And the BMJ goes One Better!

July 17th issue has a front cover showing a cup of methadone bearing the slogan: "Drug Users and HIV: Treat Don't Punish. Well amen to that, and inside is an editorial asking for an evidence based drugs policy and an excellent article by Steve Rolles titled "An alternative to the war on drugs" - with arguments that many of you might be familiar with if you have followed Transform's activities over the years. There is also a sobering article on the HIV epidemic in Eastern Europe (where methadone prescribing is not available). So, you might think - why is the NTA considering time limited methadone prescribing in the UK? (read the Guardian article here)

I don’t think this discussion from the NTA proposes that we come full circle, to the situation 15 years ago of enforced abstinence and time limited treatment, with its good evidence of being bad practice with poor outcomes. MMT studies over the past 15 years show a gratifying reduction in deaths, crime, and BBV rates – which is excellent, and the NTA would manifestly not disagree with those numbers, nor NICE etc….what I think they are trying to say is what all of us, if we are honest, know – namely that methadone for all its wondrous powers of harm reduction, is just as powerful at motivation reduction – and many patients just drift on for ever in (correctly) non punitive treatment regimes, using a bit of heroin now and again, and leading what most would consider to be very commuted lives, and generally contributing less to society and themselves than they could. Yes of course this is as good a life as is probably possible for those with mental health problems, learning difficulties or whatever ….and yes, if people want to use drugs in a controlled and relatively low-harm way, then I would defend their right to do so…. But politicians and the public have the right to question the bias towards a treatment which seems to preserve inertia (at enormous cost to the Welfare State) rather than facilitate change. We have all got anecdotes of people who are apparently wearing suits, holding down clerical jobs with a Ford Mondeo in the garage and happy children whilst taking 150ml methadone daily, but we have been bloody awful in the past 15 years at collecting evidence of that: the pleural of anecdote is not evidence….and the consequence of our failure to get evidence for what we think, is the problem which now faces us.

The most powerful motivator for an addict to change is the harm that he/she encounters, and methadone nulls out much of that harm which is why we use it. The challenge is preserve external drivers to change, whilst reducing the harm – that is the Philosopher’s Stone of addiction treatment.

BJGP has an interesting issue!

I thought that might grab your attention! this month's issue has an interesting editorial by Gerry Stimson and others on illegal drug use in an ageing population which pin points many of the challenges we will be facing in the years to come (as doctors that is!). And there is a slightly dry statistical analysis over 8 years of Scottish GPs treating drug users....but showing (with concern but no surprise to me) that "the new GP contract may have decreased GP involvement in treating drug misusers". But the star piece goes to Jenny Keen's group whose paper on a targeted GP led programme to treat addicted sex workers, which at one year recorded 100% of the cohort still retained in treatment, only 33% still sex working, heroin use had fallen and quality of life was enhanced. This is great general practice addiction work, and I suspect that many are doing equally good work elsewhere but Jenny seems to be the only one of us who has the energy, commitment and academic robustness to write papers.

(No hyperlinks I'm afraid, the BJGP is subscription only)

NICE Alcohol guidance

...has at last been released, and is fairly uncontentious. I think that some of the sections will fill acute Trusts with foreboding, as there is a clear mandate for admission for formal detox in some cases - making the standard policy (in some hospitals) of bouncing drunks out of A&E more difficult to defend. You can read the guidance here.