Prescribing smokable drugs

Prescribing heroin: John Marks, the Merseyside clinics, and lessons from history

The prescribing of heroin has a long and contentious history as a method for treating people with heroin problems. This paper revisits a controversial 'experiment' with heroin prescribing in Northwest England between 1982 and 1995, led by the psychiatrist Dr. John Marks. Marks' work has been shrouded in myth and misinformation for many years and the paper presents an evidence-based reconstruction of this episode, drawing on archival sources, published and unpublished documents, and a small number of interviews with key informants. During this 13-year period, Marks worked across clinics in Liverpool and two neighbouring towns, founding his practice on the long-term maintenance prescribing of opiates, including injectable heroin and smokable heroin reefers. The high media profile of the work, in the context of a febrile local politics in Liverpool, a powerful British addiction psychiatry establishment and an always-heated international politics of drug control, brought immense political pressure and led eventually to the closure of the clinics. The Marks 'experiment' raises important challenges to the premises, practices and philosophy of heroin maintenance - particularly the questions of thresholds and criteria for access, and the purposes of intervention - as well as to the wider regime of prohibitive drug laws.

Heroin-assisted treatment in Switzerland: a case study in policy change

BACKGROUND

Switzerland introduced a pragmatic national drug policy when the former conservative abstinence-orientated politics proved unable to cope with an escalating number of users and related negative consequences for public health and public order. The high visibility of 'needle parks' and the size of the acquired immune deficiency disorder (AIDS) epidemic called for a new approach and for national leadership.

AIMS

To describe the intentions, the process and the results of setting up the new treatment approach of prescribing heroin to treatment resistant heroin addicts, as an example of drug policy change.

MATERIALS AND METHODS

A systematic collection of relevant documents is analysed and used as evidence for describing the process of policy change.

RESULTS

Measures to reduce the negative consequences of continued use and to prevent the spread of AIDS were started mainly by private initiatives and soon taken up officially in the 'four-pillar' drug policy (including harm reduction, prevention, treatment and law enforcement). Medical prescription of heroin to chronic, treatment-resistant heroin addicts was one of the innovations, based on extensive scientific and political preparation. Detailed documentation and evaluation, ample communication of results, adaptations made on the basis of results and extensive public debate helped to consolidate the new policy and heroin-assisted treatment, in spite of its limitations as an observational cohort study. All necessary steps were taken to proceed from a scientific experiment to a routine procedure.

DISCUSSION

Comparable policy changes have been observed in a few other countries, such as The Netherlands and Germany, based on the Swiss experience, with equally positive results of heroin-assisted treatment. These experiments were designed as randomised controlled trials, comparing intravenous heroin against oral methadone, thereby demonstrating the specific value of pharmaceutical diamorphine for maintenance treatment in opiate dependence. The positive impact of policy change and the positive outcomes of heroin-assisted treatment were acknowledged increasingly nationally and internationally, but made it difficult to continue the process of adapting policy to new challenges, due to the low visibility of present drug problems and to changing political priorities.

CONCLUSION

A major change in drug policy was effectively realised under typical conditions of a federalist country with a longstanding tradition of democratic consensus building. Facilitating factors were the size and visibility of the heroin problem, the rise of the Aids epidemic, and a pragmatic attitude of tolerating private initiatives opening the way to official policy change.

Heroin prescribing in the “British System” of the mid 1990s: data from the 1995 national survey of community pharmacies in England and Wales

Prescribing heroin in the treatment of addiction has been, until recently, an exclusively UK practice. However, despite international fascination with such prescribing, no recent report exists on the extent or nature of the practice. Furthermore, no data have ever previously been available on dispensing arrangements and geographical localization of heroin-prescribing to addicts. Data are presented on heroin prescriptions being dispensed to addicts in 1995, collected through the national survey of a 1 in 4 sample of the 10 616 community pharmacies in England and Wales. The 64 heroin prescriptions constituted only 1.7% of the 3846 prescriptions for opiates being issued to addicts by regarding community pharmacists, while methadone accounted for 96.0%. Heroin daily doses were more than three times higher than for methadone. Heroin was mainly prescribed in injectable form and, in contrast to methadone prescriptions, was mainly dispensed on a daily basis. Major regional variations in the extent of heroin-prescribing in the United Kingdom have been identified, with these variations appearing to relate to the practice of individual doctors rather than the nature of the local problem.

Opioid Substitution: Critical Issues and Future Directions

Opioid substitution with oral methadone is the most widely implemented treatment for heroin dependence. In Britain, a complex array of specialist and generic health care services have evolved to deliver this treatment modality. Several minority aspects of British substitution practices receive enduring international interest, including the use of heroin itself as a substitute and the prescribing of methadone in an injectable form. This paper focuses on six linked dimensions that characterize substitution services: (1) treatment providers and settings, (2) prescribing regimes and treatment goals, (3) substitute drugs, (4) dose administration, (5) dose levels, and (6) substitute formulations. Against a background of increasing central and local accountability for the quality and efficiency of specialist providers and critical attention toward their effectiveness, the strengths and weaknesses of the British approach are considered and key issues and future directions are discussed.

Opiate treatments

One of the greatest of challenges facing medicine is to devise effective and appropriate treatments for opiate problems. Such treatments are based on principles derived from the disciplines of pharmacology and psychology, but are also shaped by social issues and even by the views of practitioners. There are many misconceptions about opiate problems. In this review it is suggested that there are good reasons for stating that opiate users do change over time, treatment can also lead to change and psychological interventions are of great importance. However, current methods of opiate detoxification are of low efficacy and methadone maintenance, although of benefit for some, is not a panacea for opiate problems.

Treatment and services for drug users in Britain

The pattern of British drug service provision was transformed during the late 1980s. Policy makers and service providers recognised the need for a more flexible response to changing drug trends and client needs; consequently community-based services proliferated. HIV has had considerable impact on the working approach of many agencies, where harm minimisation is now the immediate goal. This article provides an overview of patterns of drug use and drug service provision in Britain.

Cocaine in the UK--1991

More than 100 years after Freud's original endorsement of the drug, the use of cocaine is a problem for both users and for society, which struggles to organise effective responses to the epidemic of the last decade. During the 1980s the rapid spread of smokeable cocaine (including 'crack') was seen in the Americas (particularly the US). The initial simple predictions of an identical European epidemic were mistaken. The available data on the extent of cocaine use and of cocaine problems in the UK are examined. New forms of cocaine have been developed by black-market entrepreneurs ('freebase' and 'crack'), and new technologies have emerged for their use; with these new technologies have come new effects and new problems. The general psychiatrist now needs a knowledge of directly and indirectly related psychopathology which has an increasing relevance to the diagnosis and management of the younger patient.

Drug injecting and HIV infection: new directions for social science research

An overview is presented of the relationship between drug injecting and HIV infection. The pattern of spread of HIV infection among drug injectors and risk factors associated with the spread of HIV among drug injectors are considered, together with evidence on the adoption of behavior changes intended to reduce such risks. Some promising reduction in risky behaviors has been evident among established drug injectors. Public health prevention strategies, such as syringe distribution and exchange and AIDS outreach work, appear to have fostered decreases in HIV-related risks among drug injectors. The role of methadone maintenance remains uncertain. Despite advances, many obstacles remain. The future research agenda requires work on prevention strategies and the role of drug user treatment. Social scientists need to address the fact that patterns of drug-using behavior reflect powerful "structural factors" such as poverty, unemployment, and housing conditions.