ilw
11-23-2006, 11:45 PM
don't moan about the length, just read as much or as little as you like. The first 6 paras (italics) just explain where the article comes from and can be ignored.
reason for this being mentioned in the spoiler bit, but the interesting article imo is below in quotes
Heroin should be prescribed to drug addicts to curb crime, the deputy chief constable of Nottinghamshire has said at a drugs conference. Howard Roberts told an Association of Chief Police Officers' conference in Manchester the idea should be assessed.
He said the treatment would cost £12,000 a year per addict but added that drug users steal property valued at an average of £45,000 a year.
The idea is being piloted in London, the South East and North of England.
"At the moment across the country we see levels of burglary, robbery and murder being committed by drug-fuelled addicts who are doing so in order to get the money to buy the drugs," Mr Roberts told the conference.
"One of the things I have found is that as a treatment it has been highly effective in actually helping to reduce crime. We've seen good levels of falls in drug-related acquisitive crime."
"However, there is still a considerable problem and what I am suggesting is that we need to explore, as part of a treatment programme, the prescribing of heroin to addicts in order to take them out of the illegal market."
He added: "Of course, getting people off drugs altogether must be the objective.
"But I do believe that we have lived with the terrible consequences of relatively uncontained addiction for far too long.
"If we are to make a greater impact we need to fundamentally address the method of operation of the criminal market-place for heroin."
Martin Barnes, chief executive of drugs charity DrugScope, said: "There is compelling evidence that heroin prescribing, although more expensive than some forms of drug treatment, is cost-effective in reducing drug-related crime and other costs to communities."
Nicola Metrebian, from the charity Action on Addiction, said they were doing research which would "compare the effectiveness of injectable methadone and injectable heroin to oral methadone" for a group of hard to treat heroin users.
In the Department of Health pilots, 300 to 400 drug users receive heroin for their addiction. Similar schemes in Holland and Switzerland reported some users turning away from crime.
quote source (http://www.badscience.net/?p=327)
Suddenly heroin prescription is back in the news, so here’s an archaeological find from the hard-drive: an essay I wrote in praise of heroin prescription, for the “Roger Hole Essay Prize in Medical Scepticism”, as a young undergraduate in medicine, in 1998. The prize was judged by Lewis Wolpert, and winning it netted me the enormous sum of £250 (a month’s rent!) and a signed certificate from Prof Souhami (of Souhami and Moxham fame!).
This essay, weirdly, also served up an early insight for me in the lameness of reporting on science and health in the media, and their obsession with quoting “authority”. A friend of mine who worked for a drug law reform pressure group gave my number to somebody working on campaigning journalist Nick Davies‘ heroin addiction documentary, a couple of years later. They called me, said they’d heard I was a doctor, had researched the issue, and asked if I would do an interview.
I’d be happy to help, I said, but explained that I had only qualified as a doctor a few weeks previously, that I would feel a bit uncomfortable being an “authority”, that I was in no sense a medical expert on anything much, in fact I wasn’t even fully registered with the GMC for another year (I was a PRHO!) and that I looked about 12. They seemed to think all this might be a problem, but I chatted through what I knew on the subject, and casually offered to email this essay I had written when I was a medical student. I never heard from them again.
So imagine my surprise when, completely by accident, I happened to catch a TV show on heroin prescription a few months later. It didn’t even really occur to me that it might be connected to that brief phone call, but suddenly, the screen went black, with a dramatic pause and, if I remember correctly, a deep bass synthesiser tone in the background, and then, from nowhere, quotes from my medical student essay appeared, in big, sombre letters, filling the screen, ascribed to “Dr Ben Goldacre”, as if I was some kind of aged, leading world authority and the absolute last word.
I should mention that I was watching this sat on my mattress, which was on the floor, eating toast, in my underpants, like a proper student bachelor. The disparity was striking. I’ve never been so embarrassed, I prayed that nobody I knew had seen it, and it’s one of the many reasons why I still doggedly avoid being described as “Dr Ben Goldacre”. There’s just no need.
Anyway, here’s the essay, I hope you enjoy it, forgive the slightly pompous and youthful authorial style, it was over 8 years ago, I was practically a kid, Billie was top of the hit parade with “Because We Want To” and the Spice Girls were still together. I might see a few things very slightly differently now, with more clinical experience, and a better feel for research literature in general, and it was an “exercise in medical scepticism”, but for the most part, looking back at myself, I have to say, I think I make a pretty tonky argument. It’s certainly an extremely strong survey of the historical context. I just hope nobody quotes me as an expert again.
“Methadone and Heroin:
An Exercise in Medical Scepticism”
~ by Ben Goldacre, 1998 (aged 23 and 3/4) ~
I have often fantasised about living through an age when science was truly adversarial: to have seen Darwin at the Royal Society, or Galileo recant. But the lie of the land, the structure of our scientific territory, and our modes of warfare across it, have become domesticated and tame. Although there may be differences of opinion, we each tend to tinker at the expanding edges of our understanding, and truly mutually exclusive explanatory frameworks for reproducible phenomena rarely co-exist for long.
If we want to see real friction, some other factor must come to bear on the essentially healthy structure of the mainstream scientific community: a funding issue, for example, might influence the general trajectory of research, but for the most part temporarily; we may be transiently confounded by partisan research from a given drug-company, but only in whatever microcosm of physiology their drug acts and, albeit slightly behind schedule, we can be sure that the truth will out.
But we want the big prize: we want wholesale irrationality, we want to see the axial skeleton of our concepts truly and chronically deformed, and only politics can muster contorting forces of such magnitude. I intend to show how this influence has perverted rationality in one area, our medical treatment of those who are addicted to heroin, to such an extent that our theory and practice is now so polluted as to be scientifically untenable.
Until recently, it was common practice in Britain to prescribe heroin to heroin addicts. This apparently paradoxical practice was well founded and successful, as we shall see below. However, since the late 1960’s, addicts have mostly been prescribed oral methadone, a long acting opiate agonist with a less euphoriant effect, as a heroin substitute.
I shall demonstrate that the maintenance of addicts on methadone is less effective at reducing the use of heroin, and the harm that goes along with heroin use, than the prescription of heroin itself. I shall also show that methadone is a more dangerous drug than heroin, and causes more deaths than even adulterated street heroin.
Ultimately, the case I shall make is that heroin prescription is more effective, by all reasonable outcome indicators, than methadone; and that the reasons for its unpopularity have little to do with evidence of best practice, and much to do with our emotional and moral attitudes towards those who are addicted to drugs. To begin, we must consider the history of opiate addiction and its treatment, in order to understand how and why politics intervened, and how we arrived at the state we are in today.
A Brief History of Opiate Addiction and Rehabilitation
Heroin, or diamorphine, was first marketed by Bayer in 1898, after being developed as a cough suppressant by the same team who introduced aspirin. Although the use of psychoactive drugs (and specifically opiates) began to be considered as a medical problem in the late nineteenth century (Berridge & Edwards 1981), they were legally available until well into the twentieth, and opiates could be purchased from pharmacies with a minimum of formalities up until 1920.
At this time, the principal medical concern over drug use was the risk of accidental poisoning through the non-medical pursuit of pleasure, and the prevalence of drug addiction (frequently caused by chronic medical use) was so low that its social impact was negligible. The 1920 Dangerous Drugs Act confined the availability of opiates to prescription only and, over the next few years, penalties for offenders against the possession laws were increased, a reflection of similar developments abroad (Mott 1991).
However, where Britain departed from the rest of the world was with the Rolleston Committee report from the Department of Health in 1926. This emphasised that persistent drug use, in line with newly emerging medical and social theory, should be seen as a disease: ‘as a manifestation of a morbid state, and not as a mere form of vicious indulgence.’ (Rolleston, HMSO 1926).
By pursuing this line, Rolleston arrived almost accidentally at the sympathetic modern day conception of the drug abuser, over half a century before Hartnoll et al (1980) found evidence of serious childhood disturbance in his patients at a drug dependency clinic in UCH. In many ways Rolleston was the first proponent of the guiding philosophy of most modern drug work, ‘harm reduction’, which I shall later consider in detail.
The progressive attitude to drug use institutionalised in this report established the framework of public policy for the next five decades, and following 1926 the ‘British System’ prosecuted dealers and dilettantes, but permitted medical prescription of heroin to addicts after “every effort” had been made for the “cure of the addiction”, but when the drugs could not be fully withdrawn without “severe distress or even risk of life” or “experience showed that a certain minimum dose of the drug was necessary for the patients to lead useful and relatively normal lives … capable of work.” This twin policy of ‘policing and prescribing’ effectively contained the heroin problem (which ran at below a hundred notified heroin addicts) for the next four decades.
With the Sixties came an atmosphere of moral panic at the scale of a well-publicised increase in drug use (Plant, 1987). Although the drugs in question were mostly cannabis and amphetamines, not heroin, attitudes to drug use and regulation were re-appraised: amphetamines and LSD were brought under tight statutory control, and the government began to fear that with a rising demand for drugs, the licit opiate supply system might start supplying the illicit market.
From 1959 to 1964 the number of addicts notified to the Home Office increased from 68 to 342 (Spear 1969), and it was noted that an unusually large proportion of these new addicts were of non-therapeutic origin, that is, an unusually large proportion of new users had not come to addiction via chronic medical treatment for physical disease or injury.
In 1964, the government convened the Brain Committee, an interdepartmental re-incarnation of the Rolleston Committee, who found that ‘the major source of supply had been excessive prescribing by a small group of doctors’ (HMSO 1965). They recommended that the prescription of drugs to addicts should be restricted to specialist clinics, ‘Drug Dependency Units’, and although heroin for physical ailments could still be freely prescribed, laws were passed requiring that doctors who prescribed heroin for addicts should be specifically approved by the Home Secretary.
From the beginning of the seventies, there was a major sea change in the treatment of addicts (Stimson & Oppenheimer 1982). This was characterised by an emphasis on abstinence as the primary goal of treatment, and a refusal to prescribe heroin: instead, on condition of abstinence from all other drugs, and under ‘treatment contracts’, heroin addicts were prescribed a new drug, methadone, to be taken orally.
It has been proposed that the reluctance of doctors to prescribe heroin was probably, in a number of cases, due to the fact that most addicts were so keen to obtain this drug: this made doctors working in the field uneasy, and Glossop (1995) believes that prescribing a medicine which was less desirable for the client was more easily rationalised.
In the mid-1970’s there was an upsurge in the illicit heroin market in London. The factors alleged to have contributed to this include: an upsurge in illicit demand following the change in DDU policy; the end of the Vietnam War, requiring the South-East Asian producers to find new markets after the GIs went home; wealthy Iranian exiles using heroin as a means of getting their capital out of the country after the downfall of the Shah; and political troubles in Afghanistan and Pakistan (Mott 1991).
Over the course of the decade, the market ceased to be run by amateurs, as professional criminals extended their interests from the cannabis market to heroin (Clark 1980; Lewis 1985). Driven in part by a pyramid dealing network, where addicts at the bottom of the distribution chain had an interest in selling to fund their own use (Gilman & Pearson 1991), heroin use expanded enormously throughout the next twenty years.
The Contemporary Heroin Problem
The Home Office were notified of 35,000 heroin addicts in 1994: due to incomplete reporting, and other obstacles in reaching the addict population, this is widely believed to represent between a third and a fifth of all addicts (ISDD 1994), thus putting the true figure at between 100,000 and 160,000.
Contemporary heroin addiction is no longer an issue between the individual and their metabolism. The nature of the drug, the scale of its use, and its position in modern society, all mean that addicts experience more diverse problems, and cause more diverse problems, than the heroin addict of the nineteenth century.
The generally poor health of chronic addicts is usually not a direct result of the opiates as such. Heroin is very addictive but does not in itself cause any serious illnesses, nor does it harm any organs or tissues: the indirect consequences are of course more serious. Pain sensations are suppressed, with the results that certain signals (for example, problems with teeth, infections, cold, heat and hunger) are not noticed. Because opiates also suppress feelings and emotions, the ability to enter into social relations with others is also seriously affected, so not only physical but social functioning worsens.
Another important issue is how the addict can maintain a supply of heroin. The enormous cost of heroin on the black market is met for the most part by acquisitive property crime. The economics of the illicit market are remarkable: at the farmgate in Pakistan, a kilogram of opium costs $90; when it has been converted to heroin it costs $3,000 in Pakistan; wholesale in the USA it costs $80,000; and its final retail price on the street (at the DEA’s quoted average purity of 40%) is $290,000 per kilogram (United Nations Drug Control Program Report, 1997, p126).
On the streets of the UK, a gram of heroin costs between £50 and £120 (UNDCP 1997 p194). The cost of acquisitive crime committed to pay for this heroin has been estimated at £1.5 billion per year. Addicts in the UK generally steal to fund their addiction: thus they risk likely impoverishment and imprisonment. One study showed that 80% of addicts attending a DDU clinic had been convicted of at least one offence in the course of their drug taking careers (Hartnoll et al 1980). More crucially for long-term outcome, since they often steal from family and friends, addicts risk social isolation.
Furthermore, since the drug is at such a premium, it will be used in the most efficient fashion possible which is, of course, intravenous injection (intravenous use of alcohol under prohibition of alcohol in the USA has also been documented) (Stevenson 1994). Intravenous use of any drug carries its own dangers. A large proportion of the morbidity experienced amongst heroin addicts is due to wound infection, septicaemia, and infective endocarditis, all due to asterile injection technique (Oxford Handbook of Clinical Medicine, 1996, p.184-5).
Infection is another major cause of morbidity and mortality in intravenous drug users internationally (UNDCP 1997). Heroin addicts tend to lead chaotic lifestyles and have low self-esteem, both of which, along with expediency, contribute to a tendency to share needles with other users. Via this route they become infected with HIV, and hepatitis B and C.
10% of UK AIDS cases in 1995 were related to the use of intravenous drugs, and it is suspected that the increase in HIV infection amongst non-intravenous drug using heterosexuals is being driven by contact with heterosexual intravenous drug users (European Centre for the Epidemiological Monitoring of AIDS, 1996), and the World Health Organisation estimates that 40% of recent AIDS cases internationally were caused by drug users sharing injecting equipment (WHO 1994).
It was the spread of HIV through intravenous drug use that led to the reconsideration of heroin addiction treatment in the late 1980’s, and was the birth of the new policy of ‘harm reduction’. The HIV seropositivity rate amongst intravenous drug users in Edinburgh, where needle-exchange and maintenance programs had been vigorously opposed, rose to over 50% in the mid-1980’s (Robertson et al 1986). By comparison, in Glasgow, where such facilities were available, less than fifty miles away, the level of seropositivity was less than 5% (Follett et al 1986).
A policy of harm reduction tackles public health issues directly by seeking to reduce the personal and social costs of drug use. Abstinence is not regarded as a realistic short-term goal for most dependent users, and the principal ingredients of most programs are syringe exchanges, educational and advisory services, and treatment and maintenance services (generally with methadone).
There is a hierarchy of achievable objectives, with non-users urged to abstain, and users advised to reduce doses, and to avoid the most potent drugs and riskier means of ingestion. Those who insist on injecting are offered advice on safer technique, and those who persist in sharing needles are even taught how to clean their equipment (Newcombe 1992).
This policy has been vigorously opposed in some parts of the world, especially the USA, where drug related mortality is almost twice that of the UK (UNDCP 1997). Despite this, it has become the guiding principle behind UK drugs policy, along with the maintenance prescription of methadone.
Methadone
Methadone is an opioid receptor agonist with a half life of approximately 24 hours, far longer than heroin. Drugs with longer half-lives tend to produce less acute withdrawal effects, a phenomenon which is utilised in the choice of anxiolytic drugs in psychiatric practice (British National Formulary, September 1999). Crucially, in comparison with heroin, methadone has a greatly reduced euphoric effect. The hope for methadone, therefore, is that it can contain the opiate cravings, on a once daily oral dose, without providing so much of a ‘high’.
The aim of methadone maintenance is to stabilise and then to ‘cure’ the opiate user. This breaks down into such objectives as: improving the health of drug users, by providing clean drugs in measured doses under medical supervision; reducing drug-related crime by providing users with free legal opiates, thus reducing their need to steal to fund illicit heroin; improving the social situation of drug users (family relationships, finances, employment, housing and so on); persuading users to reduce their daily dose and ultimately take steps towards abstinence. This is in many ways an updated version of Rolleston’s rationale from 1926.
However, the policy of prescribing methadone may be criticised from many different angles, and to the best of my knowledge these criticisms have never been comprehensively considered in one article. Certainly there is no convenient meta-analysis of methadone programs. I shall consider each criticism in detail, and later compare the use of methadone to the maintenance prescription of heroin, which still continues on a small scale in the UK, and has recently been re-assessed in Switzerland and Australia.
Firstly, it is important to recognise that methadone is not a pleasant drug to take, causing nausea and vomiting, weight gain, profuse sweating, dysphoria, and tooth decay. This is no major selling point to a patient group clearly accustomed to making stringent aesthetic judgements about their drugs and this, combined with the absence of the ‘buzz’ of heroin, means that the take-up rate amongst addicts is far lower than it ever was for heroin.
Hartnoll et al (1980) found that only 29% of those offered methadone in one DDU between 1972 and 1975 were still attending 12 months later. The reality of take-up rates for methadone prescription programs amongst the general population of heroin addicts today is that only a small minority of addicts will attend methadone clinics, certainly less than 15%, although specific statistics are hampered by the unknown quantity of the denominator, that is, the number of people in a population addicted to illicit drugs (Dorn, Baker, Seddon 1994).
Treatment for drug dependency, to be successful and especially to have an impact at a community level, must have high take-up and retention rates amongst problem drug users who, unlike adults with right iliac fossa pain, may not spontaneously present themselves to healthcare professionals.
In order to be successful, therefore, a drug dependency unit must offer both treatment and the drug at a ‘price’ which the users are willing to pay: the prescriptions may be free, but the terms and conditions on which they are offered may act as a deterrent to some users, and the product offered (counseling services, advice, and possibly substitute drugs) must be appealing. Health economists have couched the problem in their own terminology: ‘for treatment to have a high take-up rate, it must sell … and be seen to sell … a good product at low cost’ (Stevenson 1994).
Retention in treatment, firstly, is an area where the philosophy guiding the work of a clinic may have as much of an impact as the nature of the drug they are offering. In a controlled study in Australia (Bell, Chan, Kuk 1995), heroin addicts were assessed and randomised to two clinics, one oriented to long-term methadone maintenance, and the other oriented to time-limited treatment, aiming primarily at abstinence from all drugs, including methadone. Both groups were urine-tested for heroin, and use of heroin outside the clinic was higher in the abstinence-oriented clinic.
An observational study in a different country showed that addicts were more likely to discharge themselves earlier from methadone clinics where the clinic staff scored highly on an ‘Abstinence Orientation Scale’, measuring their commitment to abstinence-oriented policies on heroin addiction (Caplehorn, Irwig, Saunders 1996). Other studies have shown that external compulsion to attend clinics, for example by law courts, is also associated with poor retention.
Conversely, a high re-attendance rate has been demonstrated at ‘user friendly’ clinics where needle exchange and clean drugs are available, with no uninvited counseling (Newcombe & Parker 1987). Experience has taught that regular and enduring contact with treatment services is a necessary precondition for successful treatment of addicts (Hartnoll et al 1980; Gossop, Strang, Connell 1982).
Finally, studies of drug users who present to rehabilitation programs have shown that they are often in a poorer state of health than other heroin addicts in the population (of equally long-standing) who have not chosen to present, and this is taken by some commentators to mean that addicts will only present as a last resort (UNDCP 1997). Thus methadone programs are by no means a universally attractive option to the addict population, and addicts often use their drug of choice to supplement their prescription.
Use of heroin outside the confines of a drug rehabilitation program (whilst ostensibly attending it) is, of course, associated with all of the risks of everyday heroin addiction: increased risk of intravenous drug use leading to infection, increased acquisitive crime, poor family relations. More importantly, the chaotic nature of the drug use means that the chances of abstinence after a period of regulated drug use are reduced. Thus use of heroin outside the clinic may be considered one of the definitively poor outcome measures.
However, methadone is also a dangerous drug in its own right: astonishingly, use of methadone has a higher mortality even than the use of illicit heroin, although to what extent is uncertain. For example, in 1992, there were 101 deaths from methadone, and 40 from heroin; similarly, from 1982 to 1991 there were 349 methadone deaths and 243 heroin deaths (OPCS): this is despite the fact that there are far more users of heroin, at every strata of use, by a factor of at least 3:2, than of methadone.
However, to quantify the mortality requires an accurate denominator (the number of users for each drug) and this, as we have already discussed, can only be achieved indirectly for a covert and underground activity such as drug abuse. Estimates vary widely according to the denominator used, and authors are never so disingenuous as to claim pinpoint accuracy for their figures, but the most recent data to be analysed estimates the risk of methadone related mortality at around four times that of heroin (Newcombe 1996).
The dangers of methadone have long been recognised. Ghodse et al (1985) analysed the patient records of notified addicts who died in the UK between 1967 and 1981, and found that among patients using heroin, three quarters of deaths were directly drug related, and ‘most deaths in which a drug was implicated were due to medically prescribed drugs’ (invariably methadone). A retrospective cohort study followed up 128 addicts who first presented in London in 1969, of whom 28 had died, and reported similar findings (Oppenheimer 1994).
Reasons for this high mortality have been ascribed to its long half life: a large number of deaths occur in the first few days of treatment, and this may be due to the chronic accumulation of the methadone in the bodies of addicts with reduced liver function (Harding-Pink 1993). Other reasons proposed include black market consumption, which is harder to quantify, and the co-administration of heroin and methadone, for which there is less evidence, albeit that death certificates provide notoriously poor data (Maudsley & Williams 1996).
Clearly there is a paucity of mortality data in the literature on methadone prescription. In 1994, a review of the methodology of drug treatment evaluation found that only four out of seventeen UK studies had used mortality as an outcome measure. To neglect this most ‘ineffective’ of outcomes, in studies of a drug which is prescribed to 17,000 British addicts, in whom it has a demonstrably higher mortality than the drug it is substituted for, seems extraordinary.
Finally, and perhaps most bizarrely, it is generally recognised that methadone is a more addictive drug than heroin, with a more arduous withdrawal process, and this fact is recognised both among the drug using subculture (Stewart 1985) and in the scientific literature (Gossop 1991).
Heroin on Prescription
The current situation is that very little heroin is prescribed in the UK: it was estimated that 117 addicts were prescribed heroin in 1992, while 17,000 were prescribed methadone (Gossop 1995). Maintenance prescription of heroin, the ‘British System’ until the 1960’s, is the ultimate extension of harm reductionist philosophy. There are many deductive arguments to support it, but little modern experimental data, and many criticisms that are laid against it. I shall consider these extensively, before examining the few studies of contemporary heroin maintenance programs which have recently been published.
The philosophy behind the prescription of heroin owes a lot to the findings of the Rolleston Committee in 1926, is similar to the thinking behind methadone prescription, and is essentially as follows: addiction itself is not something that is readily amenable to medical intervention, and as such opiates are prescribed to the addict for as long as they remain addicted, in order to keep them in a state of good health and leading as normal (and crime-free) a life as possible.
Addiction has been famously characterised by Vaillant (1991) as a chronic relapsing condition with a spontaneous remission rate of 5 per cent per annum regardless of external intervention. This apparently flippent description is supported by empirical data on long term follow-up of addicts (Stimson et al 1978) which show that no external agency expedites the ending of addiction, not even major life events (Sobell 1990).
With drug addiction, we are often choosing between problems, rather than solutions, and so heroin maintenance, which is only ever offered to patients who have failed with other modalities of treatment, could be considered the best of a bad lot. “with readily available prescribed opiates, there is no need to commit acquisitive crime to buy drugs, to sell drugs to others to finance one’s own use, and to risk one’s own (and others’) health, not to mention life, with adulterated drugs of unknown strength” (Marks 1991). It is also likely to promote attendance at the clinic for intervention when deemed appropriate, and an important side effect is the denial to criminals of a lucrative source of income.
There are of course a number of criticisms of heroin prescription. The first is that it negates the deterrent effect of the criminal law. However, heroin addicts already resist the deterrent effects of arrest, imprisonment, beatings by gangsters, social isolation, and injury or death through adulterants and disease. It is hard to imagine any greater sanctions than these, and so for addicts of this nature the choice may not be between detoxification or prescribed heroin, but between heroin from the illicit market or heroin from a clinic.
The second criticism is the possibility that heroin prescription would increase drug use in the general population. However, there is good evidence that untreated addicts must indulge in low level and aggressive marketing of heroin to provide themselves with a supply; that is, they push the drug in order to obtain it, thus promoting increased general consumption (Gilman and Pearson, 1991). It was partly the cessation of maintenance prescription in the 1960’s that led to the arrival of an aggressive black market (Mott 1991). Furthermore, it seems likely that the improved contact with family, friends, and healthcare providers that comes with maintenance prescription improves the chances of a healthy productive lifestyle and ultimate abstention.
This criticism of increased general use is linked to the fear of leakage of prescribed heroin onto the black market. This problem is best addressed by the careful prescription of an exact dose by specialist prescribers, and the evidence from the one remaining Rolleston clinic in the UK, or rather from the local drugs squad (who undertook to examine all arrested addicts for evidence of drugs prescribed by the clinic), was that there was no leakage onto the black market (Marks 1991).
A final criticism of heroin prescription is that it is expensive, costing up to ten times more per year, per addict, than methadone. Firstly it is important to recognise that the cost of any drug is not the sole factor in the running of a nationwide treatment and rehabilitation program. Public expenditure on drug control was £500 million in 1995, and of this £60 million was spent on treatment and rehabilitation, while £350 million was spent on police and customs enforcement, deterrents, and control (which prevents less than 15% of drugs from arriving on the black market) (HMSO 1995, quoted: UNDCP 1997).
If we calculate that there were 20,000 recipients of £500 of methadone annually, that is £10 million from the treatment budget, which would be £100 million if heroin was prescribed to a similar number. It seems likely that take-up and retention rates in clinics would increase if heroin was prescribed. Thus it would seem that this is perhaps the most viable of all our criticisms, and local health authorities have criticised heroin prescription on grounds of cost (ISDD 1996).
However, it has been claimed (ISDD Bulletin 1996) that because only one company may distribute heroin for medicinal purposes in the UK (Evans Medical), a virtual monopoly has been created, to the point where heroin is overpriced by a factor of thirty. This monopoly position was addressed by the European Court of Justice in 1995 (Pharmaceutical Journal News 1995), who ruled that the government would have to open up the market to competition, but as yet there are no plans to change the situation.
We must now consider the studies which have sought to compare heroin and methadone. Such data is extremely thin on the ground: there was one small randomised control trial in UCH from 1972-5; and one similar study in Switzerland in 1995; there is also poorly quantified data from the one Rolleston clinic in the UK which closed in 1995, and one small case-control study from Northern Ireland.
Hartnoll et al (1980) studied 96 addicts randomised to oral methadone (OM) or heroin maintenance (HM). After twelve months, 74% of the HM group were still attending, but only 29% of the OM group had maintained contact with the clinic. For both groups, illicit heroin use decreased, in the HM group from 74 to 21 mg/day, but in the OM group from 74 mg to 37 mg/day. There was no difference between the two groups in employment status, but over the course of the year 32% of the OM group had spent some time in prison, whereas 19% of the HM group did so.
Perneger et al (1998) studied 51 patients randomised similarly to heroin or methadone for six months in Geneva in 1995. At follow up, there was a significant difference in use of street heroin, with 48% of the OM group using street heroin on a daily basis, as opposed to 4% of the HM group (p=0.002). There was also a significant difference in the amount of money spent on drugs between the two groups, with the OM group spending approximately ten times the amount of the HM group (p=0.039). Associated with this, the HM group were less likely to be charged with theft (p=0.015) and less likely to be charged with drug dealing or possession (p=0.067 and p=0.008 respectively); overall, 57% of the OM group were charged with any offence over the course of the six month trial, whereas 19% of the HM group were charged (p=0.0004).
There was also a significant difference in mental health status, with 6 suicide attempts in the OM group, against 1 in the HM group (p=0.022). Finally, health related quality of life was measured with the SF-36 scale, which found a greater improvement for the HM group in mental health (p=0.025), and social functioning (p=0.041). There was no differential improvement in employment status, housing situation, or somatic health between the two groups over six months.
McCusker and Davies (1996) found similar results at a clinic in Northern Ireland over six months. The HM group manifested lower levels of psychopathology and showed greater retention in treatment, criminal activity was significantly more reduced, as was illicit heroin use, and although there were again no differences in physical health, the OM group was the only one to report the sharing of used injecting equipment.
Thus our three trials demonstrated many advantages to the prescription of heroin, and none to methadone.
Conclusions
Clearly there are stout grounds for scepticism concerning the validity of prescribing methadone in the treatment of heroin addiction. It is also clear that there is a paucity of research in this field, a failure which must surely be redressed.
There are certain things of which we can be certain. Heroin is the most attractive drug for heroin addicts, and however we might wish them to behave, they continue to use illicit sources of the drug even if a substitute is prescribed. Methadone is undoubtedly a dangerous drug, and one that retards entry of addicts into the treatment programs offered: it is also a drug whose effects have not been comprehensively researched. Heroin maintenance may well prove to be the best option we have.
Drug addiction is not a phenomenon that lends itself generously to empirical investigation. Even the outcome indicators are a subject for debate, and a viable study of what many would see as the ultimate index of success, abstention, would require a trial lasting more than a decade.
However, quantifiable indices of health status, social functioning, criminal behaviour, total opiate consumption, needle-sharing and so on are all viable and uncontroversial outcome measures, and should be comprehensively investigated for methadone and heroin. Furthermore, no indications have been found that prescribing heroin would inflict harm of a kind that might make such trials unacceptable.
Perneger et al (1998) have noted that although the Swiss trial was small, it was similar to the initial evaluations of methadone, such as the seminal paper by Dole and Nyswander (1965), which led to its widespread use in the treatment of drug addiction. It seems likely that a contributory factor was the medical profession’s emotional and moral attitudes towards drug users.
However noble our intentions when we approach a clinical or social problem, we may often be confounded by extraneous factors and preconceptions, and fail in our objectivity. We share an obligation to submit all medical interventions to rigorous, continuous and objective re-assessment. Drug addiction affects 100,000 people in Britain directly, and many more indirectly; it is responsible for an enormous drain on health care resources, a large proportion of acquisitive crime, and the fastest growing group of HIV infection. That we should apparently neglect our obligations in such an important field is astonishing.
reason for this being mentioned in the spoiler bit, but the interesting article imo is below in quotes
Heroin should be prescribed to drug addicts to curb crime, the deputy chief constable of Nottinghamshire has said at a drugs conference. Howard Roberts told an Association of Chief Police Officers' conference in Manchester the idea should be assessed.
He said the treatment would cost £12,000 a year per addict but added that drug users steal property valued at an average of £45,000 a year.
The idea is being piloted in London, the South East and North of England.
"At the moment across the country we see levels of burglary, robbery and murder being committed by drug-fuelled addicts who are doing so in order to get the money to buy the drugs," Mr Roberts told the conference.
"One of the things I have found is that as a treatment it has been highly effective in actually helping to reduce crime. We've seen good levels of falls in drug-related acquisitive crime."
"However, there is still a considerable problem and what I am suggesting is that we need to explore, as part of a treatment programme, the prescribing of heroin to addicts in order to take them out of the illegal market."
He added: "Of course, getting people off drugs altogether must be the objective.
"But I do believe that we have lived with the terrible consequences of relatively uncontained addiction for far too long.
"If we are to make a greater impact we need to fundamentally address the method of operation of the criminal market-place for heroin."
Martin Barnes, chief executive of drugs charity DrugScope, said: "There is compelling evidence that heroin prescribing, although more expensive than some forms of drug treatment, is cost-effective in reducing drug-related crime and other costs to communities."
Nicola Metrebian, from the charity Action on Addiction, said they were doing research which would "compare the effectiveness of injectable methadone and injectable heroin to oral methadone" for a group of hard to treat heroin users.
In the Department of Health pilots, 300 to 400 drug users receive heroin for their addiction. Similar schemes in Holland and Switzerland reported some users turning away from crime.
quote source (http://www.badscience.net/?p=327)
Suddenly heroin prescription is back in the news, so here’s an archaeological find from the hard-drive: an essay I wrote in praise of heroin prescription, for the “Roger Hole Essay Prize in Medical Scepticism”, as a young undergraduate in medicine, in 1998. The prize was judged by Lewis Wolpert, and winning it netted me the enormous sum of £250 (a month’s rent!) and a signed certificate from Prof Souhami (of Souhami and Moxham fame!).
This essay, weirdly, also served up an early insight for me in the lameness of reporting on science and health in the media, and their obsession with quoting “authority”. A friend of mine who worked for a drug law reform pressure group gave my number to somebody working on campaigning journalist Nick Davies‘ heroin addiction documentary, a couple of years later. They called me, said they’d heard I was a doctor, had researched the issue, and asked if I would do an interview.
I’d be happy to help, I said, but explained that I had only qualified as a doctor a few weeks previously, that I would feel a bit uncomfortable being an “authority”, that I was in no sense a medical expert on anything much, in fact I wasn’t even fully registered with the GMC for another year (I was a PRHO!) and that I looked about 12. They seemed to think all this might be a problem, but I chatted through what I knew on the subject, and casually offered to email this essay I had written when I was a medical student. I never heard from them again.
So imagine my surprise when, completely by accident, I happened to catch a TV show on heroin prescription a few months later. It didn’t even really occur to me that it might be connected to that brief phone call, but suddenly, the screen went black, with a dramatic pause and, if I remember correctly, a deep bass synthesiser tone in the background, and then, from nowhere, quotes from my medical student essay appeared, in big, sombre letters, filling the screen, ascribed to “Dr Ben Goldacre”, as if I was some kind of aged, leading world authority and the absolute last word.
I should mention that I was watching this sat on my mattress, which was on the floor, eating toast, in my underpants, like a proper student bachelor. The disparity was striking. I’ve never been so embarrassed, I prayed that nobody I knew had seen it, and it’s one of the many reasons why I still doggedly avoid being described as “Dr Ben Goldacre”. There’s just no need.
Anyway, here’s the essay, I hope you enjoy it, forgive the slightly pompous and youthful authorial style, it was over 8 years ago, I was practically a kid, Billie was top of the hit parade with “Because We Want To” and the Spice Girls were still together. I might see a few things very slightly differently now, with more clinical experience, and a better feel for research literature in general, and it was an “exercise in medical scepticism”, but for the most part, looking back at myself, I have to say, I think I make a pretty tonky argument. It’s certainly an extremely strong survey of the historical context. I just hope nobody quotes me as an expert again.
“Methadone and Heroin:
An Exercise in Medical Scepticism”
~ by Ben Goldacre, 1998 (aged 23 and 3/4) ~
I have often fantasised about living through an age when science was truly adversarial: to have seen Darwin at the Royal Society, or Galileo recant. But the lie of the land, the structure of our scientific territory, and our modes of warfare across it, have become domesticated and tame. Although there may be differences of opinion, we each tend to tinker at the expanding edges of our understanding, and truly mutually exclusive explanatory frameworks for reproducible phenomena rarely co-exist for long.
If we want to see real friction, some other factor must come to bear on the essentially healthy structure of the mainstream scientific community: a funding issue, for example, might influence the general trajectory of research, but for the most part temporarily; we may be transiently confounded by partisan research from a given drug-company, but only in whatever microcosm of physiology their drug acts and, albeit slightly behind schedule, we can be sure that the truth will out.
But we want the big prize: we want wholesale irrationality, we want to see the axial skeleton of our concepts truly and chronically deformed, and only politics can muster contorting forces of such magnitude. I intend to show how this influence has perverted rationality in one area, our medical treatment of those who are addicted to heroin, to such an extent that our theory and practice is now so polluted as to be scientifically untenable.
Until recently, it was common practice in Britain to prescribe heroin to heroin addicts. This apparently paradoxical practice was well founded and successful, as we shall see below. However, since the late 1960’s, addicts have mostly been prescribed oral methadone, a long acting opiate agonist with a less euphoriant effect, as a heroin substitute.
I shall demonstrate that the maintenance of addicts on methadone is less effective at reducing the use of heroin, and the harm that goes along with heroin use, than the prescription of heroin itself. I shall also show that methadone is a more dangerous drug than heroin, and causes more deaths than even adulterated street heroin.
Ultimately, the case I shall make is that heroin prescription is more effective, by all reasonable outcome indicators, than methadone; and that the reasons for its unpopularity have little to do with evidence of best practice, and much to do with our emotional and moral attitudes towards those who are addicted to drugs. To begin, we must consider the history of opiate addiction and its treatment, in order to understand how and why politics intervened, and how we arrived at the state we are in today.
A Brief History of Opiate Addiction and Rehabilitation
Heroin, or diamorphine, was first marketed by Bayer in 1898, after being developed as a cough suppressant by the same team who introduced aspirin. Although the use of psychoactive drugs (and specifically opiates) began to be considered as a medical problem in the late nineteenth century (Berridge & Edwards 1981), they were legally available until well into the twentieth, and opiates could be purchased from pharmacies with a minimum of formalities up until 1920.
At this time, the principal medical concern over drug use was the risk of accidental poisoning through the non-medical pursuit of pleasure, and the prevalence of drug addiction (frequently caused by chronic medical use) was so low that its social impact was negligible. The 1920 Dangerous Drugs Act confined the availability of opiates to prescription only and, over the next few years, penalties for offenders against the possession laws were increased, a reflection of similar developments abroad (Mott 1991).
However, where Britain departed from the rest of the world was with the Rolleston Committee report from the Department of Health in 1926. This emphasised that persistent drug use, in line with newly emerging medical and social theory, should be seen as a disease: ‘as a manifestation of a morbid state, and not as a mere form of vicious indulgence.’ (Rolleston, HMSO 1926).
By pursuing this line, Rolleston arrived almost accidentally at the sympathetic modern day conception of the drug abuser, over half a century before Hartnoll et al (1980) found evidence of serious childhood disturbance in his patients at a drug dependency clinic in UCH. In many ways Rolleston was the first proponent of the guiding philosophy of most modern drug work, ‘harm reduction’, which I shall later consider in detail.
The progressive attitude to drug use institutionalised in this report established the framework of public policy for the next five decades, and following 1926 the ‘British System’ prosecuted dealers and dilettantes, but permitted medical prescription of heroin to addicts after “every effort” had been made for the “cure of the addiction”, but when the drugs could not be fully withdrawn without “severe distress or even risk of life” or “experience showed that a certain minimum dose of the drug was necessary for the patients to lead useful and relatively normal lives … capable of work.” This twin policy of ‘policing and prescribing’ effectively contained the heroin problem (which ran at below a hundred notified heroin addicts) for the next four decades.
With the Sixties came an atmosphere of moral panic at the scale of a well-publicised increase in drug use (Plant, 1987). Although the drugs in question were mostly cannabis and amphetamines, not heroin, attitudes to drug use and regulation were re-appraised: amphetamines and LSD were brought under tight statutory control, and the government began to fear that with a rising demand for drugs, the licit opiate supply system might start supplying the illicit market.
From 1959 to 1964 the number of addicts notified to the Home Office increased from 68 to 342 (Spear 1969), and it was noted that an unusually large proportion of these new addicts were of non-therapeutic origin, that is, an unusually large proportion of new users had not come to addiction via chronic medical treatment for physical disease or injury.
In 1964, the government convened the Brain Committee, an interdepartmental re-incarnation of the Rolleston Committee, who found that ‘the major source of supply had been excessive prescribing by a small group of doctors’ (HMSO 1965). They recommended that the prescription of drugs to addicts should be restricted to specialist clinics, ‘Drug Dependency Units’, and although heroin for physical ailments could still be freely prescribed, laws were passed requiring that doctors who prescribed heroin for addicts should be specifically approved by the Home Secretary.
From the beginning of the seventies, there was a major sea change in the treatment of addicts (Stimson & Oppenheimer 1982). This was characterised by an emphasis on abstinence as the primary goal of treatment, and a refusal to prescribe heroin: instead, on condition of abstinence from all other drugs, and under ‘treatment contracts’, heroin addicts were prescribed a new drug, methadone, to be taken orally.
It has been proposed that the reluctance of doctors to prescribe heroin was probably, in a number of cases, due to the fact that most addicts were so keen to obtain this drug: this made doctors working in the field uneasy, and Glossop (1995) believes that prescribing a medicine which was less desirable for the client was more easily rationalised.
In the mid-1970’s there was an upsurge in the illicit heroin market in London. The factors alleged to have contributed to this include: an upsurge in illicit demand following the change in DDU policy; the end of the Vietnam War, requiring the South-East Asian producers to find new markets after the GIs went home; wealthy Iranian exiles using heroin as a means of getting their capital out of the country after the downfall of the Shah; and political troubles in Afghanistan and Pakistan (Mott 1991).
Over the course of the decade, the market ceased to be run by amateurs, as professional criminals extended their interests from the cannabis market to heroin (Clark 1980; Lewis 1985). Driven in part by a pyramid dealing network, where addicts at the bottom of the distribution chain had an interest in selling to fund their own use (Gilman & Pearson 1991), heroin use expanded enormously throughout the next twenty years.
The Contemporary Heroin Problem
The Home Office were notified of 35,000 heroin addicts in 1994: due to incomplete reporting, and other obstacles in reaching the addict population, this is widely believed to represent between a third and a fifth of all addicts (ISDD 1994), thus putting the true figure at between 100,000 and 160,000.
Contemporary heroin addiction is no longer an issue between the individual and their metabolism. The nature of the drug, the scale of its use, and its position in modern society, all mean that addicts experience more diverse problems, and cause more diverse problems, than the heroin addict of the nineteenth century.
The generally poor health of chronic addicts is usually not a direct result of the opiates as such. Heroin is very addictive but does not in itself cause any serious illnesses, nor does it harm any organs or tissues: the indirect consequences are of course more serious. Pain sensations are suppressed, with the results that certain signals (for example, problems with teeth, infections, cold, heat and hunger) are not noticed. Because opiates also suppress feelings and emotions, the ability to enter into social relations with others is also seriously affected, so not only physical but social functioning worsens.
Another important issue is how the addict can maintain a supply of heroin. The enormous cost of heroin on the black market is met for the most part by acquisitive property crime. The economics of the illicit market are remarkable: at the farmgate in Pakistan, a kilogram of opium costs $90; when it has been converted to heroin it costs $3,000 in Pakistan; wholesale in the USA it costs $80,000; and its final retail price on the street (at the DEA’s quoted average purity of 40%) is $290,000 per kilogram (United Nations Drug Control Program Report, 1997, p126).
On the streets of the UK, a gram of heroin costs between £50 and £120 (UNDCP 1997 p194). The cost of acquisitive crime committed to pay for this heroin has been estimated at £1.5 billion per year. Addicts in the UK generally steal to fund their addiction: thus they risk likely impoverishment and imprisonment. One study showed that 80% of addicts attending a DDU clinic had been convicted of at least one offence in the course of their drug taking careers (Hartnoll et al 1980). More crucially for long-term outcome, since they often steal from family and friends, addicts risk social isolation.
Furthermore, since the drug is at such a premium, it will be used in the most efficient fashion possible which is, of course, intravenous injection (intravenous use of alcohol under prohibition of alcohol in the USA has also been documented) (Stevenson 1994). Intravenous use of any drug carries its own dangers. A large proportion of the morbidity experienced amongst heroin addicts is due to wound infection, septicaemia, and infective endocarditis, all due to asterile injection technique (Oxford Handbook of Clinical Medicine, 1996, p.184-5).
Infection is another major cause of morbidity and mortality in intravenous drug users internationally (UNDCP 1997). Heroin addicts tend to lead chaotic lifestyles and have low self-esteem, both of which, along with expediency, contribute to a tendency to share needles with other users. Via this route they become infected with HIV, and hepatitis B and C.
10% of UK AIDS cases in 1995 were related to the use of intravenous drugs, and it is suspected that the increase in HIV infection amongst non-intravenous drug using heterosexuals is being driven by contact with heterosexual intravenous drug users (European Centre for the Epidemiological Monitoring of AIDS, 1996), and the World Health Organisation estimates that 40% of recent AIDS cases internationally were caused by drug users sharing injecting equipment (WHO 1994).
It was the spread of HIV through intravenous drug use that led to the reconsideration of heroin addiction treatment in the late 1980’s, and was the birth of the new policy of ‘harm reduction’. The HIV seropositivity rate amongst intravenous drug users in Edinburgh, where needle-exchange and maintenance programs had been vigorously opposed, rose to over 50% in the mid-1980’s (Robertson et al 1986). By comparison, in Glasgow, where such facilities were available, less than fifty miles away, the level of seropositivity was less than 5% (Follett et al 1986).
A policy of harm reduction tackles public health issues directly by seeking to reduce the personal and social costs of drug use. Abstinence is not regarded as a realistic short-term goal for most dependent users, and the principal ingredients of most programs are syringe exchanges, educational and advisory services, and treatment and maintenance services (generally with methadone).
There is a hierarchy of achievable objectives, with non-users urged to abstain, and users advised to reduce doses, and to avoid the most potent drugs and riskier means of ingestion. Those who insist on injecting are offered advice on safer technique, and those who persist in sharing needles are even taught how to clean their equipment (Newcombe 1992).
This policy has been vigorously opposed in some parts of the world, especially the USA, where drug related mortality is almost twice that of the UK (UNDCP 1997). Despite this, it has become the guiding principle behind UK drugs policy, along with the maintenance prescription of methadone.
Methadone
Methadone is an opioid receptor agonist with a half life of approximately 24 hours, far longer than heroin. Drugs with longer half-lives tend to produce less acute withdrawal effects, a phenomenon which is utilised in the choice of anxiolytic drugs in psychiatric practice (British National Formulary, September 1999). Crucially, in comparison with heroin, methadone has a greatly reduced euphoric effect. The hope for methadone, therefore, is that it can contain the opiate cravings, on a once daily oral dose, without providing so much of a ‘high’.
The aim of methadone maintenance is to stabilise and then to ‘cure’ the opiate user. This breaks down into such objectives as: improving the health of drug users, by providing clean drugs in measured doses under medical supervision; reducing drug-related crime by providing users with free legal opiates, thus reducing their need to steal to fund illicit heroin; improving the social situation of drug users (family relationships, finances, employment, housing and so on); persuading users to reduce their daily dose and ultimately take steps towards abstinence. This is in many ways an updated version of Rolleston’s rationale from 1926.
However, the policy of prescribing methadone may be criticised from many different angles, and to the best of my knowledge these criticisms have never been comprehensively considered in one article. Certainly there is no convenient meta-analysis of methadone programs. I shall consider each criticism in detail, and later compare the use of methadone to the maintenance prescription of heroin, which still continues on a small scale in the UK, and has recently been re-assessed in Switzerland and Australia.
Firstly, it is important to recognise that methadone is not a pleasant drug to take, causing nausea and vomiting, weight gain, profuse sweating, dysphoria, and tooth decay. This is no major selling point to a patient group clearly accustomed to making stringent aesthetic judgements about their drugs and this, combined with the absence of the ‘buzz’ of heroin, means that the take-up rate amongst addicts is far lower than it ever was for heroin.
Hartnoll et al (1980) found that only 29% of those offered methadone in one DDU between 1972 and 1975 were still attending 12 months later. The reality of take-up rates for methadone prescription programs amongst the general population of heroin addicts today is that only a small minority of addicts will attend methadone clinics, certainly less than 15%, although specific statistics are hampered by the unknown quantity of the denominator, that is, the number of people in a population addicted to illicit drugs (Dorn, Baker, Seddon 1994).
Treatment for drug dependency, to be successful and especially to have an impact at a community level, must have high take-up and retention rates amongst problem drug users who, unlike adults with right iliac fossa pain, may not spontaneously present themselves to healthcare professionals.
In order to be successful, therefore, a drug dependency unit must offer both treatment and the drug at a ‘price’ which the users are willing to pay: the prescriptions may be free, but the terms and conditions on which they are offered may act as a deterrent to some users, and the product offered (counseling services, advice, and possibly substitute drugs) must be appealing. Health economists have couched the problem in their own terminology: ‘for treatment to have a high take-up rate, it must sell … and be seen to sell … a good product at low cost’ (Stevenson 1994).
Retention in treatment, firstly, is an area where the philosophy guiding the work of a clinic may have as much of an impact as the nature of the drug they are offering. In a controlled study in Australia (Bell, Chan, Kuk 1995), heroin addicts were assessed and randomised to two clinics, one oriented to long-term methadone maintenance, and the other oriented to time-limited treatment, aiming primarily at abstinence from all drugs, including methadone. Both groups were urine-tested for heroin, and use of heroin outside the clinic was higher in the abstinence-oriented clinic.
An observational study in a different country showed that addicts were more likely to discharge themselves earlier from methadone clinics where the clinic staff scored highly on an ‘Abstinence Orientation Scale’, measuring their commitment to abstinence-oriented policies on heroin addiction (Caplehorn, Irwig, Saunders 1996). Other studies have shown that external compulsion to attend clinics, for example by law courts, is also associated with poor retention.
Conversely, a high re-attendance rate has been demonstrated at ‘user friendly’ clinics where needle exchange and clean drugs are available, with no uninvited counseling (Newcombe & Parker 1987). Experience has taught that regular and enduring contact with treatment services is a necessary precondition for successful treatment of addicts (Hartnoll et al 1980; Gossop, Strang, Connell 1982).
Finally, studies of drug users who present to rehabilitation programs have shown that they are often in a poorer state of health than other heroin addicts in the population (of equally long-standing) who have not chosen to present, and this is taken by some commentators to mean that addicts will only present as a last resort (UNDCP 1997). Thus methadone programs are by no means a universally attractive option to the addict population, and addicts often use their drug of choice to supplement their prescription.
Use of heroin outside the confines of a drug rehabilitation program (whilst ostensibly attending it) is, of course, associated with all of the risks of everyday heroin addiction: increased risk of intravenous drug use leading to infection, increased acquisitive crime, poor family relations. More importantly, the chaotic nature of the drug use means that the chances of abstinence after a period of regulated drug use are reduced. Thus use of heroin outside the clinic may be considered one of the definitively poor outcome measures.
However, methadone is also a dangerous drug in its own right: astonishingly, use of methadone has a higher mortality even than the use of illicit heroin, although to what extent is uncertain. For example, in 1992, there were 101 deaths from methadone, and 40 from heroin; similarly, from 1982 to 1991 there were 349 methadone deaths and 243 heroin deaths (OPCS): this is despite the fact that there are far more users of heroin, at every strata of use, by a factor of at least 3:2, than of methadone.
However, to quantify the mortality requires an accurate denominator (the number of users for each drug) and this, as we have already discussed, can only be achieved indirectly for a covert and underground activity such as drug abuse. Estimates vary widely according to the denominator used, and authors are never so disingenuous as to claim pinpoint accuracy for their figures, but the most recent data to be analysed estimates the risk of methadone related mortality at around four times that of heroin (Newcombe 1996).
The dangers of methadone have long been recognised. Ghodse et al (1985) analysed the patient records of notified addicts who died in the UK between 1967 and 1981, and found that among patients using heroin, three quarters of deaths were directly drug related, and ‘most deaths in which a drug was implicated were due to medically prescribed drugs’ (invariably methadone). A retrospective cohort study followed up 128 addicts who first presented in London in 1969, of whom 28 had died, and reported similar findings (Oppenheimer 1994).
Reasons for this high mortality have been ascribed to its long half life: a large number of deaths occur in the first few days of treatment, and this may be due to the chronic accumulation of the methadone in the bodies of addicts with reduced liver function (Harding-Pink 1993). Other reasons proposed include black market consumption, which is harder to quantify, and the co-administration of heroin and methadone, for which there is less evidence, albeit that death certificates provide notoriously poor data (Maudsley & Williams 1996).
Clearly there is a paucity of mortality data in the literature on methadone prescription. In 1994, a review of the methodology of drug treatment evaluation found that only four out of seventeen UK studies had used mortality as an outcome measure. To neglect this most ‘ineffective’ of outcomes, in studies of a drug which is prescribed to 17,000 British addicts, in whom it has a demonstrably higher mortality than the drug it is substituted for, seems extraordinary.
Finally, and perhaps most bizarrely, it is generally recognised that methadone is a more addictive drug than heroin, with a more arduous withdrawal process, and this fact is recognised both among the drug using subculture (Stewart 1985) and in the scientific literature (Gossop 1991).
Heroin on Prescription
The current situation is that very little heroin is prescribed in the UK: it was estimated that 117 addicts were prescribed heroin in 1992, while 17,000 were prescribed methadone (Gossop 1995). Maintenance prescription of heroin, the ‘British System’ until the 1960’s, is the ultimate extension of harm reductionist philosophy. There are many deductive arguments to support it, but little modern experimental data, and many criticisms that are laid against it. I shall consider these extensively, before examining the few studies of contemporary heroin maintenance programs which have recently been published.
The philosophy behind the prescription of heroin owes a lot to the findings of the Rolleston Committee in 1926, is similar to the thinking behind methadone prescription, and is essentially as follows: addiction itself is not something that is readily amenable to medical intervention, and as such opiates are prescribed to the addict for as long as they remain addicted, in order to keep them in a state of good health and leading as normal (and crime-free) a life as possible.
Addiction has been famously characterised by Vaillant (1991) as a chronic relapsing condition with a spontaneous remission rate of 5 per cent per annum regardless of external intervention. This apparently flippent description is supported by empirical data on long term follow-up of addicts (Stimson et al 1978) which show that no external agency expedites the ending of addiction, not even major life events (Sobell 1990).
With drug addiction, we are often choosing between problems, rather than solutions, and so heroin maintenance, which is only ever offered to patients who have failed with other modalities of treatment, could be considered the best of a bad lot. “with readily available prescribed opiates, there is no need to commit acquisitive crime to buy drugs, to sell drugs to others to finance one’s own use, and to risk one’s own (and others’) health, not to mention life, with adulterated drugs of unknown strength” (Marks 1991). It is also likely to promote attendance at the clinic for intervention when deemed appropriate, and an important side effect is the denial to criminals of a lucrative source of income.
There are of course a number of criticisms of heroin prescription. The first is that it negates the deterrent effect of the criminal law. However, heroin addicts already resist the deterrent effects of arrest, imprisonment, beatings by gangsters, social isolation, and injury or death through adulterants and disease. It is hard to imagine any greater sanctions than these, and so for addicts of this nature the choice may not be between detoxification or prescribed heroin, but between heroin from the illicit market or heroin from a clinic.
The second criticism is the possibility that heroin prescription would increase drug use in the general population. However, there is good evidence that untreated addicts must indulge in low level and aggressive marketing of heroin to provide themselves with a supply; that is, they push the drug in order to obtain it, thus promoting increased general consumption (Gilman and Pearson, 1991). It was partly the cessation of maintenance prescription in the 1960’s that led to the arrival of an aggressive black market (Mott 1991). Furthermore, it seems likely that the improved contact with family, friends, and healthcare providers that comes with maintenance prescription improves the chances of a healthy productive lifestyle and ultimate abstention.
This criticism of increased general use is linked to the fear of leakage of prescribed heroin onto the black market. This problem is best addressed by the careful prescription of an exact dose by specialist prescribers, and the evidence from the one remaining Rolleston clinic in the UK, or rather from the local drugs squad (who undertook to examine all arrested addicts for evidence of drugs prescribed by the clinic), was that there was no leakage onto the black market (Marks 1991).
A final criticism of heroin prescription is that it is expensive, costing up to ten times more per year, per addict, than methadone. Firstly it is important to recognise that the cost of any drug is not the sole factor in the running of a nationwide treatment and rehabilitation program. Public expenditure on drug control was £500 million in 1995, and of this £60 million was spent on treatment and rehabilitation, while £350 million was spent on police and customs enforcement, deterrents, and control (which prevents less than 15% of drugs from arriving on the black market) (HMSO 1995, quoted: UNDCP 1997).
If we calculate that there were 20,000 recipients of £500 of methadone annually, that is £10 million from the treatment budget, which would be £100 million if heroin was prescribed to a similar number. It seems likely that take-up and retention rates in clinics would increase if heroin was prescribed. Thus it would seem that this is perhaps the most viable of all our criticisms, and local health authorities have criticised heroin prescription on grounds of cost (ISDD 1996).
However, it has been claimed (ISDD Bulletin 1996) that because only one company may distribute heroin for medicinal purposes in the UK (Evans Medical), a virtual monopoly has been created, to the point where heroin is overpriced by a factor of thirty. This monopoly position was addressed by the European Court of Justice in 1995 (Pharmaceutical Journal News 1995), who ruled that the government would have to open up the market to competition, but as yet there are no plans to change the situation.
We must now consider the studies which have sought to compare heroin and methadone. Such data is extremely thin on the ground: there was one small randomised control trial in UCH from 1972-5; and one similar study in Switzerland in 1995; there is also poorly quantified data from the one Rolleston clinic in the UK which closed in 1995, and one small case-control study from Northern Ireland.
Hartnoll et al (1980) studied 96 addicts randomised to oral methadone (OM) or heroin maintenance (HM). After twelve months, 74% of the HM group were still attending, but only 29% of the OM group had maintained contact with the clinic. For both groups, illicit heroin use decreased, in the HM group from 74 to 21 mg/day, but in the OM group from 74 mg to 37 mg/day. There was no difference between the two groups in employment status, but over the course of the year 32% of the OM group had spent some time in prison, whereas 19% of the HM group did so.
Perneger et al (1998) studied 51 patients randomised similarly to heroin or methadone for six months in Geneva in 1995. At follow up, there was a significant difference in use of street heroin, with 48% of the OM group using street heroin on a daily basis, as opposed to 4% of the HM group (p=0.002). There was also a significant difference in the amount of money spent on drugs between the two groups, with the OM group spending approximately ten times the amount of the HM group (p=0.039). Associated with this, the HM group were less likely to be charged with theft (p=0.015) and less likely to be charged with drug dealing or possession (p=0.067 and p=0.008 respectively); overall, 57% of the OM group were charged with any offence over the course of the six month trial, whereas 19% of the HM group were charged (p=0.0004).
There was also a significant difference in mental health status, with 6 suicide attempts in the OM group, against 1 in the HM group (p=0.022). Finally, health related quality of life was measured with the SF-36 scale, which found a greater improvement for the HM group in mental health (p=0.025), and social functioning (p=0.041). There was no differential improvement in employment status, housing situation, or somatic health between the two groups over six months.
McCusker and Davies (1996) found similar results at a clinic in Northern Ireland over six months. The HM group manifested lower levels of psychopathology and showed greater retention in treatment, criminal activity was significantly more reduced, as was illicit heroin use, and although there were again no differences in physical health, the OM group was the only one to report the sharing of used injecting equipment.
Thus our three trials demonstrated many advantages to the prescription of heroin, and none to methadone.
Conclusions
Clearly there are stout grounds for scepticism concerning the validity of prescribing methadone in the treatment of heroin addiction. It is also clear that there is a paucity of research in this field, a failure which must surely be redressed.
There are certain things of which we can be certain. Heroin is the most attractive drug for heroin addicts, and however we might wish them to behave, they continue to use illicit sources of the drug even if a substitute is prescribed. Methadone is undoubtedly a dangerous drug, and one that retards entry of addicts into the treatment programs offered: it is also a drug whose effects have not been comprehensively researched. Heroin maintenance may well prove to be the best option we have.
Drug addiction is not a phenomenon that lends itself generously to empirical investigation. Even the outcome indicators are a subject for debate, and a viable study of what many would see as the ultimate index of success, abstention, would require a trial lasting more than a decade.
However, quantifiable indices of health status, social functioning, criminal behaviour, total opiate consumption, needle-sharing and so on are all viable and uncontroversial outcome measures, and should be comprehensively investigated for methadone and heroin. Furthermore, no indications have been found that prescribing heroin would inflict harm of a kind that might make such trials unacceptable.
Perneger et al (1998) have noted that although the Swiss trial was small, it was similar to the initial evaluations of methadone, such as the seminal paper by Dole and Nyswander (1965), which led to its widespread use in the treatment of drug addiction. It seems likely that a contributory factor was the medical profession’s emotional and moral attitudes towards drug users.
However noble our intentions when we approach a clinical or social problem, we may often be confounded by extraneous factors and preconceptions, and fail in our objectivity. We share an obligation to submit all medical interventions to rigorous, continuous and objective re-assessment. Drug addiction affects 100,000 people in Britain directly, and many more indirectly; it is responsible for an enormous drain on health care resources, a large proportion of acquisitive crime, and the fastest growing group of HIV infection. That we should apparently neglect our obligations in such an important field is astonishing.