Drug users should be able to get heroin from the health systemBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1753 (Published 14 April 2015) Cite this as: BMJ 2015;350:h1753
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Although I agree with the sentiment of the article at a society level, I was left pondering the practicalities of such a programme at the individual level. There are a few unanswered questions regarding the delivery of such a programme.
Firstly, the cohort of patients who require this injected therapy are those who have failed other programmes and are currently injecting. These patients are often frequent attenders to hospital and, as a junior doctor, they often provide the heart sink phrase of “You will never get blood out of me Doctor, they normally have to put a line in my neck”. In this programme I wonder how the clinician will deliver the dimorphine intravenously in such tricky customers?
As the patients inject one to two times a day; often into the major vessels- would you insert a central line, PICC line or midline for the course of the treatment? Inserting a cannula each day would be very difficult indeed and having a outpatient with intravenous access may come with its own risks.
Would the doctor simply be a prescriber of the dimorphine allowing a safer cleaner environment for the patient to self administer? After seeing the vascular injuries and abscesses caused by misplaced needles this strategy too seems suboptimal and fraught with danger.
Finally, who would be the provider of this care? They would need access to airway management equipment and opioid reversal agents, along with the skills to deal with addiction. Often GPs and Psychiatrists are experts in addiction and substance misuse, whereas anaesthetics and medics are more equipped to deal with the delivery and prescription of IV opiods.
The cost benefit analysis is very difficult to objectively measure but Professor Schechter demonstrates a convincing argument that a method of reducing the societal costs of heroin use could be cost effective in the longer term. Idealistically, the concept is sound, however, I would worry this would be impossible to deliver in a safe and effective way.
Competing interests: No competing interests
Call me cynical if you like, but there is now a major problem with the Randomised Injectable Opiate Treatment Trial (RIOTT) and similar initiatives - and hence a major problem with offering injectable Heroin as part of treatment services.
The problem is that patients are supposed to have had "optimal" oral substitute therapy first - which of course includes all the psychosocial input that is also part of substance misuse treatment.
Why is this a problem now?
Because, since Local Authorities took over commissioning drug and alcohol services, two major things have happened. The first is that funding has been reduced significantly across the board due to well recognised cuts in local government budgets, and secondly, the commissioning emphasis has shifted onto numbers of "successful completions" above all else - rather than any optimised individual treatment.
This often means now that there is an underlying pressure on service users to reduce and get off substitute medication as quickly as possible and leave a service "successfully completed". This can happen even if there are many more important factors that need addressing first which would indicate that they are recovering from the dreadful situations that addiction encourages.
Unfortunately, the evidence does not support this "get people through the service as quickly as possible" treatment approach as having the best outcomes - and an increasing number of drug related deaths (that were falling) may be partly due to this. Therefore - fewer and fewer people will be receiving any sort of optimised treatment as the system now mitigates against proper evidence based individual care.
Heroin prescribing will have to take a back seat if this situation doesn't change - in fact it may not survive the car crash at all, if the direction of travel in service provision remains as it is.
For more discussion on these issues, and ways forward to address them, may I direct you to www.competentcompassion.org.uk . Comments and feedback would be very welcome.
Competing interests: I am the founder of www.competentcompassion.org.uk
Addiction is a bad bargain with imaginary gains (euphoria) and real losses (sickness). Euphoria is a false, fleeting sense of well-being that makes addicts feel “high” and masks the sustained sickness of addiction. Even worse, the euphoria and sickness of addiction are polar opposites that reinforce each other and trap addicts in a vicious cycle of Jekyll & Hyde mood swings that are unique for each addiction. For example:
1. Sugar creates the euphoria of feeling sweet, but the sickness of being bitter.
2. Chocolate creates the euphoria of feeling love, but the sickness of being love-starved.
3. Vanilla creates the euphoria of feeling happy, but the sickness of being sad.
4. Cola creates the euphoria of feeling hydrated, but the sickness of being dehydrated.
5. Caffeine creates the euphoria of feeling energetic, but the sickness of being lethargic.
6. Alcohol creates the euphoria of feeling relaxed, but the sickness of being uptight.
7. Tobacco creates the euphoria of feeling aerated, but the sickness of being suffocated.
8. Analgesics create the euphoria of feeling pain-free, but the sickness of being pain sensitive.
9. Hallucinogens create the euphoria of feeling wise, but the sickness of being confused.
10. Gambling creates the euphoria of feeling lucky, but the sickness of being unlucky.
Addiction is a deadly paradox. Its euphoria is a false heaven, but its sickness is a real hell. The more you know it, the more it fools you; the more you use it, the more it controls you; and the more you enjoy it, the more it hurts you. Addiction is hell you enjoy.
Competing interests: No competing interests