Drug misusers are likely to abuse the system
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39303.688611.3A (Published 16 August 2007) Cite this as: BMJ 2007;335:317All rapid responses
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
Re: Drug misusers are likely to abuse the system
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_su...
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
Competing interests: No competing interests