Should heroin be prescribed to heroin misusers? No

Abstract

Some heroin addicts are very difficult to treat. Jürgen Rehm and Benedikt Fischer believe that maintenance with heroin is the way forward for this group, but Neil McKeganey argues that it is treating the effects of misuse not the addiction

Prescribing heroin to heroin addicts is a strategy beloved by top police officers¹ and successive home secretaries.² It is a strategy, though, borne of utter frustration at our seeming inability to tackle an escalating drug problem. If you cannot stop addicts committing crimes to fund their drug habit then, so the argument goes, the next best thing is to provide them with the drugs that are the reason they are committing the crimes in the first place. The logic may seem faultless, but at the back of your mind is the nagging question, “Is it treatment or is it social problem prescribing?”

The evidence in relation to heroin prescribing is far from conclusive. On the positive side Nordt and Stohler have suggested that heroin prescribing led to a large reduction in incidence of heroin addiction in Switzerland, although the authors also point out that such prescribing may have reduced individual’s inclinations to cease their heroin use.³ A London study found no health benefits associated with heroin prescribing,⁴ whereas various Dutch and Swiss heroin trials have identified a range of benefits including improved social functioning and psychological and physical health.^{5 6} What is often quite difficult to identify from these studies is the degree to which the improved outcomes are the result of the heroin prescribed or other elements of the therapeutic programme provided. The cost of treating an addict with heroin is estimated to be three to four times that of treating an addict with methadone.⁷

Risks of prescribing

In the face of the additional costs and inconclusive evidence, many clinicians are wary of prescribing heroin. Their anxieties are understandable, given the high profile cases of doctors who have prescribed heroin to addicts and then subsequently found themselves facing a General Medical Council inquiry into their prescribing practices.⁸

At a clinical level prescribing heroin to heroin addicts is a risky strategy. Once you start, it is difficult not to feel that you have ceded authority for your prescribing to your patient. What, for example, do you say to patients who threaten to resume their previous life of crime if you reduce their heroin prescription? What do you say to the cocaine addict who asks why he cannot have cocaine provided in the same way as the heroin addict? Opening up heroin prescribing to addicts could lead to massive pressure on doctors to prescribe increasing amounts of the drug.

It was in part as a result of that pressure that the Interdepartmental Committee on Drug Addiction advised the UK government in 1965 that only appropriately certified doctors should prescribe heroin to addicts. The committee’s decision was influenced by the case of Lady Frankau, a noted London psychiatrist who in 1962 prescribed more than 600 000 heroin tablets to her addict patients.⁹

What are we treating?

Prescribing heroin to heroin addicts, however, makes sense only if your primary concern is to treat not their drug dependency but the consequences of their drug use. You may want to reduce their use of street drugs, the risks to health from HIV or hepatitis C virus, the risks of overdose, or their criminality. With all of these aims in mind you may conclude that it makes sense to provide addicts with a prescription for the drug that they have become dependent on. And yet the reason they are committing those crimes, and taking such enormous and persistent risks with their health, is because the drugs have become more important than life itself—that is the nature of drug addiction. And that is the problem that drug treatment services need to tackle.

Research has shown that with the right services in place it is possible to do more than simply stabilise addicts’ continued drug use through the prescribing route. For example, the Australian treatment outcome study, which followed up 429 heroin users recruited from a random sample of drug treatment agencies 36 months after starting treatment, found that 40% of drug users had been abstinent for the preceding 12 months and 25% had been abstinent for the preceding 24 months.¹⁰ In a similar Scottish study of 695 addicts, re-interviewed 33 months after they had started treatment for drug misuse, 29.4% of those who had been provided with residential rehabilitation had been abstinent for at least 90 days before being interviewed compared with only 3.4% of those receiving methadone maintenance.¹¹ All of the residential rehabilitation services included in this study followed an abstinence based programme.

But do addicts coming forward for treatment actually want heroin to be prescribed to them? A study of over 1033 drug users starting treatment in 2001 asked participants what they wanted to get from the drug treatment services they were contacting.¹² Most of those questioned said that they wanted the services to help them become drug free. Health services need to ensure that they are supporting addicts’ attempts to become drug free, and they need to be extremely cautious about any extension of a policy that could be seen as a route to maintaining rather than reducing an individual’s drug dependency.