2 April 2001

Addiction: April 2001

Editorial and debate on injectable methadone by Zador. Addiction (2001) 96:547-553.

Zador's perfectly sensible description on the prescribing of injectable methadone by British doctors is challenged by others on some of the most spurious grounds. Both Malcolm Lader and Jerome Jaffe state that it is medico-legally fraught, being non-evidence based medicine. But they ignore the 'out' that this treatment may be the only reasonable alternative for certain heroin dependent folk in whom other treatments have proven unsuccessful or unacceptable. In such a case it may be possible be prove medical negligence by NOT continuing such apparently effective treatment. This may also be the case in a small number of previous trial subjects in Queensland who were given this treatment some years ago. Much treatment given by doctors currently is not strictly evidence based, such as antibiotics for 'bronchitis'.

Jaffe goes through several possible reasons why such prescribing is not appropriate (cost, political acceptability, evidence base) yet he accepts that research might show that it could be so! He even uses the old peccadillo about supplying alcohol to alcoholics and tobacco to smokers 'all paid for indefinitely by the taxpayers'. Of course these drugs ARE CURRENTLY made available by all our governments at reasonable cost to all addicts, and to the very great benefit of the public purse through taxes. It is unusual for this respected researcher to inject such irrelevancies into this otherwise very serious discussion.

Jaffe writes for three pages, his arguments sounding more like those of a politician or a journalist-with-a-mission. He implies that the issue is enormously complex which is simply not the case. This prescribing is either defensible as good medical practice, or it is not. If it MIGHT be, we need more research. Simple!

The limited research that does exist is virtually all encouraging. Prescribing injectables to addicts appears to 'work' in a similar manner to oral methadone, and it may do so in some patients who fare poorly with existing treatments, thus enshrining it as ethical, if of uncertain application.

The article by Strang and Sheridan on relative dosing practices between private and public sectors in England is also of interest (Addiction (2001) 96:567-576).

These authors have conducted yet another elegant and useful study documenting the poor quality of care received by English dependent patients on methadone under the NHS. It is possible that private doctors also are guilty of giving poor treatment but these surveys did not question concurrent prescription of stimulants, or if they did we are not enlightened on the findings. Some private practices are notorious for multiple, gross over-prescribing, including stimulants and one was even the subject of an episode of "The Bill" a few years back.

Since supervised consumption, even in new patients, is exceptional in England, it is not possible to know how much methadone in private of public sector was actually consumed. It is certain, however, that some public sector patients received markedly inadequate doses.

As they point out, there are weaknesses to the study, but one strength is that it is clearly shows that the mean dose of oral methadone in public patients is around 50mg daily, a finding which is consistent with other British reports. As Strang's own guidelines point out, effective doses are usually in the range of 60mg to 120mg daily with only a small proportion of patients requiring more or less than this range. Even allowing for some patients on reducing doses, a mean dose of 50mg would imply that more than half of these patients may be receiving inadequate and therefore ineffective doses. This regrettable situation is still not acknowledged by the authors despite the unfolding tragedy which is dependency treatment in England and Wales in recent years.

Editorial by Juan Negrete, Montreal. Addiction (2001) 96:543-5

This is intriguingly slanted piece heaps scorn on the large proportion of the professional community which perceives benefits in harm reduction principles. The author fails to carefully define what he means by harm reduction which makes his article almost worthless.

It outlines an unscientific and near hysterical viewpoint on harm reduction, a policy most now consider close to 'motherhood' and which has been shown to save countless lives in its various implementations.

Juan Negrete criticises supporters of harm reduction in a most unflattering manner. He says that harm reductionists' aims towards improving methadone treatment only make it easier to get by removing barriers. But he fails to accept that like every other medical intervention, methadone treatment and any variations on its implementation, are subject to rigorous evaluation and hence improvements should only follow normal research findings, not the arbitrary views of any individual parties.

Negrete roundly criticises the Swiss heroin trial, but accepts that if benefits were found, he would review his opinion. How elegantly he contradicts himself, since only by running such a trial could benefits be demonstrated? And they were! The outcomes clearly showed that among 1146 treatment refractory patients there were very high retention rates and low mortality rates along with benefits regarding employment and housing. It is inescapable that this treatment attracted large numbers of otherwise 'treatment-refractory' patients into treatment and kept them alive over the three years of the trial. Is preventing death a 'benefit to patients'?

After faintly praising methadone treatment, Negrete says that maintenance therapies are 'irreversible' and he implies that they prevent addicts attaining drug free status. But people come off methadone successfully all the time! His emotive terminology reveals his clear unhappiness with the field: "harm reduction ideologues"; "compulsive toxicophilia" (is this English?); "drug reward slavery"; [addicts are] "much diminished human beings"; "primitive self-centredness of their pursuit"; "well meaning harm reduction workers who do not assign much importance to the problem of addiction". These are not the usual terms of clear scientific writing and if applied to those dependent on legal drugs would be considered offensive and outrageous by many such people.


It is surprising to find such items in 'Addiction', the world's oldest scientific journal on dependency.

Comments by Andrew Byrne ..