Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Methadone works if used according to evidence.
- Andrew Byrne (19 August 2007)
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Harm reduction
- Judith A Yates (20 August 2007)
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Contingency Management in British General Practice
- Sally L Read (20 August 2007)
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Re: Drug misusers are likely to abuse the system
- David Marjot (21 August 2007)
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Andrew Byrne, Private addictions physician 75 Redfern St, Redfern, New South Wales, 2016 Australia
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Dear Editor, BMJ readers are entitled to ask why a senior British forensic physician would observe that methadone treatment does not work, contrary to 40 years of high quality research showing that it does (rapid response http://www.bmj.com/cgi/eletters/335/7613/233]. The reason can be found in the lack of adherence to evidence based clinical guidelines in much of the UK [ref 1]. With some notable exceptions, UK addicts are routinely given dose schedules which are contrary to guidelines (eg. mean doses of less than 40mg daily in place of double that found in well run clinics). These advise strict dose supervision for new and unstable patients with an effective dose range from 60 to 120mg daily after careful induction starting with no more than 40mg daily [ref 2]. Hong Kong, Australia and New Zealand may be the only places where methadone has been available for over 30 years under reasonably open- access and with a largely evidence-based approach. Uniquely, all three have very little HIV amongst their large injecting populations. Few would believe these are coincidental (although hepatitis C has been a different and as yet unanswered story). The issue of whether addicts should receive incentives in treatment should be decided by practical research, not moralist opinions [ref 3]. Methadone treatment is already among the most cost-effective things we do in medicine and probably compares with washing hands. It would seem logical to raise the abysmal standards of practice in the UK and then examine incentives to improve results still further if needed. Yours sincerely, Andrew Byrne .. Sydney addictions physician. References: 1. The prescribing of methadone and other opioids to addicts: national survey of GPs in England and Wales. Strang J, Sheridan J, Hunt C, Kerr B, Gerada C, Pringle M. Brit J General Practice (2005) 55 (June 2005); 515: 444-451 2. Drug Misuse and Dependence - Guidelines on Clinical Management. (1999) HMSO Department of Health. Working Group Chair: Strang J. 3. Is it acceptable for people to be paid to adhere to medication? 'Feature'. BMJ 2007 335:232-3 Competing interests: Dr Byrne charges a fee for administration of drugs in the treatment of addiction. |
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Judith A Yates, GP with Special Interest in Substance Use The Wand Medical Centre , 15 Frank St, Highgate, Birmingham, B12 0UF
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I am surprised by Dr Stevenson's suggestion that to "reduce harm" has no value. I was interested to read the new NICE guidance "Drug Misuse; Psychosocial interventions" with its clear recommendation that all treatment services should develop contingency management programmes: " The emphasis on reinforcing positive behaviours is consistent with current knowledge about the underlying neuropsychology of many people who misuse drugs and is more likely to be effective than penalising negative behaviours. There is good evidence that contingency management increases the likelihood of positive behaviours and is cost effective." (NICE Clinical Guideline: 51) When "harm reduction" includes clear benefits for the health of the individual, his or her family and the wider community, including the taxpayers, I cannot understand Dr Stevenson's objection to this evidence based treatment option. It is clear from my experience as a GP that where points mean prizes, (QOF points) we GPs are willing to jump through all kinds of strange hoops, even where we cannot personally see the benefit to anyone, and I imagine my patients may well have the same tendency to jump higher to get more carrots or whatever else may be on offer as tokens of approval and achievement. After 27 years as an inner city GP, I am aware that there are no magic pills in this field, but I think contingency management has been shown to be worthy of a place within our evidence based treatment service, and I am willing to see if my patients want to give it a go. Competing interests: None declared |
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Sally L Read, GP NFA Health Centre for Homeless People, Leeds LS9 8AA
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The debate on CM is complex and multi-faceted. I am very grateful to Tom Burns and Joanne Shaw for their clear arguments. My concerns with CM are ethical (I hope this is not the same as the "moralist opinions" objected to by Andrew Byrne) and practical. As a GP, working in a practice for homeless people, not all of my patients are drug users. Many are addicted to alcohol. All are subject to severe social exclusion and poverty.Many have a long history of abusive relationships leading to presentations fitting a diagnosis of "personality disorder". A growing number are failed asylum seekers, who are destitute with no access to any resources whatsoever. I cannot envisage how our mixed surgeries will operate if our primary care drugs service were to be engaged in contingency management, however "small" the reward. If I see an asylum seeker who is diabetic, who has reached the end-stage of his process and had all right to appeal refused, with absolutely no resources to feed himself, how can I justify giving my NEXT patient, the drug user who has produced a "clean urine" even £1? This is not ethical, and not practical. The giving of rewards is, in itself, not unethical, and I have read the American evidence that it works. But why have we singled out the users of illicit drugs to receive these rewards? Yes, injecting drug users are subject to huge harms and methadone given in therapeutic doses has reaped huge benefits in reducing those harms. However,harmful alcohol use places an even greater burden of illhealth and crime on our society. Funding for alcohol treatment services is inadequate, to say the least. My GP colleagues in the mainstream are seeing daily the cost of smoking, diabetes, obesity etc. Why not reward these patients too? Is it not unethical to suggest to drug users that their particular addiction is "worse" than anyone elses - so bad in fact, that we will pay them money we could otherwise use to help those with other addictions address their needs? Finally, I'm just not sure about Tom Burns "model of respectful and equal exchange". I can see that it COULD be like that - when things are going well. But for a desperate person, with no roof over his head, maybe moving from town to town with a resultant gap in state benefits, wouldn't it be tempting for him to try to play the system a bit? I am NOT a doctor who mistrusts drug users - but I do see the degrading effects that extreme poverty has on our patients. Our aim is to try to build "adult-adult" relationships with people who may rarely, if ever, experienced relationships of trust and respect. I am fearful that CM will lead, for some patients, to a return to "adult-child" manipulation and mistrust. Competing interests: None declared |
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David Marjot, Consultant Psychiatrist Weybridge, Surrey
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Dr. Stevenson's experiences may reflect problems in local substitute prescribing practices rather than in the opiate users themselves. The Healthcare Commission found that most methadone maintenance schemes prescribed lower doses than those needed by their patients (1). It is perhaps not surprising that he finds that opiate users 'top up' with heroin. Also it has been found that some opiate users do better on combined methadone and heroin (2). Opiate users take alcohol for the same reasons as the rest of us. However opiate users can take alcohol to relieve the symptoms of withdrawal that must occur if the dose of methadone is too low. The dysphoria that can accompany opiate use may be relieved by alcohol. Therefore the matter is not simply the hedonistic use of alcohol by those dependent on opiates. 1. Healthcare Commission. 2006. Improving services for substance misusers: A joint review. www.healthcarecommission.org.uk/_db/_documents/improving_services_for_substance_misuse.pdf 2. Wim van den Brink et al. Medical prescription of heroin to treatment resistant heroin addicts:two randomised controlled trials. BMJ.2003:327:310 Yours sincerely, David Marjot. MB BS, FRCPsych, DPM. Consultant Psychiatrist. Competing interests: None declared |
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