The State We’re In: Heroin Prescribing in the UK
“I feel like they are waiting for the last handful of us to die off and that will be the end of heroin prescribing in Britain, as we know it”, I said miserably.
Gary turned, looking at me seriously through his spectacles and replied, “If we don’t try and do something now there will be no diamorphine prescribing left anywhere in the UK."
Gary Sutton (head of Drugs Services at Release) tapped away on the computer in front of me, putting the last few lines on a letter to yet another treatment service who had been forcibly extracting a long term client off his diamorphine ampoules and onto an oral medication. It was proving to be a painful and destructive decision for the client, who was experiencing a new daily torment as his once stable life began to unravel around him.
The Release drugs team and its helpline -- known affectionately as ‘Narco’ -- receives phone calls from people in drug treatment from all over UK. By doing so it serves as the proverbial stethoscope clamped to the arrhythmic heart of our nation’s drug politik and bears a chronological witness to the fallout from Number 10 affecting the individual, both on the street and in treatment. In other words, we witness the consequences of policy and treatment decisions, and try and support or advocate for the caller.
But as winter draws the shades on yet another year in the drugs field, we find we are bearing witness to a tragedy, one of small proportions but with huge implications. It involves the last vestiges of the British System of drug treatment, the "jewel in its crown" -- heroin prescribing -- and the decline of the NHS, under assault from a mercilessly competitive tendering process and the crude procurement that is defining its replacement. Is that where we are really heading?
It may be true to say that to try and define the old "British System" is to trap its wings under a microscope and allow for a possibly contentious dissection; the late "Bing" Spear, formerly Chief Inspector of the Home Office Drugs Branch, might be the first in line by reminding us that the implications of “’system’ and ‘programme’ suggests a coordination, order and an element of (state) planning and direction, all totally alien to the fundamental ethos of the British approach.” His point being that the essence of the British System was that it “allows the individual doctor total clinical freedom to decide how to treat an addict patient."
John Strang and Michael Gossop, in their thoroughly researched double volume book, "Heroin Addiction and the British System," stated in the epilogue of volume 2, that "Amongst the (probably unintended) benefits of [this] approach may be the avoidance of the pursuit of extreme solutions and hence an ability to tolerate imperfection, alongside a greater freedom, and hence a particular capacity for evolution."
The average diamorphine prescription. A long way from street smack.
The British "Approach" (arguably a more appropriate phrase) had once allowed for a level of evolution, of experimentation and pharmaceutical flexibility; three characteristics that are glaringly missing from front line drug treatment today. Although we have no room to discuss clinical guidance here, it is often the case that when presenting services with complex individual cases at Release, we are rebuffed by the response "it’s not in the guidelines," "it’s not licensed," or even, as if drug workers are loyal party backbenchers, "it’s not government policy"!
Hindsight is a gift, and although many of us could while away the hours pontificating about just how and why it all went so publicly wrong for our "unhindered prescribers" back in the day (think Drs Petro, (Lady) Frankau, and a handful of others), that would be to miss the point. The reality is, once we pick up and examine the pieces of the last 100 years, there are shining areas of light in our British Approach. Marked by both a simple humanity and a brilliant audacity, it permitted a private and dignified discussion between both doctor and patient to find the drug that created the preconditions for the "patient" (today the "client") to find the necessary balance in life.
Are we really back to the days of having to ask to be treated as an individual? Policy in treatment is today interfering to such an extent that the formulation that the patient feels works best for them (physeptone tablets, heroin, morphine, oxycodone, DF118’s etc.) may no longer fit into today’s homogenous and fixated theme of methadone or buprenorphine, one part of a backwards step.
Although the days of unhindered diamorphine prescribing are almost gone, thankfully there is still a small group of well informed and supportive doctors, some of whom hold the rarefied Home Office licence to prescribe diamorphine to people who are opiate dependent. Regrettably, there appear to be a good number of licensees who don’t use their license to treat opiate users at all possibly having never to have had the good fortune to encounter a suitably needy client in their catchment area. Is it possible that they remain content to absorb the kudos and "super specialist status" that the licence conveys without doing any of the work?
Fear and public ignorance has forced us to collapse any new diamorphine prescribing into a tight wad of supervision, medicalisation and regulation, while prohibition, politics and the soundbite media has meant that we have been doomed to discuss this subject under the umbrella of "treating the most intractable, the most damaged, the treatment failures, the failures of treatment."
Why must a treatment that has proven to be the optimum for so many, be left until people have been forced to suffer through a series of personal disasters and treatment failures? Did this narrative help to diminish the intervention? One of the benefits of the old style of heroin prescribing has been the ability to take it home and use it like one might use insulin, which permits a level of independence central to any functioning life of work and leisure. This small, although hugely significant, freedom can still fit comfortably as part of a transitional route for people progressing through more heavily supervised heroin programmes towards less supervision, and as such needs to be retained, even embraced.
The last few dozen people left on take-home diamorphine prescriptions in the UK today seem to be stable, functioning, often working people who no longer have so much as a "drug problem" but a manageable drug dependence. This last group of diamorphine clients are remnants of the old system with, it appears, no new people taking their places once they leave. Today these are some of the very people who are now ringing the Release helpline to try and save their prescriptions altogether. They are frightened, most of them are in their fifties and having qualified for diamorphine many years ago because nothing else worked, what now are they to do?
In Switzerland, diamorphine prescribing has been so successful; they even have two programmes in prisons. (Now there is a Sun headline, if I’ve ever seen one!). Clients in their community programmes pay around 45 Euros (£32) a month for their ‘scripts, something most British heroin users/OST clients would probably agree to in an instant if it meant diamorphine was offered.
In Britain, diamorphine prescribing has been ensconced in a political and clinical debate about the expense and fears of an imaginary tsunami of diversion. Yet what of today’s financial wastage? We have ways to deal with diversion, yet poor and frequent commissioning has a number of serious consequences, including a lack of continuity of care, a slide back to postcode variance, and not least, cost. An exercise to quantify the costs of tendering services over 10 years ago came up with a figure of £300,000 as the sum expended by all bidders and the commissioner, per tender. Money that could be better spent, surely?
A few weeks ago the London School of Economics put on a mini-symposium on diamorphine with a panel of international clinicians, academics and research experts. Everyone present agreed that prescribing diamorphine, albeit in a very controlled supervised manner, had tremendous merit. Taking the idea from the success in Britain (e.g. Dr John Marks), today we see a method that has evolved across Europe; the Swiss, the Dutch, the Germans and the Danes, amongst others, are all doing it, treating thousands of clients, with great results. So it was more than frustrating to hear that our own diamorphine clinical trials had been closed this year with no plans to re-start them.
Diamorphine should not end up marginalised and discarded because a controversial new "system" finds it far harder to tolerate than the patients who receive it do. The benefit is proven. It’s not a choice between maintenance and abstinence. Addiction is not reductive to either/or and as treatment is neither just a science nor an art. Our clinicians should not be restricted to methadone or Subutex, or our clients subjected to a binary "take it or leave it" choice in services.