WHEN IS RESEARCH NOT RESEARCH?

THE RIOTT HEROIN TRIALS

(NB: RIOTT randomised injectable opiate trials is not connected with RIOT, the UK's only abstinent service user group)

“Clamour grows for heroin on the NHS” shouted the Independent last week. This was news to me, as I imagine it was to the rest of that morning’s readers, writes Kathy Gyngell of the Centre for Policy Studies. A group of nameless government-appointed drug experts were, I read, calling for a nationwide network of prescribing centres.

The article by health editor Jeremy Lawrence quoted a heroin trial’s “study leader”, Professor John Strang, as saying “the findings have sent a ripple of excitement through the addiction treatment community, which is unused to seeing progress with hard core addicts”. By Sunday, the ripple had reached Jack Straw, reported in the Sunday Times as calling for heroin prescribing on the NHS.

The ripple that reached me, however, was of disbelief and frustration. “I’m not sure where they get their facts from regarding heroin users being the hardest to treat. This is certainly not our experience,” emailed Steve Spiegel, a former ‘hard core’ addict now long-term director of the successful Providence Project, a low-cost rehabilitation centre for those the system has failed. For Theodore Dalrympole, this was “the latest expensive scheme to avoid admission of the obvious, that we have been barking up the wrong tree for years”.

Kathy Gyngell’s full blog on the Centre for Policy Studies website is here.

Highlights are below.

 

NO INDEPENDENT REVIEWS

Sadly, the main body of the media had not shared their scepticism. On BBC Online, home affairs correspondent Danny Shaw wrote that “Heroin supply clinic cuts crime”. Radio 4’s Today programme ran sympathetic features and gave a platform to Strang to assert “The reductions in heroin use were spectacular, and those are validated”. Would people get details later in the day? “Yes, Strang replied, “in proper scientific publications.” Hmm... media cart before the academic horse... Where was the principle of independent peer group review before publication?

Kings College Institute of Psychiatry, the umbrella institution for the trials, also lost its academic inhibitions. Its website displayed the banner “RIOTT a success for chronic heroin addicts” but gave no link to a publication or a report. Yet Kings College does not have to be told that it is a long-established tradition in scientific research to release findings to the media only after the process of anonymous and independent peer review.

Strang knows this, as does any researcher worth their salt. Yet in this instance he has chosen to sacrifice it in favour of securing widespread media coverage. He can save himself the postage of sending his research papers to the British Medical Journal or the Lancet – both of these internationally recognised medical journals exhort researchers not to release findings for public discussion before they have been assessed independently and published within the journals concerned. As a member of the editorial staff of academic journal Addiction, Strang has shown remarkable disregard for this principle.

For this reason alone, his findings should be regarded with considerable caution. It is notable, too, that the last substantive Cochrane Review of four such randomised trials to test heroin maintenance for patient retention, reducing illicit drug use and improved health and social functioning concluded “No definitive conclusions about the overall effectiveness of heroin is possible”.

In response to my request for evidence, I received this from Nicola Metrebian, a senior research fellow and RIOTT trial coordination at the National Addiction Centre, Kings College London: “The findings have not been published and are not yet in the public domain”.

Jack Straw should be aware of this and of the as-yet flimsy basis of his potentially dangerous policy development.

For full details, click here.  

 

NTA STANCE

The National Treatment Agency for Substance Misuse stated that, “contrary to a story in today’s Independent, it is not calling for a nationwide roll-out of shooting galleries for injectable heroin”.

However, the home page of its websiteis currently devoted to publicising that it provided the secretariat to the “expert group” on the RIOTT trials and “recommended to government that there should be further demonstration sites”.  NTA CEO Paul Hayes states there that “the interim results of the pilots’ study seem encouraging”.

Comments

[Neil McKeganey]

Although there have been calls to extend the RIOTT pilots to other areas, and even to roll out a national programme of heroin prescribing services, such calls have to be regarded as wholly inappropriate given that the results of this trial have not been subjected to independent peer-reviewed publication.
Indeed, to date the public discussion of the results of this trial have largely consisted of highly general statements about the benefits of heroin prescribing rather than the presentation of detailed results. It is indeed unusual to find recommendations being made and enthusiastically reported, given that at present there does not even appear to be an unpublished full report of the interim findings.
The fact that Drugscope and the NTA, amongst other organisations, have taken it upon themselves to actively promote heroin prescribing on the basis of the "results" of the RIOTT research tells us that we are in the area of spin where it is media coverage rather than presentation of the evidence that is guiding the policy debate.

[Mick Madden]

There are many ex-heroin users like myself that were prescribed Heroin, Coke and Methedrine amongst other substances during the 60s.I was prescribed injectables from 1966-1989 when I finally went into residential treatment.

All through that very long period I was also using street drugs and alcohol. No research could convince me that in 2009 this is the way forward.

I would love the opportunity to be interviewed to disprove any evidence. I consider the prescribing methods lengthened my misery greatly.

Regards
Mick Madden
Service Manager
SMART CJS
Oxford

[David Raines]

Such prescription, on some scale, has been available since the end of the 1920s. However, those clinicians with recent licences to do so have shown no great enthusiasm. Research has shown that most addicts want help to get clean.

In an NHS with competing demands, prescribing heroin on a widespread basis would prove very expensive.

Prescribing heroin does nothing to deal with crack cocaine addiction, the primary driver of reported crime. And medically supervised heroin maintenance is the equivalent of writing an open cheque for years, because it is not a cure.

Once such treatment is started, it would be very difficult to stop and would normalise injecting yourself, with all the other risks of hepatitis and HIV transmission between addicts. It would not stop addicts supplementing supplies with street heroin, or continuing to deal in drugs themselves.

Prescribing heroin is a sticking plaster on a gaping wound. Addicts deserve better. No alcoholic was cured by giving him a bottle of spirits a day.

David Raynes
Radstock, Somerset

[Adam W.]

Having been prescribed both injectable methadone and diamorphine during my 20 year addiction to opiates, I am glad to see that the principle of prescribing the drug of choice to the most entrenched of addicts, [as I was], is finally entering the mainstream of medical practice.

On the other hand I am disappointed, yet not surprised, by the usual froth and fury from the likes of Kathy Gyngell, who appears to have a myopic picture of what is involved in drug addiction. Indeed, Kathy, heroin addicts are not hard to treat -once they have made the decision they want to be treated. In the mean time, you can counsel, sanction, threaten, imprison and even beat an addict, but they will not stop using until they decide they want recovery for themselves. Sadly, all too often, the consequences of untreated use of street drugs -loss of family, children taken into care, homelessness and imprisonment- act in the opposite way to that which Kathy et al believe it should: far from being some sort of catharsis, which propels the addict to seek recovery, for the majority of already damaged individuals, the result is to push them even deeper into a search for oblivion.

Sadly the consequences of adopting "tough love" policies towards addiction is an inevitable rise in overdose deaths, a rise in HiV and Hepatitis C infection, and a rise in crime. Kathy is either unaware, or chooses to ignore the fact that harm reduction policies began to be adopted during the 1990's as a response to the failure of the "get tough" ideological approach of the 1980's Conservative government. That was an era that saw the almost universal end to methadone maintenance, resulting in an exponential rise in the rate of heroin addiction, and crime, the consequences of which we are still living with today.

Dealing with addiction is never helped by ideological posturing; neither the extreme libertarian agenda that believes in complete legalisation of drugs, nor the "abstinence only" model that Kathy appears so fond of. Like so many things, addiction treatment is often about making the best of a bad set of choices. In my own case, receiving a prescription for injectable methadone, and later diamorphine took me from being an angry and anti-social criminal, living in a squat, to becoming a productive, employed member of society, who gained a degree, and been the sole carer for my, now teenage, daughter. During the time that I was maintained on injectables I never committed crime, unlike before, and did not use street drugs.

Please do not think I am idealising addiction. I am not. After some 15 years on injectable opiates, I realised that I no longer wished to be dependent, and chose to make the transition to oral methadone, then to detox and rehab. I am now 3 years clean from all drugs and doing well. Some may argue that had I not been given those drugs on prescription that moment of clarity might have come sooner. To that I have no answer, except to point to the list of friends who, denied access to similar treatment to myself, died as a result of using street drugs.

If, as seems likely, the Coalition government adopt an ideological "abstinence only" approach to addiction, resulting in a reduction in substitute prescribing generally, I predict that we will witness another heroin epidemic on a similar scale to that which overtook Britain in the 1980's. That this tragedy in the making is avoidable seems to be entirely lost on those who, without any real knowledge or experience of addiction treatment, insist on adopting an ideological approach to an utterly illogical state of mind. One can only hope they see the error of their ways before yet another generation is sacrificed between the Scylla and Charybdis of drug prohibition and a restrictive drug treatment policy.

[Laurence McM]

Is Adam W reading the same article I am? He has gone off on a real tangent, ascribing statements to Kathy Gyngell that are not actually there.
And of course she understands addiction - it was Kathy who wrote the 400-page "Addictions" section of "Breakthrough Britain", a definitive piece of work in this area.
In your 20 years of drug use, she was researching how to recover in order to help addicts and their families.
You have misunderstood what she has written.
As you rightly say and research has shown, prescribing drugs can delay recovery, causing increasing cognitive damage all the while - so I congratulate Adam on finding a rewarding lifestyle and hope that it will become increasingly fulfilling.