Views & Reviews From the Frontline

Methadone is no panacea

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e5670 (Published 22 August 2012) Cite this as: BMJ 2012;345:e5670
  1. Des Spence, general practitioner, Glasgow
  1. destwo{at}yahoo.co.uk

When I was young, I drank to get wrecked. In the hospitals in the 1980s and 1990s, I witnessed the complications of heroin addiction: amputations, gangrene, endocarditis, sepsis, hepatitis, and HIV. A stream of ambulances spilt half dead overdosers onto accident and emergency trolleys. There was no drug for opioid substitution—for example, methadone—so addicts had to “take the rattle.” Many patients took irregular discharge while acutely unwell. But they were just junkies, and the sheer scale of the problems blunted me to the suffering and the deaths. It was the same when working as a general practitioner in the health centres. Chaos, overdoses in the toilets, theft of prescription pads, relentless drug seeking consultations, and our prescriptions sold on the steps of local pharmacies. This was nothing compared with the bedlam in the wider community, which saw families torn apart, dead children, children in care, stealing within families, prostitution, shoplifting, and knives. The slashed bleeding wound of addiction was a social calamity. In time, I recognised the young poor addicts and their families were little different from me. Something had to done.

So needle exchanges opened, and GPs started prescribing methadone. The rationale, from the evolving evidence base, was simple. Methadone was about harm reduction: reducing use of street drugs, and hence crime and bacterial and viral infections, and stabilising people’s lives. Whether it got addicts off drugs wasn’t the point. It was the hardest of work but I believed it was right. We tried to control the prescription through daily supervised dispensing, stopped coprescribing benzodiazepines, rarely changed doses, and settled on a dose of 60-100 mL. We established a clinic with local drug workers and had contact with drug users every two weeks. Patients still died at the hands of my prescriptions, a circle I pain to square.

Now, I have many patients who have been taking methadone for almost two decades. Few have come off substitution therapy. Did methadone work? My experience is that careful opioid substitution is a huge advance compared with chaotic drug use. But polydrug misuse on top of methadone is the norm, and many patients now misuse alcohol (which is cheap, accessible, and legal), benzodiazepines, cannabis, and crack. These patients are still imprisoned by addiction, and drug deaths in Glasgow are the highest ever, with many linked to methadone.1 As for the benefits of long term methadone, I am far less certain. The comedian Russell Brand—himself a reformed heroin addict—has suggested an alternative: more abstinence programmes. These traditionally meet with much cynicism within the medical addiction fellowship. But my experience is that the 12 step programme to abstinence led by Narcotics Anonymous offers salvation, as do some faith based abstinence interventions. Something has to be done.

Notes

Cite this as: BMJ 2012;345:e5670

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