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Guidelines for prescribing injectable heroin and methadone

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I was surprised to read that heroin prescribing was considered controversial (Luty, 2005). In the 1970s my colleague and I had no serious problems prescribing heroin and cocaine. In the 1980s and’90s Dr John Marks successfully prescribed heroin in Widnes but there was great hostility to his programmes. I have not seen his success mentioned in official or clinical discussion, including the 2003 guidelines from the National Treatment Agency for Substance Misuse. He has been ‘air-brushed’ out of history.

It is admitted that there has been marked underprescribing of methadone and a failure to undertake methadone maintenance (Dole & Nyswander, 1965; Department of Health, 1999; National Treatment Agency for Substance Misuse, 2003). In addition, few if any current addiction specialists have adequate experience of prescribing injectables. Our current specialty appears unprepared to develop established and new practices.

Current biomedical ethics embrace four principles (Beauchamp & Childress, 1994):

• Autonomy. The patient’s right to self-determination. This is the basis for ‘informed consent’. These guidelines do not allow for autonomy. Drug users can justly say ‘never about us without us’.
  
• The principle of non-maleficence. At the very least do no harm to our patients. How do we stand when we abruptly withdraw a patient from prescribed medication because of use of ‘street drugs’, as recommended by the 2003 guidelines?
  
• The principle of beneficence. This involves confidentiality and keeping a safe distance between our duty to the patient and the demands of the state.
  
• The principle of justice. We must not confuse morality, legality and respectability. It is just as right or wrong to give your children alcohol as it is to give them heroin, cannabis, ecstasy or any other recreational ‘drug’. The moral status of a drug does not change with its legal status. The morality of using a drug is not altered by the fact that the use of one drug is respectable and another is not. Laws not sinful acts make crimes.
  

These 2003 guidelines for prescribing injectable heroin (National Treatment Agency for Substance Misuse, 2003) translate into clinical terms the state policies of the prohibition of drugs. The fact that most medical practitioners accept prohibition does not make these guidelines either ethically sound or good clinical practice. Addiction medicine is a specialty betrayed.

References

BEAUCHAMP, T. L. & CHILDRESS, J. F. (1994) Principles of Biomedical Ethics. Oxford: Oxford University Press.

BRITISH MEDICAL ASSOCIATION (1992) Medicine Betrayed. London: BMJ Books.

DEPARTMENT OF HEALTH (1999) Misuse and Dependence – Guidelines on Clinical Management. London: Stationery Office.

DOLE, V. P. & NYSWANDER, M. (1965) A medical treatment for diacetylmorphine (heroin) addiction. JAMA, 193, 80 –84.

LUTY, J. (2005) New guidelines for prescribing injectable heroin in opiate addiction. Psychiatric Bulletin, 29, 123 –125.[Free Full Text]

NATIONAL TREATMENT AGENCY FOR SUBSTANCE MISUSE (2003) Injectable Heroin (and Injectable Methadone): Potential Roles in Drug Treatment. London: NTA. http://www.nta.nhs.uk

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