‘Spectacular results’ or spectacular spin behind Jack Straw’s call for heroin prescribing?
by Kathy Gyngell on Friday, 25 September 2009 12:44
"I ask myself this question: if there had been legal shooting galleries with free heroin in the UK years ago would I have ever got clean and sober. The answer to that is a categorical no." Steve Spiegel, CEO, The Providence Project, 16th September 09
'Clamour grows for heroin on the NHS' shouted the Independent last week. This was news to me, as I imagine it was to the rest of that morning's readers. A group of nameless government appointed drug experts were, I read, calling for a nationwide network of prescribing centres. A pioneering heroin prescribing programme trial had shown "major benefits in cutting crime and reducing street sales of drugs" it was claimed.[1] The article, an exclusive from health editor, Jeremy Lawrence, quoted the trial's 'study leader' Professor Strang, as saying: 'the findings have sent a ripple of excitement through the addiction treatment community, which is unused to seeing progress with hard core addicts.' By Sunday the ripple had reached Jack Straw, reported in the Sunday Times as calling for heroin prescribing on the NHS
The ripple that reached me however was of disbelief and frustration. Steve Spiegel, a former 'hard core' addict now long term director of the Providence Project - the hugely successful abstinence based, low cost rehabilitation centre for those the system has failed, emailed me: "Next they'll be prescribing alcohol to alcoholics and crack to crack addicts! Who are these so-called experts? I'm not sure where they get their facts from regarding heroin users being the hardest to treat. This is certainly not our experience." For Theodore Dalrymple this was "the latest expensive scheme to avoid admission of the obvious, that we have been barking up the wrong tree for years."
Sadly the main body of the media had not shared his scepticism. On Tuesday morning, embargo raised, this 'success' story led the news. On BBC Online, Home Affairs Correspondent Danny Shaw wrote ingenuously, 'Heroin Supply Clinic Cuts Crime'. Radio 4's Today programme ran his sympathetic news features through the morning and gave a platform to Professor Strang to assert: "The reductions in heroin use were spectacular, and those are validated". Would people get this detail later in the day, he was asked. "Yes" came the reply, "later in the day and later, in proper scientific publications."
Hmm. My suspicion that this was a case of the media cart before the academic horse was confirmed: "The next stage is for us to make our results publicly available and it's a great privilege to be doing it on the programme today," the Prof added.
More a case of spin and announce than of publish and be damned and never mind the principle of independent peer group review and only then to be followed by publication. And so it proved.
Kings College Institute of Psychiatry, the umbrella institution for the trials, had also lost its academic inhibitions - its website displayed the banner: 'RIOTT a success for chronic heroin addicts' but gave no link to a publication or a report, only to details of the aim and method of the project. 'Headline results' it said, had been presented that day to a conference organised by the charity, Action on Addiction. To their website I duly proceeded, to find ..... no report, not even any headline results.
Yet Kings College does not have to be told that it is a long established tradition in scientific research to release research findings to the media only after the process of anonymous and independent peer review. A principle of fundamental importance, not least because hot house reporting of dramatic research findings in the media is not the forum to objectively consider the accuracy of the results or indeed the robustness of the methodology. In fact it is a principle that provides just the corrective for any temptation researchers have to use the media to influence professional and political opinion, confident that they are right but unwilling to subject their research to independent assessment. Professor Strang knows this as does any researcher worth their salt.
Yet in this instance he has clearly chosen to sacrifice it in favour of securing widespread media coverage. He has indicated that he will seek independent peer review and publication of the results of the heroin prescribing trial later. But he can save himself the postage of sending his research papers to the British Medical Journal or the Lancet - both of these internationally recognized medical journals exhort researchers not to release findings for public discussion before they have been assessed independently and published within the journals concerned. As a member of the editorial staff of another academic journal, Addiction, Professor Strang has shown a remarkable disregard for this principle of due process. Judging by the media response to whatever 'results' press release or briefings he selectively gave, he has indeed achieved the aim he may have set himself - of influencing public, professional, and political opinion in the direction of supporting heroin prescribing.
For this reason alone his research findings should be regarded not with uncritical enthusiasm but with considerable caution. It is notable too that the last substantive Cochrane Review of four such randomised trials to test the efficacy of heroin maintenance versus methadone or other substitution treatments published in 2005 for patient treatment retention, reducing illicit use and for improved health and social functioning concluded: 'No definitive conclusions about the overall effectiveness of heroin is possible'.
Until that due process is completed we have to accept as an act of faith that Professor Strang's small sample will tell us something quite different. We may have to wait. In response to my request for a publication, report or research evidence to the Institute of Psychiatry I received this from Nicola Metrebian, PhD, a Senior Research Fellow, RIOTT trial coordinator at the National Addiction Centre, Institute of Psychiatry, Kings College London: "Thank you for your interest in RIOTT. The findings have not been published and are not yet in the public domain".
Her reply begs the question of when is research in the public domain. Not evidently for the Institute of Psychiatry when it appears on their website, as front page newspaper headlines and is flagged up on the BBC with the full cooperation and appearance of the research 'study leader'.
Jack Straw should be aware of this and of the as yet very flimsy basis of his dramatic and potentially dangerous policy development. The facts gleaned from 'the public domain' are overwhelmed by those that remain unknown:-
- 127 subjects across 3 sites were randomly assigned to oral methadone, to injected methadone and to injected heroin - subjects described as 'having failed' all other treatments. (Unknowns: Assessment according to the internationally accepted 'severity of dependence' criteria; Prior treatment experience or psycho social or follow up support. Data on age, life histories, co-morbidity. Data about programme retention and drop out, etc).
- The 'heroin group' subjects with up to three diamorphine injections a day were still in the main street heroin dependent, 75% had reduced their use of street heroin as a result, but only 20 % per cent of these now 'abstinent' from illicit street heroin (Strang on Today). 'The rest' still 'scoring' 4 to 5 times a month (The Independent) despite the high levels of heroin provided. (Unknowns: Continuing dependence on other substances including alcohol; prescribing patterns, continuing street dependence patterns for the two other groups etc.)
- Subjects self report drops in their criminal offences from 40 to 6 per month. (Unknowns: Which? Variation across the three groups? Reliability? One magistrate commented, in the absence of objective evidence this would be thrown out of court.)
The crime reductions and the speculated cost savings led the headlines. Journalists betrayed a disturbing credulity. None asked about the 'Hawthorne effect'. Yet had any asked to visit the trials, as I did at the start of the project or how much it was costing (I was told some £500,000 to set up and administer the Darlington site for their thirty subjects alone) they might have noted the stark contrast between this gleaming new clinical setting, the attractive and sympathetic fully trained nurses devoted exclusively to them, with the dilapidated drug services centre on offer to every other addict down the road.
With short policy memories too none remembered that similar self report claims for crime costs savings - estimates that have continued to be effectively spun - for methadone prescribing were made ten years ago, by some of the people involved in this latest project ....
If Jack Straw thinks this amounts to sufficient evidence for heroin prescribing - the inevitable abuse of which was the start of the country's drug problem in the 1960s - then we have to assume that whatever powers of analysis and critical thought he ever had, have now totally deserted him.
[1] RIOTT Randomised Opiate Injecting Trials - ongoing at three sites, Darlington, Brighton and London with a total of 127 subjects.
Comments
First we read of the failure of the Blueprint project, a Government initiative to evaluate drug education in schools, costing £6 million. It appears that the exercise was flawed from the start, only 29 schools were used instead of the 50 or so needed to make the study valid.
Now we are told that heroin prescription for hard-core addicts is a wonderful idea and has been very successful in the 3 clinics where it was piloted. But the research has yet to be published and peer reviews carried out.
Why are the basic rules of scientific research being ignored? Why are millions of pounds being wasted.
We need some answers.
I am not in any particular camp although if pushed I guess you would say Harm Reduction. What I do not understand is all the fuss.
In Gwent the NHS can prescribe injectables as is the case in other areas. I do find these pilots as an excuse for the NHS to get access to new money, but as so often people are forced to redress their research as being more than it is.
I am not intrinsically opposed to heroin prescribing but it has to only be used as a last resort and one has to consider costs.
In many areas of the UK there is not access to residential care.The costs are seen as too high in reality, well the question is what are we willing to pay.
As a treatment provider I think we need a range of options. I however want to see more challenging prescribing services. In South Wales we want to challenge people who come into treatment to make changes and support those changes. If you ask most people who enter a methadone programme they want to be drug free. They may need time, but we need to build on this motivation and give timed goals. Otherwise we support someone's initial needs but ultimately we put a plaster on a wound needing stitches.
Although there have been calls to extend the RIOTT pilots to other areas, and even to roll out a national programme of heroin prescribing services, such calls have to be regarded as wholly inappropriate given that the results of this trial have not yet been subjected to independent peer-reviewed publication. Indeed, to date the public discussion of the results of this trial have largely consisted of highly general statements about the benefits of heroin prescribing rather than the presentation of detailed study results. It is indeed unusual to find recommendations being made and enthusiastically reported, given that at present there does not even appear to be an unpublished full report of the interim findings. The fact that Drugscope and the NTA, amongst other organisations, have taken it upon themselves to actively promote heroin prescribing on the basis of the "results" of the RIOTT research tells us that we are in the area of spin where it is media comment rather than presentation of the evidence that is guiding the policy debate.
A comment on the quote from Mr. Spiegel: according to a Swiss study on heroin maintenance (Lancet 2001; 358: 1417-20.) a significant proportion of patients left the heroin program for abstinence-based treatment and there was a positive correlation between the time spent in heroin maintenance and the chance to enter an abstinence-based treatment program. Maybe a longer trial will bring similar results in the UK as well, so if you are committed to the treatment of addiction you should welcome the continuation of the project.
I hope one day my country, Hungary will be also wise enough to test heroin maintenance like the UK. You should be proud of RIOTT and not to criticise it on moral ground (masked as "scientific skepticism").
I just wonder, Ms Gyngell, what you will say if further evidence continues to support the initial conclusions of RIOTT? Will you then change your opinion?
So far almost all aspects of UK drug policy are not evidence-based, and whenever new evidence is presented that supports a move away from criminality and towards health led approaches, you and your colleagues strongly object.
If evidence-based drug policy really were enacted, there would certainly be a lot fewer drug-related harms.
For argument's sake, let's assume the author's premise that the case for heroin prescribing is inconclusive is correct (the success of Dutch & Swiss heroin prescribing programs springs to mind, but I digress). This premise of inconclusivity makes the article terribly ironic. The author states the scientific evidence for heroin prescribing is inconclusive, and then attacks various people for drawing favourable conclusions with regards to heroin prescribing. The irony is that the author does exactly the same thing by drawing their own unfavourable conclusions about heroin prescribing based on the "inconclusive" evidence. The words "pot" and "kettle" spring to mind!
human nature dictates that when someone spends money, time and effort on a controversial pet project it is just soooo tempting to 'prove' their pet theory. Scientific method is important unless your only seeking sensationalism and Jack Straw shows his complete ignorance in leaping onto this as usual like all politicians seeking a one size fits all solution to drugs problems in the uk. And this plays perfectly into the agenda of the extreme left media such as the 'independent' and left leaning bbc.
Steve Spiegel's comment that had legal heroin been available when he was addicted would have ensured he remained addicted is interesting.
Does he not remember that when he decided to stop using that availability had nothing to do with the equation; but rather it was the unmanageability of his life that prompted the decision.
If by prescribing heroin we can ensure that more people survive to make that decision, with less children taken into care, and reduced criminality, then the program gets my full support.
Evidence gathered by the World Health Authority on the Swiss heroin prescribing programs shows that these positive outcomes are exactly the result of following this approach. Dr. Strang is to be applauded, and I can only hope Jack Straw will have the courage to roll this program out nationally. It is long overdue.
Why is it OK to maintain heroin addicts on methadone with the dose gradually diminished over an agreed period in order to achieve abstinence when heroin is so freely available? After all over 90% of the heroin on our streets has country of origin Afghanistan stamped on it. Why are we so shy of robbing the illegal and legal drugs trades of their fat profits? The case for heroin prescribing may not be proven but the case for abandoning the phoney "War on Drugs" most certainly is!
Our war on drugs has been failing ever since it started, prohibition has just lead to criminals making a lot of money and forcing heroin addicts into crime and prostitution.
Methadone programs have always had a very poor success rate and total abstinence programs such as the 12 steps are even worse, I have researched both while working in the drug treatment field.
Blanket prescribing of heroin to all addicts that wanted it would no doubt reduce crime and also break the back of the heroin trade in the UK. Even if the addicts in the RIOTT trail were buying drugs a couple of times a months, well this amount of reduction of illegal heroin would be enough to put the dealers out of business. Less dealers = less new addicts, and if heroin addicts are only supplied enough heroin for themselves they are less likely to share there drugs with others therefore = less new addicts. Yes it might be very costly to set up heroin prescribing in the UK but the long term savings in policing, prison, social services would far out weigh this cost.
The general public would be appalled by heroin addicts being prescribed heroin, but within a few years when the benefits would become obvious to everyone people would get behind the idea.
All current drug policy is failing badly, we need to open our minds to new forms of treatment and heroin prescription should be at the forefront, with the option of methadone, detox centres and rehab for people ready to stop
disaster...
If the current Government really think that prescribing heroin with the 'outstanding' results of not stopping people using street drugs, nor stopping them from committing crime or becoming drug free is a 'spectacular success' then i guess i look forward to seeing crack, speed, cigarettes, cannabis in fact everything become available to those addicted to something - thank goodness the tax payer has deep pockets because those crack habits are expensive to maintain!
It would be laughable if it wasn't so serious. This 'research' is just another attempt to legitimise a failed policy that has consigned thousands to the wasteland of maintenance.
Pity they didn't 'randomise' the trial with an abstinence programme and some real treatment, actually helping addicts to change thier lifestyles and realise thier potential.
I look forward to the response to Kathy's pertinent and hard hitting questions, lets hope they kick this piece of nonsense into the long grass before it does any lasting harm...sadly i fear the worst as spin triumphs over reason for the time being.