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Effect of government recommendations on methadone prescribing in south east England: comparison of 1995 and 1997 surveys

John Strang, director,  Janie Sheridan, honorary lecturer. 

National Addiction Centre, Institute of Psychiatry and the Maudsley, London SE5 8AF

Correspondence to: Professor Strang j.strang{at}iop.bpmf.ac.uk

On instruction from the Minister of Health, the Department of Health in England convened a task force on the effectiveness of treatment services for drug misusers, and widely distributed its recommendations in 1996.¹ Methadone constituted 96% of all opiate prescriptions dispensed to drug misusers. ^{2 3} The task force specifically recommended that (a) methadone tablets should no longer be prescribed for the treatment of drug misuse; (b) daily dispensing should be used to prevent diversion of drugs; and (c) the optimal dosage for methadone maintenance treatment was probably between 50 mg and 100 g daily.¹

Much of the drug problem of England and Wales is concentrated in London, ^{4 5} with 23% of all methadone prescriptions in the area being from the Thames regions.³ We report the extent to which changes in line with the three recommendations of the task force occurred in the Thames regions between 1995 and 1997.

	Methods and results

Top Methods and results Comment References

Data were collected nationally on prescriptions dispensed to drug misusers by community pharmacists in 1995 ^{2 3} and for south east England again in 1997 (first mailshot only)that is, one year before and one year after the publication of the task force's recommendations. One in four community pharmacies was randomly selected for the 1995 national survey² and one in two for the 1997 Thames survey; they were stratified by health authority in both surveys. Overall response rates were 75% and 65% respectively. To achieve comparability, data on methadone prescriptions from community pharmacies in the Thames regions were retrieved for the first mailshot only, giving 584 and 864 methadone prescriptions in 1995 and 1997 respectively.

The table shows differences in the distribution of dosage form, dispensing interval, and dose between 1995 and 1997. The proportion of methadone prescriptions in tablet form was reduced from 12.1% to 9.5%a reduction in the same direction, but greater than that for methadone ampoules. The mean number of dispensings per week increased from 3.85 (SD 2.37) to 4.22 (2.43) (Mann-Whitney U test=209374; P<0.0001). The proportion of these prescriptions issued for daily dispensing as recommended increased only minimally (52.1% to 55.8%), although the proportion of prescriptions being dispensed weekly or less frequently decreased from 32.3% to 25.6%. There was no evidence of any increased use of methadone dosages sufficient to achieve "blockade": mean daily dose changed from 52.0 mg to 51.2 mg. For the oral mixture (to which the higher recommended maintenance dose related) the mean also remained unchanged (46.4 mg to 46.6 mg). There was also no increase in the proportion of methadone prescriptions for the recommended dose of 50-100 mg daily.

	Comment

Top Methods and results Comment References

The ministerial mandate and the financial expenditure on the preparation of the task force's report were unprecedented in the United Kingdom. Three of the task force's recommendations about methadone prescribing were amenable to study from data sets recently collected. We found only scant evidence of change that might have been prompted by these recommendations. Although tablet prescribing had reduced in line with the recommendations, this reduced proportion is against a backdrop of an annual increase of 20% per annum in the number of opiate addicts presenting for treatment.⁵ In other words, the annual number of prescriptions for methadone tablets has still increased. If the net result of an expensive review is a modest proportionate reduction (but absolute increase) in tablet prescribing, only a slight increase in the proportion of prescriptions dispensed daily, and little change in the mean daily dose, then the likelihood of substantial change in clinical practice following recommendations alone within the Department of Health's guidelines seems slim. If planners are awaiting major change in methadone prescribing as a result of central exhortation, they should not hold their breath.

	Acknowledgments

   Contributors: John Strang had the original idea for the two studies and the present analysis. Janie Sheridan designed the studies and collected and analysed the data. They jointly wrote the manuscript. John Strang is guarantor for the study.

Funding: The original reference studies were supported by funding from the Department of Health and the national NHS research and development programme. The views expressed are those of the authors and do not necessarily reflect those of the funding bodies.

Conflict of interest: None.

	References

Top Methods and results Comment References

1. Department of Health. The Task Force to Review Services for Drug Misusers: report of an independent review of drug treatment services in England. London: HMSO , 1996.
2. Strang J, Sheridan J, Barber N. Prescribing injectable and oral methadone to opiate addicts: results from the 1995 national postal survey of community pharmacies in England and Wales. BMJ 1996; 313: 270-272[Abstract/Free Full Text].
3. Strang J, Sheridan J. National and regional characteristics of methadone prescribing in England and Wales: local analyses of data from the 1995 national survey of community pharmacies. J Substance Misuse 1998; 3: 240-246.
4. Advisory Council on the Misuse of Drugs. AIDS and drug misuse: update report. London: HMSO , 1993.
5. Home Office. Statistics on the misuse of drugs: addicts notified to the Home Office, United Kingdom, 1996. London: HMSO , 1997.