Second Opinion: The methadone police
In its relentless war against drugs, the government is determined to turn GPs into deputy drug-squad narks. Its key strategic device is the prescription of the heroin substitute methadone - the central theme in the official document 'Drug misuse and dependence: guidelines on clinical management', which was published in June.
The latest version of the guidelines emphasises the leading role of GPs in managing drug misuse, and the virtues of 'methadone maintenance treatment'. This marks a significant shift away from the earlier strategy of encouraging GPs to refer drug addicts to specialist centres. It also reflects the ascendancy of what has been dubbed the 'public health' approach to drug abuse over a 'client/patient-centred' approach.
In the past, the straightforward objective in treating heroin addicts was to get them off drugs. Methadone was developed in Germany during the Second World War as a painkiller. It does not have the euphoric effects of heroin, but blocks the adverse effects of heroin withdrawal. It also has the advantages that it has a longer duration of action (and can therefore be taken as a daily dose) and can be taken by mouth, rather than by injection. Since its introduction into the treatment of heroin addiction in the USA in the 1940s, it has been prescribed in steadily reducing doses over a period of days or weeks, with a view to achieving abstinence.
The new 'public health' approach has largely abandoned the goal of abstinence in favour of 'harm reduction'. The objective is no longer to make the heroin user drug-free, but to replace dependence on heroin with long-term dependence - 'maintenance' - on methadone. The aim is that this should, in turn, reduce reliance on illicit drug supplies, curb needle-using and needle-sharing and, above all, curtail the criminal activities commonly required to raise the funds necessary to sustain a heroin habit. The main concern of this policy is not the welfare of the individual drug user, but the stability and security of society.
Promoters of the new drug policy are keen to emphasise the 'strong evidence for the effectiveness of methadone maintenance treatment' (British Medical Journal (BMJ), 5 June). In fact, this demonstration of the effectiveness of methadone has been achieved by moving the goalposts. Recognising the ineffectiveness of using reducing doses of methadone to achieve the traditional goal of abstinence, its supporters now claim that methadone maintenance is successful in reducing the wider damaging consequences of heroin use. But the evidence suggests that it is most successful in reducing 'drug-related criminal behaviours', less so in reducing illicit opiate use and even less so in reducing 'risk behaviours' associated with the transmission of hepatitis or HIV (see Addiction, April 1998).
Though prescribing methadone may have cut crime (a claim endorsed by the 'National treatment outcome research study' sponsored by the Department of Health), it has resulted in alarming reports of an increased number of deaths from methadone itself - which now exceed those from heroin. A survey in Manchester revealed 90 deaths from methadone between 1985 and 1994, with a dramatic increase following the introduction of the methadone maintenance programme in 1990, a pattern that is reflected nationally (BMJ, 3 August 1996). Another report from Lothian indicated that deaths from methadone had more than doubled between 1995 and 1996 (BMJ, 14 June 1997). Furthermore, a large proportion of these deaths occurred in individuals who had not been prescribed methadone, confirming the diversion of prescribed methadone into the illicit drug market.
Following the death of a three-year old boy in Dublin who accidentally consumed methadone kept by his parents (for measuring purposes) in a baby's bottle, a survey revealed this to be a widespread practise. The Manchester figures included four fatalities among young children (BMJ, 30 January 1999).
The official drug misuse guidelines emphasise that methadone prescription 'should be seen as an enhancement to other psychological, social and medical interventions'. The government is keen to ensure that GPs participate in a multidisciplinary, 'shared-care' approach to policing and rehabilitating drug users. As Irvine Welsh's anti-hero Renton perceptively observes in Trainspotting, 'Rehabilitation is shite; sometimes ah think ah'd rather be banged up. Rehabilitation means the surrender ay the self'.
Despite the evidence of the dangerous consequences of methadone for individual drug users and their families, the pressures on GPs to participate in methadone maintenance have intensified. In east London, GPs have been bombarded with methadone propaganda and invited to specially organised local seminars. The new guidelines are linked with cash incentives, offering GPs £20 per month per patient. More ominously, with the carrot comes the stick. The recent BMJ editorial, after asserting that the efficacy of methadone maintenance 'is now so well established', enquired rhetorically: 'for how long can it be considered ethical for some GPs to refuse to prescribe it within a shared-care framework?' (5 June)
Such is the degradation of medical ethics that it is now considered virtuous for doctors to take on the role and responsibilities of the police, and to subordinate the best interests of their patients to the dictates of government drug policy.
In his comprehensive history of modern medicine, Wellcome Professor Roy Porter comments caustically on the way in which, in the 1940s, 'the American medical profession fell into line with the criminalisation of narcotics, accepting funds made available for setting up detoxification units and the development of anti-addiction drugs like methadone' (The Greatest Benefit to Mankind: a medical history of humanity from antiquity to the present, 1997). Always discreetly deferential to the medical establishment, Porter is careful to confine his radical critique of the medical profession to the distant past. Yet his criticism of the US physicians of the 1940s has a remarkable contemporary resonance: 'They could easily convince themselves that they were helping addicts and society, while doing their careers a favour.'
Dr Michael Fitzpatrick
Reproduced from LM issue 122, July/August 1999