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Shouldn’t methadone be judged on level playing field?

Dr Meg Thomas, a GP in Newbury, Berkshire, argues that methadone maintenance treatment needs backing and shouldnt' be sacrificed as the NHS searches for cheaper solutions.

Dr Meg Thomas, a GP in Newbury, Berkshire, argues that methadone maintenance treatment needs backing and shouldnt' be sacrificed as the NHS searches for cheaper solutions.

Susie's eyes are turned to the surgery floor. Her hair hangs over them, long and lank like a curtain around her psyche. The GP has tried to raise her self-esteem (and natural endorphins) by a referral to a structured day programme or the gym – but those attempts have failed. Susie remains demotivated. She prefers to hide from the world, cocooned in a haze of heroin-induced comfort.

‘You're missing the point,' she says. ‘People take drugs to make them feel good.'

So the GP admits defeat. There is no point in repeating the health promotion mantra. Susie doesn't care about blood-borne viruses, thrombosis and the risk of overdose. She doesn't care if she lives or dies. And she is right – the human race has always turned to substances to escape. Take a look at the diverse examples from history and the present day – from Queen Victoria to Sigmund Freud to Pete Doherty. But now also look at examples from our patients.

Mr X is a 35-year-old man with chronic back pain. The pain clinic has tried a wide range of interventions. He has refused psychological approaches. He takes dihydrocodeine 60mg four times a day and attempts to wean him off have been unsuccessful.

Miss C attends regularly to collect a script for fluoxetine. The GP asks her each time if she wants to explore her problems further. She declines. Her mum needed fluoxetine to get through life. She feels she is the same.

Miss H is a 37-year-old who spent most of her childhood in foster care. She has a history of sexual abuse. After 12 years of opiate misuse, she has been clean for two years. She lives with her partner and looks after the house, garden and cat as well as doing a cleaning job. She is maintained on 15ml of methadone a day, and wants to reduce this very gradually under her own terms. She does not want to have contact with the local drug and alcohol team because ‘they are nice but don't help'.

One of these challenging, ‘non engaging' patients is at risk of rationing. No prizes for guessing which. The most disadvantaged in life are the most disadvantaged in our health system. The inverse care law is alive and well in the 21st century1.

Miss H has received a letter from the local drug service to say that as her contact has lapsed her GP will be advised to commence a ‘therapeutic' withdrawal of her script by 5ml a fortnight. Her GP faces difficult choices. If she keeps the patient as safe as possible by continuing to prescribe, she works in isolation, contrary to guidance and at medico-legal risk2. If she complies, her patient is more likely to relapse3.

This is the scenario in my area, where the specialist prescribing service is overspent, with a big waiting list to assess new problems and pressure to discharge long-standing cases. Nationally the situation is variable, but GPs elsewhere are experiencing similar problems, perhaps because methadone maintenance is seen as an easy target for funding squeezes.

The GP sympathises with the local service which is chronically underfunded and under pressure. She wonders if she should investigate cheaper prescribing options and more cost-effective pathways of care and present them to the PCT. But more acutely she considers her patient's best interest. She has reviewed the evidence for methadone maintenance treatment and it is extensive and convincing3.

Although most of the original results come from the US, UK evidence is accumulating. It shows not only the success of primary care management but also that enforced reduction in dose is ineffective4, 5.

Methadone maintenance treatment retains patients in treatment and decreases heroin use better than treatments that do not use opioid replacement therapy3. Factors that improve retention include use of optimal dosing, add-on psychosocial support, take-home doses, rapid assessment, non-punitive urinalysis and importantly ‘long-term maintenance philosophy'6. Maintenance therapy improves a range of health outcomes and saves young lives. The number needed to treat to save one life after two years of treatment is five7. This is important. The mortality risk of people dependent on street heroin is estimated to be around 12 times that of the general population7.

About half of all recorded crime is drug-related, with associated costs to the criminal justice system estimated at £1bn a year7. Maintenance therapy reduces offending behaviour – for every £1 spent on drug use £3 is saved4. The false economy of rationing services is therefore infuriating.

Although some dependent people may make dramatic changes without treatment, the inherent chronicity of opiate misuse makes methadone maintenance therapy the most realistic option for the majority. Abstinence occurs only after repeated cycles of cessation and relapse. Treatment histories span decades. Maintenance prolongs periods of abstinence, allowing health and social factors to improve.

The RSA Commission spent two years investigating drug policy8. It concluded more emphasis should be placed on harm reduction. It has been ignored. GP prescribers and their patients are in the firing line.

Dr Meg Thomas is a GP in Newbury, Berkshire.

The patients mentioned in this article are fictional but based on real life scenarios.

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