Heroin Addiction and The British System

Volume II Treatment & Policy Responses

Michael Gossop, John Strang, Michael Gossop, John Strang

• Publisher: Routledge
• Year: 2004
• ISBN:
  9781134428502
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

The British system of dealing with drug addiction is notable for its flexibility and its capacity to adapt to changing circumstances. Because of this it has attracted considerable international interest, although it is rarely fully understood or accurately represented.Presenting a comprehensive account of the development of policies and treatments, Heroin Addiction brings together the perspectives of policy makers, practitioners and social commentators. The book contributes to a proper understanding of how policy and practice has evolved so that lessons for future policy and practice may be identified.
Volume II of Heroin Addiction charts the development and use of treatment and policy responses in the UK, highlighting the limitations of these approaches as well as their achievements. It is a unique source of reference for students, researchers, healthcare professionals and drug agencies both in the UK and overseas.

Chapter 1
The history of prescribing heroin and other injectable drugs as addiction treatment in the UK

John Strong, Susan Ruben, Michael Farrell, John Witton, Francis Keaney and Michael Gossop

(This chapter draws on a chapter originally published in J.Strang and M.Gossop (eds) Heroin Addiction and Drug Policy: The British System, Oxford University Press, 1994.)

Introduction

For years, prescribing injectable heroin to opiate addicts in the name of treatment has been unique to the UK. Indeed, until the mid-1990s, the prescribing of any injectable agonist as part of the treatment for opiate addiction occurred only in the UK, apart from a small scheme with injectable methadone in the Netherlands (Derks 1990), and three patients who represented the rump of 27 heroin addicts who were started on injectable methadone in 1977 in Queensland, Australia (Adrian Reynolds, personal communication, 1993). However, through the late 1990s and early years of the new century, interest in this area has expanded greatly (Bammer et al. 1999; Fischer et al. 2002). New experimental clinics of supervised injectable heroin prescribing were introduced initially in Switzerland (Perneger et al. 1998; Rehm et al. 2001; Guttinger et al. 2003) and subsequently in the Netherlands (van den Brink et al. 2003), prompting consideration of similar new services in other countries also. In addition, there are also a small number of patients on injectable methadone in the east of Switzerland (Stohler et al. 1999; Stoermer et al. 2003), and a couple of entrenched dependent opiate addicts being treated with injectable methadone in New Zealand (Lee Nixon, personal communication, 2002).

At first glance (and, for some, at second and third glance also) there is something inherently paradoxical in an approach which involves the prescribing of the very drug of addiction as part of the treatment of that addiction. For any consideration of this approach, a particular clarity is required with regard to the goals of treatment. Is it the containment of the ‘epidemic’ to those already ‘infected’? Is it the overcoming of the dependence? Is it the protection from, or muting of, the associated harm? These options will be considered in more detail later in the chapter.

The prescribing of injectable heroin is perhaps the most famous characteristic of the ‘British System’. And yet, at the time of writing, it is probably no more than 1 or 2 per cent of the estimated 250,000 heroin users in the UK who receive a prescribed supply of any injectable drug—and only a small proportion of these, probably less than a quarter, will be receiving injectable heroin. In the mid-1990s, the total number of addicts who were receiving a prescribed supply of injectable heroin was estimated from prescription data as approximately three or four hundred (Strang and Sheridan 1999), whilst a further three thousand or so were receiving injectable methadone (Strang et al. 1996; Strang and Sheridan 1998). A later report from the same investigators described the steady year-by-year decline in the proportion of NHS methadone prescriptions for injectable versus oral methadone— from 9 per cent of all NHS methadone prescriptions in 1995 down to 3 per cent by 2002 (Strang and Sheridan 2003). For heroin, through their survey of doctors with heroin-prescribing authority, Metrebian et al. (2002) identified 448 addict-patients receiving heroin maintenance across the UK. In truth, although this practice may attract considerable local and international attention, the prescribing of injectable drugs in the UK of the late twentieth century was numerically of small significance in the overall UK response—even though the continuity or cessation of the practice may be a subject of great concern to the practitioners and patients for whom it forms the basis of a current treatment.

The guarding of clinical freedom—‘each physician is a law unto himself’

Commentators from abroad, and perhaps especially the USA, are fascinated by the extraordinary clinical freedom which is given to the medical practitioner in the UK with regard to the prescribing of drugs to the opiate addict. As Connell (1975) commented in his review of methadone maintenance schemes, ‘each physician in charge of a special drug dependence clinic is a law unto himself as to how he treats and manages patients’. Whilst the prescribing of heroin, cocaine and dipipanone (Diconal) is now restricted to those doctors who hold a special licence (in practice, the doctors who work in National Health Service (NHS) drug treatment centres), any qualified medical practitioner can prescribe oral or injectable methadone, morphine, or any other available pharmaceutical drug. However, despite this extraordinary clinical freedom, the majority of general practitioners choose not to exercise this right so that, paradoxically, the average UK doctor is often extremely conservative in his prescribing to the addict, with three-quarters of a recent national sample of general practitioners reporting that they would not be willing to prescribe oral methadone (Sheridan et al., submitted). Thus a strange situation has developed, where a small number of general practitioners develop a degree of quasi-specialist expertise in the management of opiate addicts (Gerada et al. 2002; see also Chapter 6, this volume), whilst many other general practitioners react hostilely to seemingly modest proposals—such as that they should be involved in the prescribing of oral methadone for at least the purposes of detoxification.

The great variability in prescribing practices results, at least in part, from this lack of central direction. As a result, there is a startling degree of individual clinical freedom for medical practitioners in the UK. For example, there is probably no prescribing whatsoever of any injectable drugs to addicts in the whole of Scotland, Wales, Northern Ireland and much of England, whereas some other areas have NHS drug specialist doctors and other doctors who include the prescribing of injectable heroin or methadone as part of their overall prescribing response. For example, in the national survey of community pharmacists and their dispensing of substitute opiate prescriptions, the proportion of methadone prescriptions in injectable form varied from less than 5 per cent of all methadone prescriptions in several regions up to nearly 25 per cent in one other region (Strang and Sheridan 1998). Whilst the overall number of opiate addicts in a region might obviously vary according to the size of the population and the extent of the local addiction problem, it is hard to believe that such a different proportionate use of injectable maintenance could be explained in this way—as the authors of the study concluded, this seems unlikely to be appropriate tailoring to individuals and is far more likely to be indicative of ‘therapeutic anarchy’. This has led to periodic calls for the introduction of new guidelines and new controls: but, meanwhile, the prescription of the injectable drug of main use (or an injectable substitute) continues to exist as a tool within the armamentarium of every doctor in the UK.

The early history of injectable maintenance

In the early twentieth century, the international anti-narcotics movement was becoming influential, and, with the lead taken by the USA, both national and international legislation was passed. After a period during which injectable opiates were prescribed in the USA, the Harrison Act was passed and, after threatened prosecutions to the early maintenance clinics, all prescribing of pharmaceutical opiates to addicts stopped. In contrast, the UK establishment chose not to criminalize but to ‘medicalize’ the problem, following guidelines from the influential Rolleston Report, which had been prepared as an inter-ministerial report under the chairmanship of Sir Humphrey Rolleston (Ministry of Health 1926; for a fuller account, see Chapter 2 in Volume I by Virginia Berridge). In essence, this report established the right of the medical practitioner in the UK to prescribe regular supplies of an opiate drug to an addict in the following circumstances:

1 where patients are under treatment by the gradual withdrawal method with a view to cure;

2 where it has been demonstrated, after a prolonged attempt to cure, that the use of the drug cannot be safely discontinued entirely on account of the severity of the withdrawal symptoms produced; and

3 where it has been similarly demonstrated that the patient, while capable of leading a useful and normal life when a certain minimum dose is regularly administered, becomes incapable of this when the drug is entirely discontinued.

Thus it was established that the doctor might legally prescribe injectable opiates to an addict provided this was ‘“treatment” rather than the “gratification of addiction”’.

The next 30 years were a period during which there was no significant problem of injectable opiate use in the UK (also see Chapter 3 in Volume I by Bing Spear). However, although some commentators have eulogized about the effectiveness of the British System during these years, the direction of causality between policy and lack of problem is not clear.

The date when intravenous injecting became established in the UK is not at all clear. The injectable opiate use under consideration by the Rolleston Committee (1926) was subcutaneous or intramuscular, whereas the new opiate injectors in the 1960s (see next section) were mostly using the drug intravenously. In the USA, over this period, there had been a steady spread of the intravenous habit, and this diffusion has been described in some detail (O’Donnell and Jones 1968).

As cracks began to appear in the British System during the 1960s, there was a temptation to look back on what appeared to be the success of the previous decades, identifying characteristics such as the absence of any illicit traffic in drugs, the absence of an addict subculture, and the absence of any young users. However, other commentators suggested that the previous decades had merely been ‘a period of non-policy’ (Smart 1984) in which ‘there was no system, but as there was very little in the way of misuse of drugs, this did not matter’ (Bewley 1975). As Downes concluded, the British System had perhaps been ‘well and truly exposed as little more than masterly inactivity in the face of what was an almost non-existent addiction problem’ (Downes 1977).

Injectable prescribing and the growth of a modern-day problem

In the late 1950s and early 1960s, there was a modest influx of a new type of opiate addict to the UK—a North American (mainly Canadian) addict with an established criminal history. About a hundred such addicts entered the UK during these years, attracted by the accounts of prescribed supplies of injectable pharmaceutical opiates—alongside a lack of immigration restrictions. Some caught the boat to Liverpool and then a train straight to London. For others, the transfer was more direct: ‘I got a taxi from the airport to a GP in the Holloway Road, and got an immediate prescription for heroin and cocaine.’ (Also see Chapter 3 in Volume I.) Up until this time, the opiate addict population in the UK had been substantially middle-aged and middle-class, with a high representation of doctors and of patients who became dependent on their analgesic drugs. Thus, as a result of the prevailing patterns of prescribing of analgesics, heroin itself was rarely prescribed. For example, during the 1940s and 1950s, the total number of known opiate addicts in the UK never exceeded 500, of whom only about 10 per cent had been using (i.e. were prescribed) heroin.

The interpretation of the events during the 1960s varies greatly, with some observers concluding that the growth of a new drug culture was caused largely by the over-prescribing of a handful of doctors (Second Brain Report (Interdepartmental Committee on Drug Addiction) 1965) whilst others suggest that the lax regulations and generous prescribing potential of UK doctors was a system waiting to be blown open by the newly arrived North American junkies (Blackwell 1988). Whatever the explanation, a youthful hedonistic drug-using culture became established in the UK during the 1960s —particularly in London. The use of injectable opiates involved prescribed pharmaceutical opiates (particularly heroin) which were prescribed by a small number of doctors in or around London, and from whom the daily doses prescribed rose steadily: for example, some of the opiate addicts steadily increased their daily intake from about one to 40 grains of injectable heroin daily (60–2, 400 mg daily).

Prescribing injectable drugs from the new clinics (1968 onwards)

NHS drug clinics were established for the first time in 1968. They were expected to address multiple agenda, which included the need to provide treatment to the new addicts, and the need to contain the spreading ‘epidemic’. More immediately, there was a need for them to take over the care of more than 1,000 addicts who had been receiving their heroin (and sometimes cocaine) from doctors who were no longer allowed to prescribe either of these two drugs. In practice the majority of these patients were taken on by the clinics on prescriptions very similar to those which they had previously been receiving—at least in the first instance (for further details on the changes at this time, see Chapters 2 and 3, this volume.)

During the early months of operation of the new drug clinics, the new NHS heroin prescribers also took over responsibility for prescribing injectable cocaine —almost exclusively to a population of injecting drug users who were taking both heroin and cocaine. For patients who received both drugs, doses of cocaine were either equal to or lower than the dose of heroin prescribed. However, w...