Kathy Gyngell authored the Addictions reports for Breakdown and Breakthrough Britain, the Conservative Party’s 2007 Social Justice Policy Review. Her recent reports, The Phoney War on Drugs (CPS, 2009) and Breaking the Habit: why the state should stop dealing drugs and start doing rehab (CPS, 2011) have attracted widespread media coverage and attention. She researches, writes and is media commentator on a range of social policy issues – including family, gender, employment and childcare.
No one in their right mind would give an alcoholic alcohol to cure their addiction.
Yet this approach has been used to treat drug addiction for years – and is still advocated by the government’s medical advisors.
Methadone, an opiate substitute, is still the National Health’s preferred ‘treatment’ for heroin addiction - or for any other drug addiction for that matter, if heroin is involved at all. Since 2001 billions of tax payers’ money primed a massive expansion of prescribing in the name of ‘harm reduction’. Experimenting with taxpayer-funded heroin was added to the mix too where methadone proved not enough to keep addicts off street drugs. And now, in Scotland, naloxone, the heroin overdose antidote, is routinely added to the addict’s drugs cupboard. This handy resuscitation kit is meant to be administered by a ‘carer’ - more often a co-user. Into this heady cocktail addictive add benzos – prescribed for anxiety but which like methadone leak onto the illicit market.
The received medical wisdom is to ‘give the addict more’ if this is what it takes to stop their street drug dependency. Never mind that it doesn’t, that the addict’s teeth drop out over time, that they may never work (especially as research indicates methadone lowers IQ) or that they suffer other debilitating side effects and that their alcohol or crack dependency may go up. Never mind that these attempts at ‘harm reduction’ accommodate destructive behaviour.
Doctors have been pushed down this prescribing route whether they like it or not. Addicts are a difficult client group. Financial incentives for doctors to get addicts on scripts secured Labour’s treatment targets and offered doctors a solution at the same time. Incentives to get addicts off drugs and alcohol are another matter. Despite the Coalition government’s new payment by results driven drugs recovery policy they don’t exist.
The standard (evidence based from short duration trials) justification for prescribing is that it helps addicts stabilise their lives. Dr Claire Gerada, a prominent and highly influential methadone exponent, is by no means alone in her adherence to this. She refused to budge one inch when confronted with ex addict Russell Brand’s scepticism in his BBC documentary, “From Addiction to Recovery”. She appeared as married to methadone treatment as Brand previously had been to his drugs.
But her position is not sustainable. Methadone replacement therapy has been tried, tested and found, in its long term use, ineffective and dangerous. Scotland’s record drug deaths, now dominantly associated with methadone, announced this August, put paid to the idea that managing an addict’s life with more drugs works. It doesn’t. 5,000 methadone deaths in the US per year are testament to that.
Distribution is not without leakage into the general population. It is likely that half of methadone-associated deaths are among people not prescribed methadone.
As Dr AN Daniels wrote for the Journal of the Royal College of Physicians: “For doctors to prescribe a drug to people in the knowledge that their prescription will kill people other than their patients is surely questionable, to say the least. It is also a matter of ethical concern to doctors whether their patients die as a result of their own conduct alone, or whether they die with the assistance of the treatment that they have recently prescribed for them. If it is not of concern, it can only be because the patients are not regarded as autonomous or self-determining human beings: a view that is not only empirically mistaken, but has sinister implications from a policy point of view.”
The Scottish Conservative leader Ruth Davidson was right to warn that: “This appalling loss of life illustrates the human disaster that is the methadone programme”,
But her common sense sadly has not permeated through to Scotland’s SNP Ministers. Though a longitudinal study of Edinburgh addicts shows that methadone actually extended addicts ‘injecting careers’ and resulted in higher morbidity and mortality risk, they are intransigent.
For how long is anyone’s guess. Doctors after all used leeches to let blood for hundreds of years before they observed it did more harm than good.
Instead the SNP’s ‘silver bullet’ solution to drug deaths is another fundamentally flawed harm reduction idea - addict administered naloxone resuscitation.
That handing out these kits encourages even more risky behaviour by creating a false sense of security (making it ‘safer’ to shoot up) has escaped them. So too has the risk that naloxone, like methadone, will lead more deaths than it temporarily saves.
This is not just Scotland’s problem.
Methadone deaths have risen exponentially in England and Wales too – from 248 in 2001 to 486 in 2011. And the response is similar - more of harm reduction not less.
In fact far from an investment in recovery, the Coalition’s drug treatment legacy risks being expansion of harm reduction.
For this is where investment is still directed. Referral to rehab is all but non existent. There is no interest in, let alone commitment to, trialling abstinence programmes. By contrast nearly a million pounds has been awarded by the MRC to a trial of naloxone resuscitation kits for newly released prisoners - the first 10% of an anticipated 50,000 prisoner programme. If it produces the necessary justificatory evidence it is designed to elicit, then every newly released prisoner with any history of heroin injecting, will be armed with a kit. Justification of the prison time and expense involved seems not to have been considered or whether this money would not be far better spent on trialling a prison release meeting and support service.
But adherence to harm reduction is strong within the establishment. The National Treatment Agency has already invested significant funding in training programmes for naloxone administration. It is establishing itself by stealth in the National Health’s ‘harm reduction’ arsenal.
Together DH and the NTA are committing several more millions to another extreme harm reduction measure – prescribing addicts with pure heroin itself – that was instituted under Labour. The original multi million pound RIOTT (heroin treatment trials) programme is currently morphing into a ‘provider service’. This is since the Coalition took office. In January this year the DH published ‘pre invitation’ to tender for contracts valued up to a cool £6 million pounds, referring to a commitment to continue the diamorphine programme that was written into the small print of 2010 Drug (Recovery) Strategy.
The new junior health minister, Anna Soubry, should take note. She should ask her officials how consonant this is with the government’s recovery objectives, whether this is an appropriate allocation of scarce resources. She should question them hard about the nature and the substance of the scientific evidence that justifies it. She should demand they weigh this evidence against the wider context of risk, scarce resources and ethics. Why are not similar sums to be invested in rehab or abstinence trial – given the government’s recovery ambitions?
Finally she should examine the links between these research interests and the beneficence and the research beneficiaries of the pharmaceutical companies - particularly those manufacturing methadone, diamorphine, naloxone and benzodiazepines.
She should be aware of the various powerful interests involved. For example the National Treatment Agency’s chief addictions adviser, is still Labour’s key advisor, Professor John Strang, who has a long term scientific and policy interest in the promotion of naloxone and heroin prescribing. Not only is he the key mover and shaker behind both the injectable heroin programme and the N Alive Trials but he is also the author of the NTA’s new ‘interim’ clinical guidance, the stated intent of which is translate the government’s new recovery policy into clinical practice.
As was observed by practicing drugs counsellors at an APPG meeting on drugs policy this summer with Lord Henley, this report is worrying. It was criticised for sanctioning indefinite substitute opiate prescribing – just what the government is trying to end. At the start for example it reads: “Existing practice, and the extensive evidence on which it is based, already describes much of what is best practice”.
But this is the evidence that has long been regarded as a totally inadequate basis for a holistic and comprehensive treatment policy. It is one sided, focussing on opiate substation – with psychological interventions treated as subsidiary.
Basically it leaves review of long term methadone patients to doctors’ discretion. The only proviso they must meet is for, “all those on a substitute prescription engage in recovery activities”. That could mean anything; “recovery” is undefined.
Whatever its nod in the direction of ‘imbalanced treatment systems’, whatever the many clichéd references to recovery and ‘recovery oriented drug treatment’, these are only words. In the absence of specific prescribing conditions and parameters they are meaningless.
The new health ministers should not be satisfied.
The depressing but ineluctable fact is that the medical establishment’s love affair with the easy option of methadone has yet to change. Without investment in formal abstinence trials the officials’ case against rehab will, conveniently, though incorrectly, be the lack of evidence for it.
I do not doubt the Coalition’s desire to catalyse recovery. But language is not enough when old practice persists, repackaged, in a new guise.
The policy beneficiaries are still the same. They are the bureaucrats, the doctors, researchers and pharmaceutical companies whose addiction to opiate substitution keeps them in business.
They are not the addicts or the families that bear the burden of addiction that the government’s recovery policy was designed to help.