5 May 2013

Reply to Luty - BMJ letter - Maintenance not rocket science.

This letter was published in response to Luty's interesting item about the UK decision to ban methadone maintenance and insist that all treatment be abstinence directed (!). http://www.bmj.com/content/346/bmj.f1481

Dear Editor,
Luty is unduly pessimistic about long term abstinence after opioid maintenance treatment.1 About 4% of addicted people become abstinent each year, regardless of treatment.2 By 10 years, over a third are abstinent. The remainder are mostly on maintenance treatment, a small, efficient part of any health system, which often needs little more than an experienced GP and pharmacist. This saves lives and reduces many negative aspects of addiction.3

Those denied appropriate treatment have death rates up to seven times higher than those treated.4 This is especially important on prison release, where access to treatment should be the dual responsibility of the health and custodial systems.

Politically inspired rule changes by the NHS cannot alter what is sound medical practice. Opioid pharmacotherapy is fundamentally no different from treating other chronic conditions but is better researched than most. New and unstable patients need frequent reviews, whereas others can be seen less often to check dose levels, progress, ancillary services, and so on.

Another disadvantage in the UK is that buprenorphine, the only evidence based alternative to methadone, is sometimes not available because of its high cost.

Opioid maintenance is not rocket science, yet for decades the UK had the twin problems of inadequate dose levels and almost non-existent formal dose supervision.5 These factors so limited success that many now doubt the benefits of the treatment as used in the UK. Current and past leaders in the dependency field must take responsibility for those deficiencies, which are currently causing politicians to dismantle an essential intervention implemented in most Western countries, and now even in China.