conclusion that giving someone like myself drugs to combat another drug problem doesn’t help. I believe that for me total abstinence from all mind altering chemicals is the solution. What I have found is that since being clean and not on methadone my world has opened up and I have the choice to do and become anything that I want to be.


26 27

So, which is it? Good or bad? Actually I think it can be both. I’ve

been working with drug users for almost 30 years. In this time, I have seen people turn their lives around completely, with the help of a methadone prescription. I have also seen people who feel trapped in a methadone treadmill.

The trouble is we are all different. We have different experiences and react differently to similar circumstances. In an ideal world we would all follow the Orange Guidelines (Drug misuse and dependence, UK Guidelines on clinical management) and all the service users would fit neatly into the system. But alas this is not real

T H E A D D I C T I O N W O R K E R

life. People’s motivation changes, they go through life’s ups and downs, they forget their coping mechanisms, their relapse management techniques and end up using.

So, is it the methadone failing them or is it the treatment system? Well, if the treatment system worked as it should everything would be fine...wouldn’t it? Where I work, I’d happily bet that every single addiction worker really wants to help people to address their addiction, be it to heroin or methadone. However, given the size of their caseload and the fact that addiction services are not exactly an NHS priority things don’t always work out so well. If the patients don’t attend all their appointments they

they want to hear. So the worker/patient relationship is vital. If folk feel that they can be entirely honest with their worker then progress can be made, but they have to feel safe to do so. Many are worried that if they admit to a lapse then, “I’ll get cut off.” This is not the case. Staff can then work with them on this and help them get stable again, maybe with an increased amount of methadone.

So, I think methadone works if everything else is in place, but then again so would prescribed heroin. But as ever it’s all about the money, money, money...

INITIATION

WAITING

“Methadone saved my life.”

“It’s just swapping one addiction for another.”

“Without Methadone, I’d be in trouble.”

“I would never go on Methadone again.”


may only see their worker 5 or 6 times a year. With 30 minute appointments, forms, action plans and Blood Borne Virus testing to squeeze in too, a couple of hours a year can’t be enough to make a significant difference.

Why prescribe methadone in the first place? The rational seems to be around stabilising the chaos. If somebody is prescribed methadone the theory is that they no longer have to buy heroin and therefore raise funds, sometimes by illegal means. Let’s face it, often by illegal means. Also, they are then in contact with a treatment service, thus improving their chances of surviving this mad period of their lives.

The reality is, once again, a bit different in many cases: “I used my script as a safety net, so I’d never have to rattle”; “I always used on top, but would stop a few days before I saw my worker in case I had to do a piss test.” People tend to tell their worker what they think


28 29

I was twenty-one years old, with my life supposedly ahead of me.

I had a college degree, I should have been starting a career, going out with friends, enjoying my youth. Instead, I was struggling with addiction. Yet, I didn’t visit a GP, or seek out services, because I’d only been using a couple of years and thought I didn’t ‘qualify’ as an addict. Instead, I tried to manage things myself.

This was in the early nineties when the phrase ORT had yet to enter the vocabulary. My ex-partner was a registered addict and, when the methadone programme was introduced, he was given a prescription by his GP. There was very little information about the drug, and as yet, there were no controlled distribution points in pharmacies. Without being aware of the dangers, in a single evening, I consumed almost an entire bottle. There was a delayed effect I wasn’t used to, and I didn’t think about the

M A RIA

I D IDN’T

TH I NK

AB O UT THE

PO S SIBILITY

OF

OV E RDOSING

M E M O I R

with addiction. Many years have passed since my experience with methadone, and services seemed to have improved, with more emphasis on recovery, but all of this depends on sufficient funding being made available to manage both treatment and recovery. If services are starved, it can only lead to more of the health problems that come with chronic addiction, more stigma towards addicts, and more cases like my own, where people are unable to get help when they need it most.

VICTUALS

HIEROGLYPHS

DISSOLUTION


possibility of overdosing. I vomited methadone into my lungs, and would have stopped breathing completely if my ex-partner hadn’t found me the next day.

I had to be given a tracheotomy and, for the next six weeks, I was hooked up to a ventilator in intensive care. I was given a twenty percent chance of survival. During that time, I’d no idea where I was. I went from one hallucination to another. When I eventually came round, I’d been in a hospital bed so long that my muscles no longer worked and I had to learn to walk again. I continued to use for a time afterwards, but did not touch methadone again. I admit that my experience was extreme, and that a daily dose of methadone can have a stabilising effect. While most people are understanding when I tell them my story, reactions vary, depending on the person, and there is still a certain amount of stigma that goes along


30 31

INSIDE OUT

BITTER PILL

PRAYER


I am a clinician and have worked in addictions for 25 years. I am

now a specialist Psychiatrist in Scotland – previously working as a GP in Edinburgh in the 1980s and in English drug treatment services in the 1990s. As a clinician I have seen few medical treatments which can deliver such a remarkable improvement in people’s lives as opioid replacement therapies can, when delivered well. My experience is that people who find themselves in difficulties with opioid drugs like heroin can readily use such treatments to significantly improve their health, to move themselves away from the many hazards associated with their drug use and, on occasion, can transform their prospects. Lives change. People begin to look up and see the opportunities they may have forgotten in a life dominated by addiction.

the range of issues we see in services, the deficiencies of services, which have often been designed simply to supply drugs like methadone or buprenorphine as ORT for heroin addicts, become clear. If people’s needs are not assessed comprehensively, their aspirations not understood or the reality of their struggle not recognised, many will not be helped by these treatments. Instead, they will find them unsatisfactory – indeed, they may feel the treatment becomes the problem.

ORT is just one part of the range of options which must be made available if we are to optimise care. People should have access to the right care at the right time.

Scottish policy is refreshingly pragmatic. Government strategies have followed the recognised needs of the day – reducing harm associated with heroin injecting in the 1994 strategy, increasing capacity of the services in 1999, increasing aspiration

But it’s not always like that. I have also seen people who have just started to struggle with drugs – often as a kind of “self-medication” and who approach doctors for help to overcome their difficulties. They may actually be seeking access to counselling or more formal psychiatric or psychological care. They may be genuinely worried about the future of their family or kids or job and looking for practical help to stop everything disintegrating. They may want treatment for their hepatitis – but not be ready to change their injecting habits. They may have pain – physical or psychological – and be seeking resolution for that – not always with a medicine. They may want to explore options to move away from their drug use completely – through detoxification or through being admitted to a residential rehabilitation facility. They may not be using opioids at all.

In these diverse presentations – representing just some of


POLICY PERSPECTIVE

and rediscovering recovery in 2008. All of these strategies accept that ORT has a place. But there is much to be improved. The Drugs Strategy Delivery Commission review of 2013 simply reiterated the deficiencies and challenges described by Integrated Care (2003), Reducing Harm, Promoting Recovery (2007) and Essential Care (2008). If we cannot improve the quality and consistency of care delivery, making ORT-based services much more aspirational and recoveryfocused, then we will continue to fail to achieve the best outcomes possible.


32 33

At the age of 21 I got put on methadone by my GP due to my heroin

addiction. I was told by my GP that this would be a solution to my heroin abuse. I was also told I would not be on methadone long term but this lasted 12 years. I started on 30mls and every time I went to see my doctor he would put me up 10mls. The highest amount I ended up on was 180mls. This was not a solution; it was more of a problem. I tried various detoxes and none of them worked. Methadone was in my life now and there was no way out.

I have been on methadone 4 different times, the last time I had to pay for a detox and naltrexone implant myself. While I was on methadone I carried on using heroin; methadone enabled me to keep using heroin. If I knew the amount of time and how much I would have ended up on I would never have went on the prescription. I spent years and years in the chemist, GP surgeries

I H AD

TO START

FI N DING OUT

AB O UT MYSELF

BE F ORE I

BE C AME

WI L LING TO

ST A Y DRUG

FR E E

F R ANK

M E M O I R

CHEMICAL BONDS

MONKEY BUSINESS


and CAT teams. Methadone ended up my worst addiction and I never ever thought I would get free from it. If I could give any advice to anyone thinking of going on it, I would say ‘don’t’.

GPs and CAT teams tell you it’s short term. In my time using I have never heard of anyone on a methadone programme using it the way it’s meant to be used. It is a horrible, horrible drug and I would love to see it banned. Methadone was a really big problem for me, total abstinence was the only way forward for me. Methadone made me feel like a zombie. I had to start finding out about myself before I became willing to stay drug free.


34 35

The demonisation of drug use and users has, in

part, resulted from ‘drug panics’. Stanley Cohen in his book Folk Devils and Moral Panics (1972) describes how every now and then society appears to be subjected to periods of moral panic. Something emerges to become defined as a threat to societal values and interests; its nature is presented in a stereotypical fashion by the mass media: the moral ‘barricades’ are manned by editors, bishops, politicians, and other right-thinking people.

Cohen argues that one of the functions – the main function – of moral panic is to preserve the societal status quo, in order to protect groups with a vested interest. He argues that the process can also be underpinned by fear and ignorance.

With regard to psychoactive drugs (‘drug scares’), these phenomena often take the

T H E M E D I A

form of statements such as:

• The drug is a ‘breakthrough’ with incredibly powerful (often pleasurable) effects• The drug is ‘medicinal’ (and should be controlled, e.g. by doctors)• The drug enslaves and corrupts (which threatens the nation)• Bad people take it (and they should be punished)• IT MUST BE BANNED

It could be argued that methadone relates to all of the above! The Daily Record (Scotland) had its infamous front page alluding to the Methadone Millionaires (pharmacy profiteering, crime at chemist shops). It is interesting to note – even from reading some of the perspectives in these memoirs – that methadone is a legally prescribed drug that has evidential research and backing into its effects. And yet, it is still portrayed in the same way that illegal drugs are – what is really going on here is an interesting phenomena that, as yet, has little research done on it.

on letters pages, often in response to the alarmist double-page spreads the days before. These humble and polite responses simply said, “despite what you say, methadone helped me”.

If we are looking for truth, we will struggle to find it in the media – let alone the tabloids. The truth lies in us realising who the vested interests are that want to develop this narrative around death and money.

With thanks to Dr Alasdair Forsyth, his amazing collection of press cuttings at GCU and his paper “Observing Drug Use in the Media and Popular

Culture” (2010)

STREET PHILOSOPHY

PARALLEL UNIVERSES

LOVE NOTE


When the SRC ran the photography classes that resulted in the pictures you see in this book, we asked the participants to look at press cuttings relating to methadone. Two themes emerged:1. Money2. Death

The language used is often ‘Maritime’ in theme – “pours in”, “tide”, “flood”, “waves”, “hit rock bottom”, “swamped”, “awash”, “surge”, “seeping”, “engulf”, “invasion”. Why? Methadone is a liquid after all – it is as basic as that. This complicated jargon used by the media is then adopted by policy makers – and vice versa.

Participants felt shameful of taking this drug – one that has after all been prescribed to them by professionals – often with no alternative option. The media reinforces this shame.

The truth? When looking through the newspapers, one or two very small items were found. They appeared


36 37

I thought it would be relatively easy to get started on a

methadone script. I thought that when I decided I had had enough of heroin, I would register with a drug worker and be given a methadone prescription that very same day. It took 6 weeks....

March 2000. The day I first went to the chemist with my methadone prescription was the day I stopped taking heroin. In place of going to my drug dealer for heroin, I was going to my chemist to get methadone. It probably wasn’t that strange that I saw many of the same people at the chemist as I did at the dealer’s.

I noticed as I went to the chemist at different times for the first few weeks that people hung around outside the chemist in large numbers. I would hear people in the shop next door speaking about them, calling them “junkies” and “scum”. I didn’t want to be thought of like that but it became increasingly difficult to walk

I SOON

REALISED THAT

IF I WENT

LATER IN THE

MORNING THE

GROUP HAD

DISPERSED AND

I COULD GET

AWAY WITH

JUST SAYING A

QUICK HELLO

TO ANYONE WHO

PASSED

into the chemist and out again without someone in the group stopping me and wanting to talk. Mainly the conversation was gossip about drugs, crime, jail and each other.

I soon realised that if I went later in the morning the group had dispersed and I could get away with just saying a quick hello to anyone who passed.

So my routine began. Getting myself and daughter ready in the morning and then to the chemist late morning. Wednesday was a half day at the chemist and there seemed to be hoards of people no matter what time I went at so I would wait until almost closing time. I used to see the same people at that time every Wednesday. They never stopped to talk, maybe they felt the same as me?

For years I continued with this routine. If I was going away for the day I would have to go to the chemist early, I hated that. It was a lovely chemist and very busy. The pharmacist would hand me my methadone to

OBSTRUCTION

RITE OF PASSAGE


take in front of everyone and I hated that too. I began to hate going to the chemist. My life revolved around a chemist. I went on holiday a few years ago. I had to ask permission from my psychiatrist, drug worker and pharmacist. Where I was going on holiday was only a 2 hours drive away. I wasn’t living a life, I was asking permission to function. I wanted to blame the system but my addiction was my responsibility and I knew my recovery was too.

The first step into my recovery was when it was decided to demolish the scheme where I lived. I moved to the centre of town and transferred to one of the big pharmacies. It has late night opening and a private room for methadone dispensing, people have to leave the dispensing area clear so it’s straight in and straight out and no hanging about. I like that. I have decided to start detoxing so my drug worker has agreed that I need only go to the chemist twice a week, Wednesdays and Saturdays. I like that too.


K ATE

M E M O I R

38 39

To assess public perception of methadone, the SRC

carried out a random survey in Glasgow city centre, where commuters of varying ages and backgrounds were asked their opinion of the methadone programme in Scotland.

Results showed that whilst public perception of methadone tends towards a sympathetic view of those suffering from substance abuse, actual knowledge of methadone, including how it is used and the issues surrounding recovery, remains sparse at best. Although most people were aware that it was ‘something to do with the treatment of heroin,’ many people admitted they did not know what methadone looks like, and viewed methadone users as belonging to a world and a ‘drug’ culture that was quite separate from their own and with which they had little contact.

T H E P U B L I C

Asked if the word ‘methadone’ carried negative or positive associations, the response was ‘negative’ almost one hundred per cent of the time. Nevertheless, public consensus seemed to be that if methadone can help in the treatment of addiction, then the programme is worthwhile and should be continued. Others believed that methadone is only part of the solution, and that its success depends on a number of contributory factors, such as the person undergoing treatment being at a stage where they are ready to undertake the process of ‘getting clean.’ In addition, there was little public knowledge of recovery services and what might be needed to assist recovery. A small proportion of those asked knew someone who had been prescribed methadone, but most admitted that their perception and knowledge about the drug and its uses comes largely from media reports. Despite this lack of knowledge, the

ON REPEAT

CHEMISTRY OF LIGHT


general feeling portrayed by those members of the public willing to talk about methadone was one of sympathy and compassion towards people who find themselves suffering from substance abuse, and of wholehearted support for any steps that can be taken to alleviate suffering and improve the chances of recovery.


40 41

GI LLIAN

Methadone saved my life. That was the truth while I was on

methadone and remains the truth now that I am off it. Other things I believed to be true while on methadone have changed dramatically.

I believed that I could lead a satisfying, fulfilling life if I remained on methadone for the rest of it. I held the belief for so long that I would need methadone to function as a human being, that as a human being I was different from “normal” people and would require some type of medication to live in this world.

The most absurd belief that I had was this: the longer I was on methadone the more likely it was to have seeped into the very fibre of my being making recovery from it absolutely impossible.

All these truths were validated by the fact that I never came into contact with anyone who had ever came off methadone

ME T HADONE

SA V ED MY

LI F E

M E M O I R

successfully. I had never seen the lived experience of recovery from methadone, therefore, didn’t believe it was possible. That changed several years ago and the only truth that remains is, methadone saved my life.

I now believe that I was not living and could never live a satisfying, fulfilling life while on methadone. I believe I am living that life now. As an addict I may be different from “normal” people but I now believe I do not need drugs to function as a human being. Methadone did not seep into every fibre of my being making recovery impossible. Methadone does suppress every feeling and emotion and I didn’t realise to what extent until now. To live life without methadone we say is to experience an emotional and physical awakening and I believe everyone deserves the chance to experience this. I now believe that everyone on methadone where possible should be put in contact with the lived experience. People need

AGAINST THE WILL

BREAKING THROUGH

DOWN THE DRAIN


to know that recovery is possible. I believe I remained on methadone far too long and the sad truth is I’m not the only person to feel this way. I have heard many people talk of the stigma surrounding methadone, I believe along with being stigmatised we stigmatise ourselves. There are ways to reduce this stigma and one of those ways is to show our community that recovery from methadone is possible and by doing this we take responsibility for our recovery.

I believe that my recovery from methadone, psychologically, was one of the hardest things I have ever done. As for my life as a whole, it’s undoubtedly the best.


42 43

44 – Chapter 11

This work is the product of over 45 individuals collaborating creatively and practically. The book has been in production for over 2 years and

has been a labour of love for those taking part. The contributors gifted their words and images for free; no one was paid to make a contribution. It’s the kind of undertaking that is only possible when a recovery movement is flourishing nationally and people believe they do make a difference. To all of those who contributed, you know who you are, thank you.

NEVER DOUBT THAT A SMALL

GROUP OF COMMITTED

THOUGHTFUL INDIVIDUALS CAN

CHANGE THE WORLD. INDEED IT

IS THE ONLY THING THAT EVER

HAS.

Margaret Mead, Anthropologist.

Editorial TeamBrian Morgan, Project ManagerMark Gatti, DesignTracy Patrick, EditorKuladharini, Advisor


I have just completed two tours of Scotland speaking with

over 500 clinicians and people in recovery about their experiences of Opiate Replacement Therapy (ORT) treatments, including methadone and suboxone. I wanted to hear the truth of what people really think about methadone and other ORTs in Scotland.

What I found is that many clinicians are really afraid of getting it wrong. By and large they want to do right by their patients, and are afraid that if their patient overdoses and dies while under their supervision they, as clinicians, will be blamed. This anxiety is part of what lies behind the understandable drive for evidence and more research on which to base difficult treatment decisions. Nevertheless, this same anxiety about evidence is used as a spurious reason to avoid encouraging patients to use recovery communities and mutual aid organisations

like Narcotics Anonymous, Cocaine Anonymous, ORT Recovery & Me and SMART recovery. There is a good body of supporting evidence for the effectiveness of mutual aid.

Many people in early recovery from ORT experience a period of strong anger about the length of time they have spent on it and can often feel they have been forced onto the drug without being fully informed of the challenges it may also present. However most of this anger tends to dissolve as soon as clinicians and people in recovery actually talk to each other, human to human. Or as the individual’s recovery journey lengthens and they take more responsibility for their own part in what happened.

ORT professionals are less afraid of getting it wrong when they are working collaboratively with local recovery communities and are able to refer people actively to local mutual aid opportunities. They feel the

risk has been substantially lowered. Within these partnerships people in recovery who have been angry often soften in their relationships with GPs and nurses. Hearing each other’s perspectives and concerns really helps build trust. The new mutual aid organisation ORT Recovery & Me set up and led by people in recovery from ORT is helping close the gap between treatment services and mutual aid. It creates a space where only ORT recovery stories are shared and patients in treatment get the chance to try out these self-help groups. Many people go onto other mutual aid organisations from here.

The truth about methadone and other ORT treatments is that by dropping the fear and starting to connect with each other more deeply as human beings and not labels, we all have something to offer the recovery process.

S R C P E R S P E C T I V E

A F T E R W O R D ...

MA N Y PEOPLE

IN EARLY

RE C OVERY

FR O M ORT

EX P ERIENCE

A P ERIOD OF

ST R ONG ANGER

AB O UT THE

LE N GTH OF

TI M E THEY

HA V E SPENT

ON IT...


www.scottishrecoveryconsortium.org

Charity No SC041181 (Scotland)

Documents

FOREWORD - Scottish Recovery Consortium · CHAPTER 10 38 KATE MEMOIR)(40 THE PUBLIC PERSPECTIVES)(CHAPTER 11 42 GILLIAN MEMOIR)(44 SRC PERSPECTIVES)(01. In my experience ... completely