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Drug users should be able to get heroin from the health system

BMJ 2015; 350 doi: (Published 14 April 2015) Cite this as: BMJ 2015;350:h1753

Rapid Response:

Reality check please.

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 . Comments and feedback would be very welcome.

Competing interests: I am the founder of

17 April 2015
Joss Bray
Substance Misuse specialist doctor
Alnwick, Northumberland.