From “Angels” to “Liquid Handcuffs”—MMT Patients Use Metaphors as Tools to Aid in Recovery

owlInvestigators in this study explored the experiences of patients in methadone maintenance treatment (MMT) for opioid addiction in order to better understand the challenges of maintaining a sustainable recovery. Study participants used spontaneous, picturesque metaphors to illustrate their experiences, feelings, challenges, and successes, enabling investigators to identify key turning points in substance dependence and recovery. Investigators show “how participants made sense of treatment and how their communicative framing had important consequences for recovery.”

Study Group

  • 68 participants from four racial/ethnic groups in six major metropolitan communities, divided into eight focus groups
  • Patients had minimal education; most were unemployed, in their 40s or 50s

Metaphors as Tools

Metaphors compare things that are different but have an important quality in common. Simple examples include “he’s a night owl; she’s an early bird.” “Her hair is a golden river.” “His home is a prison.” But the study authors aptly defined metaphors as tools for expressing issues that are “confusing, complex, hidden, and difficult to state analytically or literally,” and for conveying topics that are largely unacknowledged, or too emotionally shattering to articulate. By teasing out the implications of patients’ metaphors, the authors shed light on challenges in substance abuse recovery.

Drug Use. Patients described drug use in lively metaphors—“hustling,” “chasing down a fix,” “scoring,” and “shooting.” They spoke nostalgically of hits, highs, and slams, admitting that they’d enjoyed getting high, but, in general, deeply regretting their actions. One described his first heroin use as “that’s a wrap,” and quoted the “wrapping” line from the film Casablanca—implying an end to other relationships, and linking drug use with glamour and love and a difficult choice.

Transition and Motivation. Seeking treatment was for some a court mandate, for others a personal decision, and for still others, a miracle —like the “angel” who intervened in a woman’s behalf at a clinic. “Money in my pocket”—encompassing both “the good life” and the monetary benefit of MMT—emerged as a spontaneous metaphor in all eight focus groups.

Recovery and MMT.  Patients saw methadone as a continuing “safety net,” “life saver,” “security blanket.” But stigma made methadone also “a crutch,” something to “dose down” from. Patients spoke of “going straight,” “being detoxed,” and “getting clean.”

Maintaining Recovery.  Most patients saw recovery as simply meeting their needs for food and shelter—a far cry from their lively metaphors of drug use. Patients wanted to avoid “slipping” back and being “dope sick” (going through withdrawal). They feared “being detoxed.” Although grateful for methadone, they regretted needing it. “Liquid handcuffs,” one woman called it. She explained that if she suddenly had an opportunity to go to China and get rich, she couldn’t do it; she’d get sick without methadone.

Downward Spiral.  At each step—from drug use to recovery—patients’ language became increasingly passive. Patients used avoidance as a tool, and spoke of being acted upon, instead of acting. They saw recovery as “bleak, lonely, difficult, and boring,” a time of relinquishing power and control.

These findings pointed to the need for clinicians to promote patients’ self-efficacy, help patients develop active language and capability, and create “narratives of success, healing, and hope.” A key step was to develop treatment strategies with clinicians and patients setting goals together.

Goals are easier to reach when stated affirmatively and broken into small pieces. An avoidance goal, “I will maintain my recovery by not taking drugs and staying away from my former drug partners for the rest of my life,” becomes instead, “I will take X milligrams of medication each day this week,” hoping to decrease it “by X percent next week,” and “I’ll attend three meetings per week to maintain my recovery.” Missing one meeting or dose-decrease becomes one misstep, rather than a total failure at recovery. Thus, constructing better narratives can create positive paths for patients to follow, provide motives for them to change, and help them transition between the cultures of addiction and recovery.

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Redden SM, Tracy SJ, Shafer MS. A metaphor analysis of recovering substance abusers’ sensemaking of medication-assisted treatment [published online ahead of print May 6, 2013].  Qual Health Res. 2013; May 6. doi:10.1177/1049732313487803.