Intended for healthcare professionals

Rapid response to:

Head To Head

Should heroin be prescribed to heroin misusers? No

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39422.503241.AD (Published 10 January 2008) Cite this as: BMJ 2008;336:71

Rapid Response:

We need to treat patients not communities

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

Competing interests: No competing interests

13 January 2008
Andrew J Ashworth
GP
Davidsons Mains Medical Centre, 5 Quality Street, EDINBURGH, EH4 5BP