Letters

Reducing deaths among drug misusers

General Medical Council may be destroying the British system

Standard of care in Britain was not addressed

Authors' reply

General Medical Council may be destroying the British system

EDITORGabbay et al argued that tightening controls by extending the licensing system to all controlled drugs is likely to bring about adverse consequences.¹ Drug related deaths will increase in number rather than decrease. The hidden message in the editorial, written by four doctors experienced in treating addiction, was equally important. There is a growing and ultimately destructive schism in the United Kingdom's medical profession regarding the proper controls on doctors treating drug misusers.

On the one hand, there are doctors such as Gabbay et al who argue that the British approach to treating drug misusers has enduring value. This means that the judgment of an individual doctor should be trusted in tailoring treatment for each patient. Thus, each drug misuser is treated as a patient with unique needs, and drug misusers in general as constituting a heterogeneous, not a homogeneous, population. Trust in doctors extends to decisions to prescribe narcotics. Doctors operating from the British system assume that there is no specific treatment of drug abuse. This realistic concept has encouraged experimentation and innovation by British doctors, including general practitioners, in taking on and treating difficult patients. Medical practice based on the British system has worked to hold down the spread of addiction and disease.

On the other hand, there are doctors wielding considerable power in the drug misuse establishment who view the clinical freedom accorded by the British system as both an anachronism and a threat to public health. This politically dominant group of doctors has, over the past several decades, imposed increasing control on the clinical freedom of doctors abiding by the British system. This control has been implemented through several editions of clinical guidelines and also through an activist role for the General Medical Council: the GMC disciplines and erases selected doctors who abide by the approach of the British system to helping drug misusers. These actions by the GMC have been viewed as arbitrary and unpredictable by respected medical experts. Many doctors are afraid to accept drug misusers as patients because they worry about being irrationally persecuted by the GMC.

The planned extension of the licensing system to all controlled drugs would be an illness masquerading as a cure. Stricter controls signal the death knell for a humanitarian and efficacious system of addiction prevention and treatment. The GMC has a duty to keep that tragedy from happening. Yet it almost seems intent on creating it.

Arnold S Trebach, professor emeritus. 
American University, Box 185, 5505 Connecticut Avenue, NW, Washington, DC 20015-2601, USA arnold{at}trebach.com

Competing interests: AST is an adviser to John Patrick Hickey of Cornwall; an expert witness to the court in various legal matters involving Dr Hickey.

Standard of care in Britain was not addressed

EDITORDespite criticising American treatment practices, the editorial by Gabbay et al does not address the standard of care in Britain.¹ The United Kingdom reportedly has the highest death rates from opioids in Europe, at 22 per million,² and a proportion of these are from methadone.³

Other European countries have reported substantial decreases in such fatalities in the 1990s. Most have used both carefully prescribed opioids as well as other public health measures.² It is unwise to prescribe unsupervised supplies of a strong medicine to unstable addicted patients. Doses may be taken early, they may be injected, or they may be used by others because of theft or on-selling. Most published addiction outcome studies have employed supervised dosing. With increasing stability, less frequent attendance is necessary and more flexibility possible. Despite widespread circulation of the British dependency guidelines,⁴ self regulation has apparently failed to encourage British doctors to follow the advice on supervision and dose levels. To avoid cravings, most dependent patients require 60-120 mg methadone daily.⁴ Initial doses, however, should not be higher than 40 mg, with prompt increases after careful assessments in the following days to avoid treatment dropouts. Inadequate dose levels, a lack of supervision, and poor access to treatment can all restrict treatment outcomes.

Such deficiencies in the United Kingdom may have sabotaged a potentially positive public health achievement. This could yet be attained, utilising the twofold British attributes of the profession's freedom to prescribe and universal access to treatment under the NHS. Although clinic induction is ideal for severely dependent patients, it is possible that general practitioners, with adequate support, can implement such treatment successfully, as practised in Scotland for over a decade.⁵ After stabilisation, any sympathetic, knowledgeable general practitioners should be able to manage patients having methadone maintenance treatment by using community pharmacies and established professional support systems. In rejecting government interference for dependency management, these authors confuse evidence based treatment (for example, methadone maintenance) with the practice of continuing to prescribe to known addicts under harm reduction principles (as for benzodiazepines, stimulants, and perhaps cocaine). Some have termed this "the British system," although this ambiguous term should be discarded.

As with heart disease, diabetes, or depression, patients with dependency deserve a careful history and physical examination plus special tests if required. Predictably, favourable outcomes should follow judicious prescribing when necessary, with appropriate safeguards and psychosocial supports. The threat of licensing should encourage British doctors to re-establish themselves as providers of best practice in the field of addiction as they have long done in other fields.

Andrew Byrne, general practitioner. 
Drug and Alcohol, 75 Redfern Street, Redfern, New South Wales 2016, Australia ajbyrne{at}ozemail.com.au

Competing interests: AB makes a proportion of his income from treating addiction and pain management patients.

1.	Gabbay MB, Carnwath T, Ford C, Zador DA. Reducing deaths among drug users. BMJ 2001; 322: 749-750. (31 March.)
2.	European Monitoring Center for Drugs and Drug Addiction (EMCDDA). 2000 annual report. Lisbon: EMCDAA, 2000:17-18.
3.	Newcombe R. A reply to Ward et al. Addiction 1996; 91: 1728.
4.	Strang J, chair. Drug misuse and dependenceguidelines on clinical management. London: Stationery Office, 1999:54.
5.	Greenwood J. Six years' experience of sharing the care of Edinburgh's drug users. Psychiatr Bull 1996; 20: 8-11[Abstract/Free Full Text].

Authors' reply

EDITORMortality and morbidity of problematic drug users reduce substantially when the users are receiving treatment.¹ Methadone treatment on the basis of reduction of harm, in which the use of illicit drugs is tolerated, is strongly related to decreased mortality from both natural causes and overdose.² Any intervention that prevents people who want and require treatment for their drug problem from receiving that treatment is thus likely to be detrimental to their health and fails to address the impact of their addiction on society.

Licensing could act as a barrier to providing readily accessible treatment. We are pleased that Trebach agrees with our view. Byrne has, however, missed this point in our editorial. Byrne focuses his reply on methadone diversion, supervised consumption, and opiate related deaths. These are not the main point of our editorial and would require another article to be discussed fully.

We do not believe that reducing methadone diversion would have a significant impact on opiate related deaths. We believe that supervised consumption has benefits and costs, neither of which has been properly evaluated. Its advantages must be balanced against other important issues such as accessibility of service, retention in treatment, and convenience for the patient.

The United Kingdom has the highest death rate from opioids in Europe because it also has the highest rate of consumption of opioids. Recent figures from the UK's Office for National Statistics show the number of methadone deaths falling for the past three years, with deaths from heroin continuing to rise. The number of cocaine related deaths is continuing to rise steeply, which suggests that deaths are a result of increasing misuse, not irresponsible prescribing.

We do not advocate inadequate dose levels or poor access to treatmentquite the reverse. We hope for a wider range of treatment options, the steady improvement of services through clinical governance, and a wider availability of high quality treatment. Supporting general practitioners through shared care schemes and training, rather than encumbering them with additional bureaucratic mechanisms that do not improve care, will achieve this.

We agree with Trebach that the population using drugs is no more homogeneous than any other group of people with a particular condition, and we treat them as such at our peril. We also agree with Byrne that all patients with a dependency deserve a careful history and examination, and favourable outcomes should follow judicious prescribing when necessary, with appropriate safeguards and psychosocial support. Where we disagree is that licensing will help this process. Prescribing policies for people who undertake problematic drug use should also be supported by available evidence. What little available evidence there is suggests that limiting treatment options and availability through further licensing restrictions will have adverse effects on the quality and availability of evidence based treatments. Furthermore, there is no evidence to support the notion that restricting prescribing in this way will necessarily increase community and patient safety.

Chris Ford, general practitioner. 
London NW6 6RR

Tom Carnwath, consultant psychiatrist. 
Manchester M33 1FD

Mark Gabbay, senior lecturer in general practice. 
University of Liverpool, Liverpool L69 3GB

Competing interests: None declared.