More than a quick fix
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39434.460694.AD (Published 10 January 2008) Cite this as: BMJ 2008;336:68
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I' ve read both articles regarding this subject on the last magazine
12.01.08. There is plenty of evidence now that it works, in terms of
physical and mental health and social situation of the addicts and don´t
forget the important reduction in criminality. Acceptance of the treatment
by the patient is an important concept to consider before starting any
treatment, why should it be different in the case of heroin addicts? The
ideal aim should be to end the habit but there are lots of evidence
telling us that, unfortunately this is not the case with addictions (of
any type: legal or illegal drugs, food, sex, work, games...). Methadone
substitutive treatment is more risky and not cheaper than heroin.
Maintenance or abstinence using other drugs on their own or as co-
adjuvant treatment is still more expensive than heroin. Considering this
specific group could need maximum dose because of their addiction, we
only have to check prices in the BNF: Heroin (diamorphine) 120mg a day
costs around £1.44 (injectables definitely more expensive) while methadone
120mg a day costs around £2, Buprenorphine at maximum dose per day costs
more than £1.60, Lofexidine to treat withdrawal syndrome could cost £10
per day and Naltrexone to prevent relapse could cost around £10 per week.
The explanation for not prescribing heroin to addicts could be a
misunderstood, I would like to believe, moralising and patronising concept
of care. I would be very grateful for feedback from anybody who disagrees
with me and would like to correct my data.
Dr Tomás-Tello
Competing interests:
None declared
Competing interests: No competing interests
This was a timely article with interesting points of view following
in the "head to head" section.
I was undecided on "yes" or "no" before I read them - but I have come to
the conclusion that for a small number of people, Heroin prescription with
supervised use may be the best way of providing the pharmacological side
of treatment.
We already prescribe Methadone and Buprenorphine because many studies have
shown benefits and not harm from long term prescription of these drugs. If
the same is shown for Heroin, then why not prescribe it as an option in
treatment for opiate addiction? The argument that Cocaine addicts would
ask to be prescribed Cocaine (as McKeganey suggests)is countered by the
known facts that Cocaine has long term significant side effects and
therefore it is illogical to prescribe it - unless it was for purely
social prescribing as he puts it - ie to reduce crime. In that case, we
are into a whole different scenario which would clearly need a different
discussion. This argument also applies to cannabis, high dose
benzodiazepines and tobacco - amongst others.
I believe therefore that medically, Heroin prescribing is logical, but
practical difficulties may be a signifiant limiting factor - ie the costs
involved and provision of skilled personell in well run services.
However,before we all jump on the Heroin bandwagon, my final observations
are firstly that the studies were done compared to Methadone treatment -
not Buprenorphine , and the results may have been different had that
comparison also been made. And secondly that Heroin prescribing is only
reccommended for people who have failed other treatments.
I would very much like to be reassured that treatment services we offer
now are universally high quality and up to date - but unfortunately I am
not.
Perhaps we should make sure that we have such services in place for anyone
with a substance misuse problem wherever they are before we commit
significant resources to such a relatively small group of addicts who may
not have been treated optimally in the first place.
Competing interests:
None declared
Competing interests: No competing interests
Addiction is a worldwide mysterious plague that infests every level of
society. It baffles and corrupts teachers, doctors, lawyers, police, and
politicians. What is addiction, and why is it so powerful and pervasive?
Addiction is a rebellion against metabolism, especially hunger. Metabolism
requires food to satisfy hunger and create health. But addiction short-circuits
metabolism by replacing food with addictive substances, hunger with
euphoria, satisfaction with craving, and health with sickness. So addiction is a
flight from hunger to euphoria, with a stopover in craving, and a crash
landing in sickness.
Euphoria is a false heightened sense of well-being. Euphoria enables us to
control our mood and avoid feelings of inadequacy and loneliness. But
euphoria disables our judgment and blinds us to the craving and sickness of
addiction. Ironically, addiction makes us feel more alive with euphoria, while
it insidiously kills us with craving and sickness. So addiction is a bad bargain,
with imaginary gains and real losses.
The most popular addictive substances are sweets, chocolate, cola, coffee,
tea, alcohol, tobacco, and drugs. Although some of these substances are
considered harmless fun, they all create insatiable cravings that reinforce
other addictions. For example, sweets, chocolate, cola, coffee, and tea
reinforce alcohol, tobacco, and drug addiction. So addictive substances are
seductive saboteurs that masquerade as familiar friends.
Addiction is big business. The craving of addiction supports the "food"
industry. "Food" companies that sell addictive substances spend millions of
dollars to advertise the imaginary gains and hide the real losses connected to
their products. The sickness of addiction supports the health-care industry.
If alcohol, tobacco, and junk food were eliminated, many hospitals, insurance
companies, and doctors would not have enough patients to stay in business.
So our economy depends on addiction, euphoria, craving, and sickness.
Competing interests:
None declared
Competing interests: No competing interests
Re: What is addiction?
Addiction is a frame of mind created and reinforced by societal
interests aimed at dominating, controlling, and ultimately profiting from
persons who can be induced to suffer from addiction. The entertainment
industry makes us addicted to violence and exploitation. The advertising
industry makes us addicted to gender stereotyping. The mass media industry
make us addicted to the quick fix of short sensational stories with little
information and less balance. The military-industrial complex (to use
Herbert Schiller's term) makes us addicted to offence as a form of
defence. And so it goes. The problem is how to break free of such
addictions when government and corporate entities have a vested interest
in acquiesence and compliance? No easy task in today's societies North and
South.
Competing interests:
None declared
Competing interests: No competing interests