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.


  1. says

    I have to say that as a Methadone Maintenance Treatment Patient myself, this bothers me greatly. The opinions of those patients sought for focus group and the ‘interpretation’ of metaphors at that are depressing!
    My own experience with my MMT is nothing short of hopeful, encouraging and life saving. I think that had you focused those questioned in a larger span of individuals ranging in age alone, you would have gotten a very different outcome as many of the outlooks and comments would have been very different. Many individuals who are in MMT are looking forward to all that life has to offer and myself, a patient for 11 years now, I look back at my years in MMT and see a constant and steady reawakening and a working effort in to the woman I have become,……the mother, the wife, the writer and photographer.

    I agree that the issues of offering the proper foundations to achieve success in ones life, whatever that may be, is often lax at many OTP’s, but to me that only stands in PROOF of the fact that there are not nearly enough Opioid Treatment Programs (methadone clinics) to serve those who suffer with the debilitating and all too often fatal disease of Opioid Addiction. Many counselors are overworked and due to needless requirements from Legislation and Regulations that prevent these issues from being focused on. As a matter of fact, these issues prevent Patients from being the focus of the treatment. And if not to treat the Patients, then what for?
    To say that many look at MMT as ‘ I have to take x amnt of medication each day this week or a missed Group or ‘missed’ dose decrease as a ‘slip’ is surprising to me! Most MMT Patients are not focused on those kind of negative aspects….nor are the focused on a decrease dose.
    Instead their focus regarding their dose is stability and maintenance and their Groups and Counseling are a means to the psycho-social learning and recovery that one needs.
    I’m just disappointed in the fact that so many of my fellow MMT Patients are saturated with untruths and myths and that there isn’t MORE focus on the Hope and the ability to LIVE again that MMT brings. I was merely existing in the hell that my disease had lead me into. It wasn’t until MMT that I saw HOPE and through this treatment of MM, I am LIVING now and have been for years.

    ~ AC

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