Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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No to prescribing heroin to addicts
- Julian C Law (11 January 2008)
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Prescribing heroin for drug addicts -the fantasy must end.
- Jason Luty, Southend on Sea, Essex SS4 1RB (13 January 2008)
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We need to treat patients not communities
- Andrew J Ashworth (13 January 2008)
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Solutions to living without addiction to illicit drugs
- Dreena Kelly (14 January 2008)
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Sun headlines are not always reliable facts
- stephen black (15 January 2008)
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Re: The 'fantasy must end'.
- Peter O'Loughlin (15 January 2008)
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Re: Sun headlines are not always reliable facts
- Peter O'Loughlin (16 January 2008)
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Julian C Law, GP Kyle of Lochalsh IV408DD
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I find it difficult to see why a heroin addicts should be singled out to receive maintenance prescritptions of heroin. My experience as a GP dealing with this group of patients is that they have considerable pyschological, social and physical problems. However feeding them drugs in the long run is less helpful than aiming for abstinence. It is important to treat their dependency not maintain their drug addiction. We do not suggest to alcoholics that they have maintenance doses of alcohol. We offer them detoxification, advice and support and help with trying to maintain abstinent. We should aim to reduce the dependence of all addicts on drugs but this requires comprehensive and well organised services rather than the patchy treatment available nationally. Competing interests: None declared |
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Jason Luty, Consultant in Addictions Psychiatry. South Essex Partnership NHS Trust The Taylor Centre, Essex Street, Southend on Sea, Essex SS4 1RB
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The Editor, British Medical Journal Dear Sir Prescribing heroin for drug addicts -the fantasy must end. I note the debate regarding prescribing heroin 1 I have to admit I have done rather well out of this controversy with three separate editorials to my name2 3 4 5. Personally, I feel the evidence shows that the “medical” benefits of heroin prescribing are negligible although it is likely to reduce acquisitive crime in the small number who receive prescriptions. However the “medical evidence” is entirely irrelevant. The UK Randomised Injecting Opioid Treatment Trial study of diamorphine prescribing costs around £15 000 per addict per year for medication6. (I read about this in The Sun7, Britain’s most popular newspaper, in an article entitled “Junkies get NHS heroin”. This also contains the statement, “The cost of the heroin treatments is up to £15,000 per patient. It comes as the National Institute for Clinical Excellence denies Alzheimer’s sufferers drugs costing £2.50 per day.”) Giving heroin for addicts to inject at the taxpayer’s expense is political suicide. Any British (or American) career politician would dive for cover. This is self evident even to an amateur politician such as myself. (I am a “wobbly Conservative” Councillor for the local Borough Council). Of course, the Prime Minister is not an amateur. He is a vastly experienced, competent, premier league Parliamentarian. If he were to endorse an expansion of NHS heroin prescribing the Opposition would have a field day. (“Does the Prime Minister really support a policy which requires doctors to act as legalised drug dealers?”) The press would crucify Gordon Brown and, lets face it, the British Press hate him anyway. It‘s a lesser point but, following the MTAS fiasco and the reduction in burden of proof in GMC cases, Gordon Brown is about as popular as cancer with the medical profession. Consequently doctors leaders are likely to join the mob baying for his blood. (At least they would if they were not so spineless.) Anyone who imagines that the British Governments would endorse an expansion of heroin (“diamorphine”) prescribing to addicts is living in a political fairyland. Yours sincerely, Councillor Dr Jason Luty MB ChB Bsc PhD MIBiol CBiol MRCPsych Southend Borough Council (Conservative) Consultant in Addictions Psychiatry. South Essex Partnership NHS Trust Honorary Consultant in Addictions Psychiatry, Cambridge & Peterborough Mental Health Partnership NHS Trust 1. Rehm J, Fischer B & McKeganey N (2008) Should heroin be prescribed to heroin misusers? BMJ 2008;336:70-71 2. Luty J (2005) New guidelines for prescribing injectable heroin in opiate addiction Psychiatric Bulletin, Apr 2005; 29: 123 - 125. 3. Luty J (2004) New guidelines for prescribing injectable heroin to addicts. Journal of Substance Use 9, 2-4. 4. Luty J (2003) Prescribing injectable heroin to addicts: unproven, unpopular, unbelievable. Journal of Substance Use 8, 5-6. 5. Luty J (2003) Hospital Doctor. May Pp 16 6. Randomised Injecting Opioid Treatment Trial (RIOTT) http://www.iop.kcl.ac.uk/projects/?id=10114 (Accessed 12/01/2007) 7. The Sun (2007). Junkies get NHS heroin. 20 November http://www.thesun.co.uk/sol/homepage/news/article484023.ece (Accessed 12/01/2007) Competing interests: None declared |
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Andrew J Ashworth, GP Davidsons Mains Medical Centre, 5 Quality Street, EDINBURGH, EH4 5BP
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Prescribing heroin to those who use it other than for analgesia simply redefines “offenders” as “patients”. The term “misuser” implies a lack of social acceptance. Prescription removes the “mis” but, in so- doing, allows the “user” to re-enter the social group and solves crime at a stroke by legitimising previously criminal behaviour. Argument between palliation and cure for patients is sterile when applied generally since the affected population is heterogeneous. Unfortunately services are funded politically and so social objectives secondary to the normal patient centred primary objectives of medical treatment are generally applied. The funding of services tends to follow the politics of a community drug problem based on the effectiveness of lobby groups rather than empirical evidence of effectiveness of any intervention for individuals, be they “offenders” or “patients”. In reality people with drug problems need services that take them through a continuum of Making Safe (eg reducing immediate risk of overdose), Harm Reduction (eg reducing later risk of blood borne virus), Dose Stabilisation, Detoxification and Relapse Prevention. Prescribing of Heroin probaby affects those needing services towards the beginning of the continuum. Current NHS services tend to concentrate on Harm Reduction and Dose Stabilisation, with the private sector offering Detoxification and the criminal Justice sector (often police custody sergeants) providing Making Safe services. Despite its importance as the final part of a potentially curative process, effective relapse prevention, such as the use of Naltrexone with low frequency TENS that I have previously described (1) is of little interest to those in the public sector with a vested interest in acquiring ever growing numbers in their substitute prescribing programmes or those in the private sector who profit from repeating their detoxification interventions. The answer to the question posed about heroin prescribing lies between “perhaps” and “probably” but it is a question that fails to address the real problem: current treatment of individual drug users is palliative for commuities rather than curative for individuals; those specialising in this field need to recognise their own vested interests in maintaining the status quo, not only to allow “offenders who act bad” to become “patients who feel better” but to help them move on to become “people who have got better” . 1. Why let fact interfere with a good theory ? A J Ashworth http://bmj.com/cgi/eletters/335/7618/464-a#176174, 7 Sep 2007 Competing interests: None declared |
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Dreena Kelly, GPwSI Addictions Health and Homeless Team Blantyre G72 OBF
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I have worked in a fulltime position for several years as a medical officer in the Glasgow Drug Problem Service with a case load of 250 patients and now partime as a "GPwSI" looking after approx 60 patients who are homeless and addicted to opiates, spanning the last 7 years of my professional life. I prescibe methadone and suboxone where clinically indicated and prescribe as necessary for other general medical problems and refer on when necessary. Substitute prescibing in my opinion should be used as a way of gaining stability to allow the patient and everyone in their rehabilitation to work out a plan for living without drug dependency. These are some of my ideas: The people I look after need solutions for living: They need homes in decent areas (somewhere we would be happy to
live)
In my experience people can leave drug dependency , this includes dependency on prescribed methadone or suboxone only when living a life without drugs is better than life with drugs and this happens unfortunately on a vary rare occasion. Competing interests: None declared |
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stephen black, management consultant london sw1w 9sr
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I was awfully suspicious of the numbers quoted by Jason Luty ("The cost of the heroin treatments is up to £15,000 per patient"). So I checked his references and some others. As far as I can tell the £15,000 number is the total cost of setting up and running the trial divided by the number of addicts enrolled. This is not exactly a reliable basis for evaluating the ongoing cost of treatment. Just because the Sun is popular doesn't make it right, nor does it mean rational decision makers can't do the right thing even if it is unpopular. Competing interests: None declared |
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Peter O'Loughlin, Principal Beckenham BR3 3AT
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Jason Luty is, or should be aware, that we are already prescribing heroin for heroin addicts in at least three different cities in the UK. Further those people at the Home Office, whose knowledge of addiction and the mental processes of addicts are considerably less than Jason Luty's, are well advanced in their proposals to extend prescribing of heroin to nurses and pharmacists; proposals that this writer understands has been approved by the Royal College of Practitioners. It is of course legalisation in all but name. Similar proposals are also contained in the NICE guidelines. Competing interests: Alcohol and Drug Recovery |
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Peter O'Loughlin, Principal Beckenham BR3 3AT
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Stephen Black is correct, Sun headlines are not always reliable and in this instance they appear to be grossly inadequate. Professor Strang who is heading up the current heroin trials in the UK is quoted in The Independent (20.11.07) as putting the cost of the project for the 150 volunteers in the current experiments, as £2.5 million. Therefore if Mr. Black is prepared to take his own method of calculation, and assuming that Professor Strang has been quoted accurately, he would be free to acknowledge the cost would be considerably more than that indicated by Jason Luty. Competing interests: Drug and alcohol recovery |
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