Finding David Nutt latching onto Professor Steve Jones’ BBC Science Review in Comment is Free in the Guardian last week was hardly a surprise when it finally reached me down under in the Australian outback where I have been holidaying. The page is now closed for response. But I couldn’t let this bit of blatant opportunism pass without response. Not least because he cast me with Peter Hitchens (his particular bete noir) as the villains of the piece - representatives of the nameless fringe scientific groups he accuses the BBC of giving too much airtime to. It did him no favours - nor the scientific community that he purports to represent. For in accusing the BBC of devaluing scientific method by airing our views and seeking to ban us from its airwaves, Professor Nutt forgot the beam in his own eye …. as the parable says.
Peter lost no time in laying bare Nutt’s scientifically dubious ‘multicriteria decision analysis’ (which he has damningly exposed for the value laden hybrid science and ‘social science’ ranking of drug harms that it is) that the Lancet shamefully published as dispassionate science.
But it falls to me to debunk Nutt’s similarly grandiose and suspect claims about opiate substitution - his insistence that ‘treatment works’ and that substitution and maintenance are more efficacious for recovery than abstinence programmes.
His ‘scientific case’ for substitution and maintenance stands or falls on whether you believe, as he seems to, that only randomised control trials – in this case a limited number of methadone and buphrenorpine trials – produce the only evidence that can justify (national investment in) a drug treatment. But this view of the primacy of RCTs has come under question. Nutt’s former colleague and predecessor at the ACMD, Professor Sir Michael Rawlins argues that RCTs, though long regarded at the 'gold standard', “have been put on an undeserved pedestal”. In a speech to the Royal College of Physicians in 2008 he explained why:
“RCTs are often carried out on specific types of patients for a relatively short period of time… There is a presumption that, in general, the benefits shown in an RCT can be extrapolated to a wide population; but there is abundant evidence to show that the harmfulness of an intervention is often missed in RCTs”.
The findings of a recently published longitudinal cohort study, based in Edinburgh, show just how much can be missed – the grim unintended consequences of ‘treatment’ that are not picked up by short term opiate substitution trials. They confirm the downside of long term methadone maintenance, downsides that countless former addicts, addicts in treatment and several addiction psychiatrists have voiced. The longer you are on methadone the less likely you are to come off drugs altogether the study confirmed. Indeed its authors concluded that “exposure to opiate substitution treatment was inversely related to the chances of achieving long term cessation”. They also reported the disturbing finding that methadone maintenance extended ‘the median duration of injecting’ from 5 to 20 years, that injecting over the years, alongside scripts, compromised the health of the survivors of the methadone cohort and, perversely, increased their vulnerability to infection and overdose. If this evidence does not call for a review of the state’s default methadone programme I don’t know what does.
But on the particular planet ‘science’ that Professor Nutt inhabits this is not up for debate. He continues to insist not only that opiate substitution and maintenance ‘work’ and but that they are also more efficacious for recovery (which I notice he puts in inverted commas as though it were a myth) than abstinence programmes. It is hard to see on what scientific basis he can possibly make this claim. For while the RCT ‘evidence base’ demonstrates relative reductions illicit drug use and associated crime – hardly surprising given the free prescription of substitute drugs - these are short term findings. The RCTs do not show that medication is more likely to lead to recovery than abstinence treatment. They could not. The trials did not set out to control for or test abstinence treatment efficacy.
Professor Nutt challenges me for ‘my’ evidence that abstinence treatment programmes help recovery. Well he can easily find the key references in my recent CPS publication ‘Breaking the Habit – why the state should stop dealing drugs and start doing rehab’.
DORIS, the three year Scottish national treatment outcome survey showed abstinence based rehab to be significantly more efficacious for recovery than community methadone and a better predictor of a range of health and social outcomes. American epidemiological research too suggests that recovery largely takes place outside the purview of medical and pharmaceutically driven ‘clinical’ treatment - that it is not doctors who get addicts better in the long run better but abstinence based mutual aid groups and programmes. I could go on.
But it is up to Professor Nutt whether he chooses to discount this social survey data. It is entirely his choice to refuse to debate the risks versus the benefits of substitution and maintenance in light of new information. He can also ignore addicts’ aspirations for medication free recovery, recovered addicts testimonies and rehab outcomes data. He is free to do all of this and to continue to advocate pharmaceuticals as the only valid intervention for heroin addiction. But his attempt to stifle debate and blackball all other opinion puts him, not his critics, on the fringes of reasonable discourse.
 Rcplondon.ac.uk [Internet]. Royal College of Physicians: Sir Michael Rawlins attacks traditional ways of assessing evidence. [updated 2008 Oct 16; cited 2011 Jan 27] Available from http://pressrelease.rcplondon.ac.uk/Archive/2008/Attack-on-traditional-ways-of-assessing-the-evidence-of-therapeutic-interventions
 Kimber J, Copeland L, Hickman M, MacLeod J, McKenzie J, De Angelis D et al. Survival and cessation in injecting drug users: prospective observational study of outcomes and effect of opiate substitution treatment. BMJ 2010; 341:c3172. doi: 10.1136/bmj.c3172 (794 patients with a history of injecting drug use presenting between 1980 and 2007.