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LETTERS: Roger Weeks Prejudice based medicine? BMJ 2008; 336: 173-a [Full text]

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Treatment or Social Engineering

Peter O'Loughlin   (27 January 2008)

Heroin prescription to misusers

Geoffrey Venning   (29 January 2008)

Treatment or Social Engineering 27 January 2008
Peter O'Loughlin, Principal. Beckenham BR3 3AT Send response to journal: Re: Treatment or Social Engineering	The writer would like to thank Dr. Roger Weeks for his succinct contribution to this debate.Whether one can change the behaviour of addicts, whilst increasing the severity of their addiction with continued administration of their drug(s) of choice or, addictive psycho active substitutes, is at best subjective.(1) Dr. Weeks appears to have omitted what the National Treatment Agency (NTA) described as ‘key issues’ of their treatment strategy, which includes 'Harm Minimisation' defined as 'a public health approach to dealing with drug related issues that aim to reduce drug related harm, while also promoting abstinence'. Key Elements of the strategy include Social Reintegration and employment. (2) The Harm Minimisation strategy is predominantly based on substitute drug treatment. Numbers in Substitution treatment in UK in 2005 totalled 135,000, of which 109,000 are in Methadone treatment, a highly addictive drug in itself. No figures are available for the numbers in Abstinence Focused Treatment.(AFT) (3) The treating the physical and mental comorbidity of patients, which Dr Weeks points out are ‘laudable aims’ appears to have been neglected inasmuch as Hepatitis C among Injecting Drugs Users, (IDUs) increased from 4,476 in 1998 to 55,000 in 2005. (4) HIV Cases have increased from 122 in 2001 to 4392 in 2005(5) An email request by this writer to the NTA asking if they could provide any information on the numbers in treatment with mental health problems, together with the size and scope of facilities available to address their needs, received the single word response of ‘No’ neither is any such information on the following websites: The Mental Health Foundation, National Statistics Agency, or the DoH which is responsible for the NTA. Insofar as ‘Social Reintegration' and employment is concerned, no information on the numbers in treatment who have been ‘successfully discharged’ who have achieved this is available from The National Monitoring Drug Treatment Service, the ‘Back2Work’ initiative, or the NTA; a request to the latter for such information received the response that the NTA records the numbers ‘in treatment’, a further request awaits response. Notwithstanding the NTA website claim to promote abstinence, there are no reliable or independent statistics as to how many of those ‘in treatment’ emerge abstinent,for how long they stay abstinent,or the numbers ‘in treatment’ who were discharged abstinent and are back in treatment.Nor are there any statistics of the numbers who are in abstinence focused recovery treatment. The writer assumed that the object of treatment is recovery, or where that is not possible, alleviation of the condition. In view of the fact that the severity of addiction increases with continued use of the drug(s) of choice, it is difficult to understand how prescribing heroin to addicts can be justified as treatment, however he acknowledges that notwithstanding the independent Cochrane review of this protocol,6) there is some evidence that what are termed as ‘treatment resistant’ patients have benefited. However since the term ‘treatment resistant appears to lack universal criteria or definition, who makes that judgement, and on what basis? and in doing so condemns the patient to ongoing addiction? The severity of which increases to the point where the patient has irretrievably lost the ability to make a choice between addiction or recovery. (7) Addiction in common with other intractable conditions, does respond to effective treatment, however the nature of treatment has to be tailored to the individual, together with parrallel interventions for mental or physical comorbidity. In the absence of accurate and detailed diagnosis and appropiate interventions of that combination, relapse to any of the conditions diagnosed is more likely than not. This writer believes that the administration of heroin to addicts, who have not been independently assessed by at least two psychiatrists who have specialised knowledge of addiction, as either'untreatable', or 'treatment resistant' is more accurately described as social engineering rather than treatment. References: 1. Ferri M, Davoli M, Perucci CA. Heroin maintenance for chronic heroin dependents: Cochrane Database of Systematic Reviews 2003,Issue 3.Art .No.CD00341014651858.: 2. http://drugs.homeoffice.gov.uk/treatment/strategy. 12.12.07 3. European Monitoring Centre for Drugs and Drug Addiction: Annual Report 2007: 4. Link - Health Protection Agency 14.12.07 5. EuroHIV. /AIDS Surveillance in Europe. Mid-year report 2006 Saint- Maurice; French Institute for Public Health Surveillance, 2007. No.74. 6. As in 1. 7. Moran M. Citing Volkow, N. “The Neurobiology of Free Will”; Psychiatric News July 6, 2007 Volume 42, Number 13, page 16© 2007: American Psychiatric Association Competing interests: Drug and alcohol recovery.
Heroin prescription to misusers 29 January 2008
Geoffrey Venning, Consultant in Pharmaceutical Medicine (semi-retired) High Wycombe HP13 6QG Send response to journal: Re: Heroin prescription to misusers	The three correspondents reviewing this problem have not addressed a major issue. Where heroin has been available on prescription, in Switzerland and Holland, there has been a significant reduction in crime. This has also been noted in connection with trials in the U.K. Misusers of illegal heroin resort to crime to obtain money for their heroin. This is clearly reduced by legalising prescription and at the same time there is a reduction in the criminal activities of illegal suppliers. Weeks(1) and O’Loughlin(2) make no mention of this and Ashworth(3) merely comments that prescription “legitimises criminal behaviour”, which misses the point. When taken together with the benefits to misusers there is a compelling case for government action. Permitting and encouraging prescription is required. I know of no valid objections to this policy. This is, of course, not the same as “legalising heroin”, and detailed strategies need to be developed involving general practitioners in collaboration with specialist centres. (1) Weeks, R. Prejudice based medicine? BMJ 2008, 336; 173 (2) O’Loughlin, P. Treat addicts, not the addiction. BMJ 2008, 336; 173 (3) Ashworth, A.J. Treat patients, not communities. BMJ 2008, 336; 173 Competing interests: None declared