Heroin has been a growing problem in Wales for many years, with referral statistics indicating that heroin has been the most problematic substance since 2014 (Welsh Government 2019d, 24). England and Wales reached their highest levels of drug related deaths since 1993, with heroin and opioids relating to over half of deaths in 2018 (ONS 2020, 3).

Methadone is the initial treatment drug that is offered in Opioid Substitution Therapy (NICE 2020, 8). There has been much debate regarding the effectiveness of methadone (Du Rose 2015), which raises questions to whether an alternative drug may have more socio-economic and personal benefits. Methadone is shown to be effective for reducing drug/heroin use, which is a key harm reduction initiative the Welsh Government are working towards in their most recent Substance Misuse Delivery Plan 2019-22.

This research explores the use of methadone as a treatment option for heroin, opioid and other opiate dependency. It aims to understand the challenges experienced by people referred to substance misuse services from a third sector perspective. The third sector have been both collaborative and competitive with the NHS (Kalk et al 2018, 195), and play an important role in the recovery journey of service users. Three Welsh key policies were analysed to determine best practice guidance and to assess translation into practice: Integrated Care (2010), Community Prescribing (2011) and ROISC (2013).

Six semi-structured interviews were conducted with five service providers from the third sector working with people who use substance use and dependency and one with a Welsh Government affiliation. They were recruited using purposive and snowball sampling. This primary data was analysed following Braun and Clarke’s (2006) thematic analysis approach and used some a priori coding following an extensive literature review. The three Welsh policies were analysed using Walt and Gilson’s Policy Analysis Triangle Framework (1994) and using a priori coding based on the literature review and interview findings.

The interview findings have shown that Third Sector Organisations (TSOs) interviewed in this present study perceived methadone as ineffective for abstinence. This is likely due to their individual perception of recovery (seemingly abstinence) and problems with community resources and infrastructure. Different understandings of recovery culture and negative attitudes from some mainstream services and the general public can cause barriers for people accessing services due to associated stigma. Information sharing and the lack of time/money to effectively work with other organisations was a major challenge and could cause services to become insular. The policy analysis found that some areas of the policies were translated into practice (i.e. community prescribing and developing a focus on harm reduction recovery culture), but other areas were not (i.e. a single point of access and integrated care pathways). This may be due to unrealistic policy objectives compared to the resources and means available.

This overall study found issues with access to services, understanding population need and overburdened services. A perception of disempowering hard-to-reach service users, despite policies emphasising a person-centred service delivery. This may be due to service providers and commissioners not having a full understanding of service user needs and differences in recovery journeys. Services should take on board guidance from Social Services and Wellbeing (2014) Act and focus on the “What matters?” conversation. This will help developing an understanding of service user aims and goals for treatment and their personal definition of recovery. As part of these conversations, services could better understand what treatment would be best for a person - methadone, buprenorphine, heroin-assisted treatment or detoxification, rather than habitually focus on methadone which brings additional challenges.

TSOs reported perceptions that they are supporting people who ‘fall through the gaps’, adding to the potential frustrations between TSOs and the NHS.