Substitute Prescribing Paul Smith BS.c Addiction Counselling

Methadone and OST Background 1924 – Rolleston Committee; set out principles that have remained fundamental to the British approach to heroin addiction ever since. 1.People with incurable addictions could be maintained on a usually small amount of the drug. 2.Addiction is a predominantly middle class phenomenon, so criminal sanctions were unnecessary as few, criminal, or lower class addicts were known. 3.Addiction to such drugs as heroin or morphine was a minor problem in Great Britain. 4.Doctors should be allowed to supply addictive drugs in the same manner as they supplied controlled drugs (

1960’s - The number of addicts was increasing rapidly from 500 upwards. Doctors’ were prescribing excessive amounts of heroin which was finding its way onto the black market The Brain committee recommended the restriction of heroin prescribing to licensed Doctors who were working in hospitals or special clinics – Special clinics started substitute prescribing of heroin by methadone, first by injection, swiftly followed by oral administration. (Kooyman 1993) The first study of heroin addicts being treated with methadone was by Dole and Nyswander (1967) in the United States. The outcomes were deemed as successful and the term Methadone Maintenance Treatment was born.

Evidence The Medical Case - Studies show that there are no serious side effects to methadone use. Minor side effects such as head aches, nausea and a changed libido had been documented but they all diminished upon the patient finding their correct dosage See fig 2. The Psycho-social case - Methadone or sublingual pharmacological opiate replacement treatments can help support people to have better social relationships; holding down an occupation; feeling good about oneself; being independent, and having a meaningful life. Conversely, stigmatisation; discrimination and dependence on methadone and the drugs paralysing effects on emotions are all noted negative consequences (De Maeyer et al 2011). The Moral Case - A moral argument has been underway for some time in the substance misuse treatment field and in wider society, in regards to whether methadone is the best way of treating opiate addicted individuals See fig 2. However, recently the argument is focussing more and more on time limited opiate substitution treatment

Methadone Related Deaths in England & Scotland – Deaths peaked in the 1990’s in both methadone only and any mention of methadone. Scotland - 20 people per million in 1996 to 2 per million by 1999 and has stayed steady. Any mention of methadone reduction was more graded from 58 per million falling gradually to 18 per million. England – Annual deaths due to methadone was at its highest level in per million in just methadone, decreasing over the next 6 years to 6 per million and levelling out. A similar reduction in deaths of any mention of methadone occurred. (Strang et al 2010)

What Could Be Happening ? This drop off in mortality rate coincided with supervised consumption Better education re: Dangers of mixing methadone and other drugs especially alcohol ? People getting the correct dosage ? Other opiate substitute treatments becoming available such as: Subutex and Suboxone ? Changing culture, drug habits and social norms ? More focus on abstinence based treatment ?

OST and Recovery “..No longer, will addicts be “parked” on methadone or similar opiate substitutes without an expectation of their lives changing. We must ensure all those on a substitute prescription engage in recovery-driven support to maximise their chances of being free from any dependency as soon as is practicable and safe..” (Uk Gov Putting Full Recovery First 2011) Putting Full Recovery First, outlines the Government's roadmap for building a new treatment system based on recovery, guided by three overarching principles– wellbeing, citizenship, and freedom from dependence. These principles can be found in various studies looking to define what recovery is “..Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health and citizenship (Betty Ford Institute 2007).

In 2014 the Advisory Council for the Misuse of Drugs (ACMD) was asked to look at whether the evidence supports the case for time-limiting opioid substitution therapy (OST); and if so, what would be a suitable time period and what would the risks and benefits be? The overall conclusion of this report is that the evidence does not support the case for imposing a blanket time limit on OST treatment for heroin users, and this approach is not advised by the ACMD. OST can be a very helpful part of treatment and recovery for those with heroin dependence, but it is unhelpful to focus on the medication alone and if heroin users are receiving ‘medication alone’ without concomitant psychosocial interventions and recovery support – this approach is not in line with national guidelines and limited recovery outcomes are likely (ACMD 2014)

Where Next for OST ? There was little mention of drug treatment strategy in any of political parties manifesto’s. The present Government did mention before being elected that they would look to a report by the Centre for Social Justice entitled Ambitions for Recovery (2014) if elected. This report champions abstinence suggesting “..far too many heroin addicts, up to 150,000 are languishing on OST, effectively replacing one addiction for another (many users’ supplement their methadone with heroin).” Adding that the 2010 drugs strategy failed to produce the Recovery Revolution it set out to. Moved on but in the same place ?

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