Should heroin be prescribed to heroin misusers? No

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

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)

They need work and training into a job they want to do and one which
offers a living wage.

They need support to make better choices , they have to learn the skills
we take for granted ie "actions we take have repurcussions"

We have to instil hope, where often there is despair and regret.

We have to help them rebuild lives which have been torn apart with child
abuse , domestic violence, loss of their children to adoption. I could go
on..

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

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