Monday, March 13, 2006

It is harder to come off methadone than heroin, so why prescribe it on the NHS?

Sunday Herald

During First Minister’s Questions last week, Annabel Goldie of the Scottish Tories had three related issues on her mind. How many Scots, she asked the First Minister, are on methadone? How many weeks, months, or years have they been on the drug? How many of them have children?

The immediate context was as obvious as it was tragic: a two-year-old dead of a methadone overdose in East Lothian after ingesting his parents’ prescribed dose. Goldie, though, was attempting a broader debate. The Tories argue, predictably, that there should be zero tolerance towards narcotics. Simultaneously, and not entirely logically, they claim that efforts to rehabilitate users need to be reformed drastically.

They are sceptical, too, when it comes to methadone programmes. Their leader believes that far too many people are being “parked” on the drug, their addictions legitimised and concealed. Or as Goldie told parliament: when the well-off have drug problems they pay for residential rehab, while “the masses use methadone”.

“Masses” isn’t far short of the mark. In a partial answer, McConnell said that according to his (out of date) figures, the drug is being prescribed in 19,200 cases. He conceded, further, that there is “not enough information about the individuals who are prescribed methadone”. The database would be expanded, but surely Goldie was not calling for an end to such treatment programmes?

She didn’t go that far. In her view, there is a place for methadone. At a rough guess, after all, there may be upwards of 50,000 heroin users in Scotland: no strategy should be dismissed. But Goldie’s insistence, unusual in a Tory, that a “two-tier” drug treatment system exists in Scotland was not disputed seriously by the First Minister. Then, quoting one strand of medical opinion, she said something interesting: people with money choose not to use methadone to end addiction.

Why not? Isn’t that the purpose of the drug, at least in the public’s mind? If methadone inspires so little faith in those who can afford alternatives, why are at least 19,200 Scots – the 2006 figure is undoubtedly higher – being prescribed an approved alternative to smack?

The green syrup, as addicts know it, is interesting stuff. It is what is known as an opioid, officially a long-acting synthetic painkiller that mimics heroin. First developed by German scientists during the second world war when morphine was in short supply, it has a structure and actions similar to that drug. It was first used on heroin addicts in New York, in 1964, and since then it has been deployed in programmes around the world.

But here’s the problem: methadone, like morphine, like heroin, like opium, is a class A drug. It is highly addictive. According to some addicts , freedom from methadone is harder and slower to achieve than freedom from heroin. The former can produce a range of side-effects – confusion, nausea, vomiting, suppression of breathing reflexes – and it can kill. Sometimes death is caused in error, by overdose, sometimes because street methadone has been mixed with other narcotics. Nevertheless, as long ago as 1997, 421 deaths in the UK that year were attributed to a “harm reduction” drug, vastly more than could be attributed to heroin. The figure has continued to increase.

In the US, methadone-related incidents requiring emergency room treatment increased by 37% between 2000 and 2001. Florida reportedly saw an 80% increase in methadone related deaths in the same period, and in North Carolina fatalities increased eight-fold between 1997 to 2001. These alarming figures may be attributable to illicit use, without medical supervision, but as a report by two doctors from Amsterdam’s Municipal Health Service has put it: “Methadone is not an innocent substance; one man’s methadone maintenance dose is another’s poison.”

In cases of drug addiction, the green syrup is used in one of two ways: either in a rapid detox programme, or in what is known as a “maintenance or long-term programme”. In the latter case, methadone is rarely, if ever, described as a “cure”, even by its advocates. Instead, it is held to “improve health”, to “stabilise” lives, to reduce the use of contaminated heroin, to remove the risk of hepatitis and HIV from injections, and to cut addiction-driven crime.

Better than nothing, surely? Where harm to individuals and society is concerned, less is less. But what of the addicts who simply use methadone as a “top-up” for heroin? What of the critics who say that the treatment simply does not address the core problem, and instead simply prolongs drug addiction, with a narcotic that lingers in the body far longer than heroin? And what of the fact, now well-established after 40 years of medical use, that many of those being “treated” with methadone will be state-sponsored addicts for years, possibly for life?

The simple answer is that at least they will be alive, most of them; addicts but still alive and, with luck, functioning. You can find any number of anecdotal accounts from long-term junkies who claim that methadone has transformed their lives. Against that you will find those prepared to state baldly that the drug is “as dangerous and as harmful as heroin”. Smack addicts who have done it the hard way, cold turkey, meanwhile have a tendency, according to some studies, to be dismissive of methadone users. They say harm may have been reduced, but the problem of addiction has not been confronted , far less dealt with.

To be fair, you would struggle to find a supporter of methadone programmes prepared to say that the drug can ever be fully effective in isolation. Addicts and their families need support in all sorts of ways and they need it before problems run out of control and lives are destroyed. That, nevertheless, does not answer the central question: is it really wise to maintain addicts in their addiction?

On the other side of the coin sits a reminder of a simple, well-established fact: prosperous junkies, with a reliable supply and a shred of self-awareness, can function perfectly well for decades. Things fall apart when cash becomes scarce, when crime becomes unavoidable, when prostitution seems like the answer, when the smack has been cut, the needle shared and the family unit dismantled. It is no accident that heroin hits our poorest communities hardest: they were the most vulnerable to begin with.

Goldie may be correct, then, to talk about a two-tier system, but she would be as well employed talking about a two-tier society. It is in the bottom layer that you will find the methadone users, kept afloat only by dint of medical supervision, with luck, and what is allegedly a less-worse drug. The suspicion lingers, nevertheless, that methadone is, as a friend said the other day, the politicians’ panacea. They can call it a weapon in their perennial war on narcotics while keeping the real casualties out of sight, out of mind, and addicted with the state’s blessing. Better that, surely, than the alternatives?

I’m not so sure. Well into the 1960s, after all, a different policy endured: heroin on prescription. Why not? The chemical difference between smack and methadone is slight. The real demarcation lies in illegality, purity, and modes of use. Yet if it is easier to come off heroin than it is to be rid of methadone, aren’t we offering the wrong treatment?

Heroin on the NHS? One of the first symptoms to arise from that course of treatment would be mass apoplexy among the political and media classes. The fact that such a policy would steer us closer to common sense would be neither here nor there. The fact that the drugs problem is a function of illegality is a truth, meanwhile, that very few people are prepared to discuss.

Clean, legal, modestly-priced: what do you achieve by legalisation? A great deal of harm reduction, as it happens, if you are truly worried about crime, health and social welfare. Addicts would still exist, as alcoholics continue to exist, but we would not be mired in the half-answer that is methadone, or trapped in the mythology of the “war on drugs”.

Prescribe heroin and end the pretence. Prescribe a drug of which the body can be cleansed in weeks, rather than months. Then spend some real money on rehabilitation. If not, the masses will go on queuing, deluded, for their methadone.

By Ian Bell


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