Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Treat the addict not the addiction.
- Peter O'Loughlin (11 January 2008)
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No Heroin - Prejudice Based Medicine?
- Roger Weeks (15 January 2008)
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Hello Heroin
- RISHIKA SINHA (15 January 2008)
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Heroin prescribing has a role for patient sub groups
- Dr Francis O Labinjo (16 January 2008)
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What about possible deaths/complications from anaphylactoid reactions?
- Fabio De Giorgio, Achille M. Luongo and Giuseppe Vetrugno (18 January 2008)
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Peter O'Loughlin, Principal. Beckenham BR3 3AT
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The authors in calling for what amounts to the legalising of heroin have selectedevidence to support their view. they did not however include the Cochrane review (1) which concluded from Randomised Control Trials (RCTs) that no definitive conlusions about the overall effectiveness of heroin trials is possible. The authors also appear to be unaware that heroin addicts continously use other psycho active drugs, and therefore simply by prescribing heroin all one is doing is treating that addiction rather than the addict who is also likely to be experiencing severe emotional and mental problems. In precribing heroin to heroin addicts one is instrumental in increasing the severity of the addiction. Would the authors recommend smoking for those with emphysema? or alcohol of those with alchohol related liver disease? References: 1 Ferri M, Davoli M, Perucci CA. Heroin maintenance for chronic heroin dependents. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003410. DOI: 10.1002/14651858.CD003410.pub2 Competing interests: Drug and alcohol recovery. |
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Roger Weeks, GP 2 Deanhill Road London SW14 7DF
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Treating heroin addition is about changing the addict’s behaviour. This is not a moral issue. We are not trying to save their souls or turn them away from depravity. No! The point of treating our vulnerable heroin addicts is five fold: 1. To help them come off filthy brown street heroin. 2. Reduce harm to: a) the addict; b) the addict’s family, especially children and co-habitees c) Society (e.g. crime reduction). 3. Treat the patient’s physical health problems. 4. Treat the patient’s mental/psychological health problems. 5. Provide social care including support, occupation and safe housing. These laudable aims are professed by the National Treatment Agency for substance abuse and shared by all of us who work at treating drug addiction in the UK. If just one addict can be helped to achieve these aims by prescribing heroin and the clinician in charge believes that other substances like Methadone, buprenorphine and the like are really not suitable then I believe he/she must have the option to prescribe clean pure white heroin. The question I would like you to have asked is why is government so keen to micro-manage drug addiction treatment to the extent that they proscribe prescription of certain substances? This is in spite of evidence highlighted by your articles which seems to show benefits from heroin prescribing in a few cases. Is this another example of government trying to stop prescribers from acting on evidence i.e. Evidence based Medicine (EBM) and moving us to government controlled prescribing or as I like to call it - Prejudice Based Medicine (PBM)? Competing interests: I run a heroin addiction service from my GP surgery |
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RISHIKA SINHA, GP Principal KINGSWAY MEDICAL CENTRE, KINGSWAY,BILLINGHAM,TS23 2LS
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I strongly feel as a GP that heroin should be prescribed and I whole heartedly welcome this proposal.Heroin misusers are patients with various health needs and who very rarely come for help to health professionals and are very difficult to reach.This will be an opportunity to develop a good relationship with these patients and deal with difficulties that they are facing.They need to be aware of health risks due to drug misuse.They have already had a difficult life that they have gone through ,and may be making them aware of provisions of help will make life easier.Life is meant to be lived and not to get lost in the world of HEROIN. Competing interests: None declared |
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Dr Francis O Labinjo, Consultant Addiction Psychiatrist Cygnet Hospital Godden Green TN15 0JR
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In my experience of treating this group of patients with treatment- resistant opiate dependence, things are never polarised in very much the way the debate appears to be leading the discussion, those for it, those against it. There is an established role for heroin maintenance treatment, and lack of robust data is more an issue of a need to develop research methodologies that mirror the attributes of this client group, rather than those that will withstand rigorous statistical analyses. Whatever the configuration of the service that provides heroin maintenance, there should be local mechanisms for supervised self administration of diamorphine and this would be for up to 3 injections daily. There are currently no guidelines on take-home heroin. Treatment resistant opiate dependence should continue to be the key eligibility criterion for prescribing injectable diamorphine. Some of the patients by the time of consultation no longer have good venous access; the veins may be too damaged. It should be noted that this service is not cheap. However, patients are able to function as responsible members of society and tend not to be involved in drug related crime. It is therefore a question of treatment philosophy and not based on the unaffordable luxury of ethical/ideolongical conviction. Competing interests: None declared |
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Fabio De Giorgio, forensic pathologist Institute of Legal Medicine U.C.S.C. Rome 00168 (Italy), Achille M. Luongo and Giuseppe Vetrugno
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Drug abuse is a widespread problem in many countries and sometimes the solutions that are proposed - which are often conflicting - reflect widely diverging ideological positions. However, in order to allow a more precise analysis of the cost/benefit ratio, leaving aside socio-political considerations for a moment and assuming the scientific validity of the therapeutic value of heroin prescription to dependent users, we would have expected, authors (1) to give due consideration not only to the well-known side effects associated with heroin use but also and especially to the fact - actually well documented in forensic toxicology literature - that the lethal dose has not been determined (2). In fact, there is no consensus but a long-standing question on what are the levels of morphine associated with overdose (3): there are too many fluctuations of the values found in cadaver blood which are attributed at times to individual factors, such as a reduced tolerance, and, at other times, to exogenous factors, mostly related to the contamination of the substance that had been used in the preparations that are sold in the black market (sugar, talc, flour, etc.). Some authors have suggested that heroin deaths, in the presence of blood levels that are not particularly high, could be attributed to anaphylactoid reactions (4, 5). As a matter of fact, the possibility of opiates inducing human cutaneous mast cell degranulation in nonspecific way has been very well described in the literature (6, 7). Therefore, however we may agree with the social objective of preventing the distribution of heroin in the illegal market through the controlled sale of heroin to known users, before considering abandoning methadone treatment, we should acknowledge the need for a more in depth discussion on the side effects of morphine and in particular on those secondary to anaphylactoid reactions, which are responsible for deaths that otherwise would appear unexpected if correlated with the blood- morphine levels found in cadavers (8). References 1. Rehm J, Fischer Benedikt. Should heroin be prescribed to heroin misusers? Yes. BMJ, 2008; 336:70; 2.Garriot JC, Sturner WQ. Morphine concentrations and survival period in acute heroin fatalities. N Engl J Med, 1973; 289: 1276-8; 3.Staub C, Jeanmonod R, Fryc O. Morphine in post-mortem blood: its importance for the diagnosis of death associated with oppiate addiction. Int J Legal Medicine, 1990: 39-42; 4. Edston E, Van Hage-Hamsten M. Anaphylactoid shock - A common cause of death in heroin addicts? Allergy, 1997: 950-954; 5. Ordoqui E, Zubeldia JM, Aranzabal A et al. Serum tryptase levels in adverse drug reactions. Allergy, 1997: 1102-1105; 6. Barke KE, Hough B. Opiates, mast cells and istamine release. Life Sci, 1993: 1391-1399; 7. Casale TB, Bowman S, Kalimer M. Induction of human cutaneous mast cell degranulation by opiates and endogenous opioid peptides: evidence for opiate and non opiate receptor partecipation. J Allergy Clin Immunol, 1984: 775-781; 8. De Giorgio F, Vetrugno G, Arena V et al. Tryptase: a possible marker for fatal anaphylactoid shock among heroin users. Italian Journal on Drug Addiction and Alcoholism, 2003: 7-12. Competing interests: None declared |
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