METHADONE: WHAT THE MEDIA SAY

BBC Radio four programme The Report put methadone in the news – and in a rare balanced way without the ideology of limitless prescribing which has long lined the wallets of drug dispensers. Professor Neil McKeganey reports on this and rounds up other news items.

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Methadone is in the news again (Pressly 2010).  Last month, BBC radio four’s The Report outlined the growing debate in Scotland and England about the use of methadone in the treatment of drug dependency. This debate is heated, wide-ranging – and on occasion has involved personal attacks on those involved.

People defending the use of methadone have clearly been irked by what they see as the regrettable media coverage that has been garnered by some of the methadone critics. Their irritation has been fuelled by reports that the new coalition government might be considering rebalancing the drug treatment system in England and reducing the reliance on methadone which is presently prescribed to over 170,000 addicts in the UK.

Dr Chris Ford, writing in the Guardian newspaper, summed up her view of the possible proposals from the coalition government in a comment piece titled Methadone works; stop meddling (Ford 2010). For Ford and other supporters of methadone, doctors should have a free hand to prescribe methadone for as long as they deem necessary to as many addicts as they deem necessary. Talk of reducing the use of methadone for these medics is tantamount to a red rag to a bull.

Writing in the Scotsman newspaper, a collection of 40 interested parties from around the world, led by the Edinburgh GP Dr Roy Robertson, signed up to the view that “If policy makers were to heed the critics’ advice to close down methadone treatment or impost arbitrary time limits on its administration, the community can anticipate more overdose deaths, more HIV and more crime.

"Surely”, they wrote, “this is not what the public want or deserve” (Robertson et al 2010).

METHADONE WITHOUT LIMIT...

The supporters of limitless methadone prescribing have been more influential in Scotland than in England.

Fergus Ewing, the minister in the Scottish government with responsibility for drug policy, has clearly been influenced by those who argue against any limit on methadone prescribing. Interviewed on the BBC Radio Four programme, the minister stated that “the idea that there should be a national policy whereby we say to thousands of people ‘no more methadone’ is the height of irresponsibility. It would lead to a resumption of many people injecting drugs, it would lead to a resumption of serious criminal activity including prostitution, theft on a large scale. It is not something which any responsible government minister could advocate and it is not an option, if I may say, as far as I understand it, that is being put forward by any serious commentator in Scotland”.

...BLOCKING ROAD TO RECOVERY

It is ironic that the minister should be articulating such a view when his own words in Scotland’s Road to Recovery drug strategy, published in 2008, powerfully underlined the importance of drug treatment services working towards addicts becoming drug free... For the Scottish government, it seems “drug free” has come to mean the continuation of life-long methadone (see glossary).

ARE MODERATE VIEWS GETTING THROUGH?

In England, the arguments for limiting methadone appear to have received a more sympathetic hearing.  The Department of Health recently sent out revised guidance to prison medical authorities advising that, where prisoners receive a sentence in excess of six months, they should not be put on a maintenance dose of methadone but should instead be on a reducing dosage leading to their becoming drug free.

Most recently, the National Treatment Agency in London noted in its Business Plan 2010-2011 that “no one should be parked indefinitely on methadone or similar opiate substitute without the opportunity to get off drugs”.

“New clinical guidance,” the business plan continues, “has introduced strict time limits to end the practice of open-ended substitute prescribing in prisons. This principle will be extended into community setting”.

According to the NTA, the intent of this revised guidance “is to see a fundamental shift in the balance of treatment for opiate addiction away from long-term maintenance towards abstinence and long-term recovery”.

For the supporters of lifelong methadone, the proposed revised guidance smacks of ministerial unwanted interference in a “medical matter”.

For others, however, the worry is that for too long in the UK we have had a situation in which recovery from dependent drug use has been marginalised by a policy which:

• has long favoured life-time methadone prescribing
• has seen a methadone prescribing bill soar in excess of £600million a year
• has resulted in a situation in some parts of the UK where almost every addict seeking treatment is on methadone; only 2-4% manage to get to rehabs guiding them to drug-free lifestyles
• has resulted in a situation where methadone supporters have effectively worked to curb the development of any alternative carepaths for fear that, in the event that those alternatives were taken up, this would inevitably mean a reduction in the funding for methadone services.

THE BRITISH MEDICAL JOURNAL SCRIPT WHICH GAINED PUBLICITY...

Recent research published in the influential British Medical Journal, and authored by Dr Roy Robertson among others, reveals why the debate on methadone has continued to rage in Scotland and in England and why the question on whether there should be limits on the use of methadone is so crucial.
Trumpeted by its authors as a vindication of benefits of maintenance methadone prescribing, the research report shows that addicts who were prescribed the drug had a reduced risk of death compared to those who were not prescribed opiate substitute medication.

...AND THE OTHER BMJ RESEARCH: “[METHADONE] TREATMENT INVERSELY RELATED TO LONG-TERM CESSATION”

However, the BMJ report contained another finding which received almost no attention from the media. That finding was that “exposure to [methadone] treatment was inversely related to the chances of achieving long-term cessation”.

The provision of opiate substitution treatment to the patients attending the Edinburgh general practice where this research was carried out was associated with a lower likelihood of the drug users managing to become drug free.

In other words, treatment in these terms was not only failing to enable addicts to become drug free, it was also reducing their chances of becoming abstinent.

The published paper went on to give an indication of the magnitude of this negative effect. For patients who did not start opiate substitution treatment, the median duration of injecting was five years – with almost 30% ceasing within a year – compared with 20 years for those with more than five years’ exposure to treatment (Kimber et al 2010).  Here in a nutshell is the issue at the heart of the methadone debate.

WE NEED BALANCE AND RESPONSIBLE PRACTICES

Nobody doubts that methadone can be useful in reducing various aspects of drug users’ risk behaviour. But when methadone is administered on a maintenance basis, it runs the very real risk of locking the addict into long-term addiction and continued drug dependency.

For the supporters of methadone, this is an acceptable outcome of a policy that they say keeps the addicts alive. For the addicts and their families, however, the notion that a treatment which they began in the hope of becoming drug free could lock them into a life of long-term dependency might be a price much greater than they initially understood they would be paying for the treatment they were receiving.

Doctors have a habit of underinforming patients about the adverse side effects of their magic-bullet potions, as many millions of patients found to their cost as a result of the over-prescribing of benzodiazepines in the 1970s and beyond (see www.appgita.com).

Doctors have an important voice when it comes to shaping drug policy matters. But when their voice becomes more influential than any other – including those who have successfully recovered and/or guided others into recovery – addiction comes to be seen as a life-long disease requiring life-long medication, and recovery comes to stand in inverse relation to treatment exposure.

That is what has happened in Scotland and that is what needs to be avoided if we are to secure a balanced treatment system which maximises rather than minimises the numbers of addicts becoming drug free.

REFERENCES:

BBC Radio Four (2010): The Report.
Ewing Fergus (2010): from The Issue BBC Radio 4 BBC Radio Four (2010) The Report
Ford, C (2010): Methadone works. Stop the interfering. Guardian 26 July 2010.
Kimber J, Copeland L, Hickman M, Macleod J, McKenzie J, De Angelis D, Robertson R (2010): Survival and cessation in injecting drug users: prospective observational study of outcomes and effect of opiate substitution treatment. British Medical Journal 1 July; 341:c3172.
National Treatment Agency (2010): Business Plan 2010-2011.
Pressly L (2010): Why quitting heroin substitute methadone is ‘vital’
Robertson R (2010):  Methadone is key to effective drug treatment. 5 April 2010. Scotsman Publications.

NEIL McKEGANEY is professor of drug misuse research at the University of Glasgow and founding director of the Centre for Drug Misuse Research. He has advised the Home Office, the World Health Organisation and the US Department of Justice. His latest book, Controversies in Drugs policy and Practice, will be published later this year by Palgrave.