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FEATURE: Tony Sheldon More than a quick fix BMJ 2008; 336: 68-69 [Full text]

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What is addiction?

Hugh Mann   (13 January 2008)

It's time to think consistently

Joss Bray   (13 January 2008)

Heroin prescribing

MariaDolores Tomás-Tello   (14 January 2008)

Re: What is addiction?

Philip Lee   (19 January 2008)

What is addiction? 13 January 2008
Hugh Mann, Physician Eagle Rock, MO 65641 USA Send response to journal: Re: What is addiction?	Addiction is a worldwide mysterious plague that infests every level of society. It baffles and corrupts teachers, doctors, lawyers, police, and politicians. What is addiction, and why is it so powerful and pervasive? Addiction is a rebellion against metabolism, especially hunger. Metabolism requires food to satisfy hunger and create health. But addiction short-circuits metabolism by replacing food with addictive substances, hunger with euphoria, satisfaction with craving, and health with sickness. So addiction is a flight from hunger to euphoria, with a stopover in craving, and a crash landing in sickness. Euphoria is a false heightened sense of well-being. Euphoria enables us to control our mood and avoid feelings of inadequacy and loneliness. But euphoria disables our judgment and blinds us to the craving and sickness of addiction. Ironically, addiction makes us feel more alive with euphoria, while it insidiously kills us with craving and sickness. So addiction is a bad bargain, with imaginary gains and real losses. The most popular addictive substances are sweets, chocolate, cola, coffee, tea, alcohol, tobacco, and drugs. Although some of these substances are considered harmless fun, they all create insatiable cravings that reinforce other addictions. For example, sweets, chocolate, cola, coffee, and tea reinforce alcohol, tobacco, and drug addiction. So addictive substances are seductive saboteurs that masquerade as familiar friends. Addiction is big business. The craving of addiction supports the "food" industry. "Food" companies that sell addictive substances spend millions of dollars to advertise the imaginary gains and hide the real losses connected to their products. The sickness of addiction supports the health-care industry. If alcohol, tobacco, and junk food were eliminated, many hospitals, insurance companies, and doctors would not have enough patients to stay in business. So our economy depends on addiction, euphoria, craving, and sickness. Competing interests: None declared
It's time to think consistently 13 January 2008
Joss Bray, Substance Misuse Specialist Huntercombe Centre. SR2 9DJ Send response to journal: Re: It's time to think consistently	This was a timely article with interesting points of view following in the "head to head" section. I was undecided on "yes" or "no" before I read them - but I have come to the conclusion that for a small number of people, Heroin prescription with supervised use may be the best way of providing the pharmacological side of treatment. We already prescribe Methadone and Buprenorphine because many studies have shown benefits and not harm from long term prescription of these drugs. If the same is shown for Heroin, then why not prescribe it as an option in treatment for opiate addiction? The argument that Cocaine addicts would ask to be prescribed Cocaine (as McKeganey suggests)is countered by the known facts that Cocaine has long term significant side effects and therefore it is illogical to prescribe it - unless it was for purely social prescribing as he puts it - ie to reduce crime. In that case, we are into a whole different scenario which would clearly need a different discussion. This argument also applies to cannabis, high dose benzodiazepines and tobacco - amongst others. I believe therefore that medically, Heroin prescribing is logical, but practical difficulties may be a signifiant limiting factor - ie the costs involved and provision of skilled personell in well run services. However,before we all jump on the Heroin bandwagon, my final observations are firstly that the studies were done compared to Methadone treatment - not Buprenorphine , and the results may have been different had that comparison also been made. And secondly that Heroin prescribing is only reccommended for people who have failed other treatments. I would very much like to be reassured that treatment services we offer now are universally high quality and up to date - but unfortunately I am not. Perhaps we should make sure that we have such services in place for anyone with a substance misuse problem wherever they are before we commit significant resources to such a relatively small group of addicts who may not have been treated optimally in the first place. Competing interests: None declared
Heroin prescribing 14 January 2008
MariaDolores Tomás-Tello, Freelance GP Bradford BD15 7UQ Send response to journal: Re: Heroin prescribing	I' ve read both articles regarding this subject on the last magazine 12.01.08. There is plenty of evidence now that it works, in terms of physical and mental health and social situation of the addicts and don´t forget the important reduction in criminality. Acceptance of the treatment by the patient is an important concept to consider before starting any treatment, why should it be different in the case of heroin addicts? The ideal aim should be to end the habit but there are lots of evidence telling us that, unfortunately this is not the case with addictions (of any type: legal or illegal drugs, food, sex, work, games...). Methadone substitutive treatment is more risky and not cheaper than heroin. Maintenance or abstinence using other drugs on their own or as co- adjuvant treatment is still more expensive than heroin. Considering this specific group could need maximum dose because of their addiction, we only have to check prices in the BNF: Heroin (diamorphine) 120mg a day costs around £1.44 (injectables definitely more expensive) while methadone 120mg a day costs around £2, Buprenorphine at maximum dose per day costs more than £1.60, Lofexidine to treat withdrawal syndrome could cost £10 per day and Naltrexone to prevent relapse could cost around £10 per week. The explanation for not prescribing heroin to addicts could be a misunderstood, I would like to believe, moralising and patronising concept of care. I would be very grateful for feedback from anybody who disagrees with me and would like to correct my data. Dr Tomás-Tello Competing interests: None declared
Re: What is addiction? 19 January 2008
Philip Lee, Editor WACC, Toronto, M4C 4X7 Send response to journal: Re: Re: What is addiction?	Addiction is a frame of mind created and reinforced by societal interests aimed at dominating, controlling, and ultimately profiting from persons who can be induced to suffer from addiction. The entertainment industry makes us addicted to violence and exploitation. The advertising industry makes us addicted to gender stereotyping. The mass media industry make us addicted to the quick fix of short sensational stories with little information and less balance. The military-industrial complex (to use Herbert Schiller's term) makes us addicted to offence as a form of defence. And so it goes. The problem is how to break free of such addictions when government and corporate entities have a vested interest in acquiesence and compliance? No easy task in today's societies North and South. Competing interests: None declared