For the stories behind the news
and public ignorance have forced us to
collapse any new diamorphine prescribing
into a tight wad of supervision, medicalisation
and regulation while prohibition, politics and
the soundbite media have 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 people be left
until people had been forced to suffer through
a series of personal disasters and treatment
failures? Did this narrative help to diminish
the intervention?
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 a
‘drug problem’ as 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 to save their prescriptions
altogether. They are frightened, most of them
are in their fifties and had qualified for
diamorphine many years ago because ‘nothing
else worked’; what now are they to do?
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 more than ten
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 LSE 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 (eg Dr John Marks), today we
see a method that has evolved across Europe;
the Swiss, the Dutch, the Germans and the
Danes, among others are all doing it – treating
thousands of clients and 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 restart 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, clinicians
should not be restricted to methadone or
subutex, or our clients subjected to a binary
‘take it or leave it’ choice in services.
Erin O’Mara is editor of
Black Poppy
magazine
and it currently volunteering at Release
December 2015 |
drinkanddrugsnews
| 7
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 two, 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 British ‘approach’ (as may arguably be
a more appropriate phrase to use) had once
allowed for a level of evolution; of
experimentation and pharmaceutical
flexibility; three characteristics that are
glaringly missing from frontline 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 publically
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 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 is
now interfering in treatment to such an
extent that the formulation that the patient
feels works best for them (physeptone tablets,
heroin, morphine, oxycodone, DF118s
etc
) may
no longer fit into today’s homogenous and
fixated theme of methadone or
buprenorphine, one part of a backwards step.
The days when heroin prescribing was
defended as tenaciously as a doctor's right to
prescribe unhindered are almost gone. Fear
‘Why must a treatment that has
proven to be the optimum for so
many people be left until people
had been forced to suffer
through a series of personal
disasters and treatment
failures? Did this narrative help
to diminish the intervention?’
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