I Think You'll Find It's a Bit More Complicated Than That by Ben Goldacre Page A
Book: I Think You'll Find It's a Bit More Complicated Than That by Ben Goldacre
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Authors: Ben Goldacre
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to healthcare professionals.
In order to be successful, therefore, a drug dependency unit must offer both treatment and the drug at a ‘price’ which the users are willing to pay: the prescriptions may be free, but the terms and conditions on which they are offered may act as a deterrent to some users, and the product offered (counselling services, advice, and possibly substitute drugs) must be appealing. Health economists have couched the problem in their own terminology: ‘For treatment to have a high take-up rate, it must sell … and be seen to sell … a good product at low cost.’
Retention in treatment, firstly, is an area where the philosophy guiding the work of a clinic may have as much of an impact as the nature of the drug it is offering. In a controlled study in Australia, heroin addicts were assessed and randomised to two clinics, one oriented to long-term methadone maintenance, and the other oriented to time-limited treatment, aiming primarily at abstinence from all drugs, including methadone. Both groups were urine-tested for heroin, and use of heroin outside the clinic was higher in the abstinence-oriented clinic.
An observational study in a different country showed that addicts were more likely to discharge themselves earlier from methadone clinics where the clinic staff scored highly on an ‘Abstinence Orientation Scale’, measuring their commitment to abstinence-oriented policies on heroin addiction. Other studies have shown that external compulsion to attend clinics, for example by law courts, is also associated with poor retention.
Conversely, a high re-attendance rate has been demonstrated at ‘user-friendly’ clinics where needle exchange and clean drugs are available, with no uninvited counselling. Experience has taught that regular and enduring contact with treatment services is a necessary precondition for successful treatment of addicts.
Finally, studies of drug users who present to rehabilitation programmes have shown that they are often in a poorer state of health than other heroin addicts in the population (of equally long standing) who have not chosen to present, and this is taken by some commentators to mean that addicts will only present as a last resort. Thus methadone programmes are by no means a universally attractive option to the addict population, and addicts often use their drug of choice to supplement their prescription.
Use of heroin outside the confines of a drug-rehabilitation programme (whilst ostensibly attending it) is, of course, associated with all of the risks of everyday heroin addiction: increased risk of intravenous drug use leading to infection, increased acquisitive crime, poor family relations. More importantly, the chaotic nature of the drug use means that the chances of abstinence after a period of regulated drug use are reduced. Thus use of heroin outside the clinic may be considered one of the definitively poor outcome measures.
However, methadone is also a dangerous drug in its own right: astonishingly, use of methadone has a higher mortality even than the use of illicit heroin, although to what extent is uncertain. For example, in 1992, there were 101 deaths from methadone, and forty from heroin; similarly, from 1982 to 1991 there were 349 methadone deaths and 243 heroin deaths: this is despite the fact that there are far more users of heroin, at every stratum of use, by a factor of at least 3:2, than of methadone.
However, to quantify the mortality requires an accurate denominator (the number of users for each drug), and this, as we have already discussed, can only be achieved indirectly for a covert and underground activity such as drug abuse. Estimates vary widely according to the denominator used, and authors are never so disingenuous as to claim pinpoint accuracy for their figures, but the most recent data to be analysed estimates the risk of methadone-related mortality at around four times that of heroin.
The dangers of methadone have long
In order to be successful, therefore, a drug dependency unit must offer both treatment and the drug at a ‘price’ which the users are willing to pay: the prescriptions may be free, but the terms and conditions on which they are offered may act as a deterrent to some users, and the product offered (counselling services, advice, and possibly substitute drugs) must be appealing. Health economists have couched the problem in their own terminology: ‘For treatment to have a high take-up rate, it must sell … and be seen to sell … a good product at low cost.’
Retention in treatment, firstly, is an area where the philosophy guiding the work of a clinic may have as much of an impact as the nature of the drug it is offering. In a controlled study in Australia, heroin addicts were assessed and randomised to two clinics, one oriented to long-term methadone maintenance, and the other oriented to time-limited treatment, aiming primarily at abstinence from all drugs, including methadone. Both groups were urine-tested for heroin, and use of heroin outside the clinic was higher in the abstinence-oriented clinic.
An observational study in a different country showed that addicts were more likely to discharge themselves earlier from methadone clinics where the clinic staff scored highly on an ‘Abstinence Orientation Scale’, measuring their commitment to abstinence-oriented policies on heroin addiction. Other studies have shown that external compulsion to attend clinics, for example by law courts, is also associated with poor retention.
Conversely, a high re-attendance rate has been demonstrated at ‘user-friendly’ clinics where needle exchange and clean drugs are available, with no uninvited counselling. Experience has taught that regular and enduring contact with treatment services is a necessary precondition for successful treatment of addicts.
Finally, studies of drug users who present to rehabilitation programmes have shown that they are often in a poorer state of health than other heroin addicts in the population (of equally long standing) who have not chosen to present, and this is taken by some commentators to mean that addicts will only present as a last resort. Thus methadone programmes are by no means a universally attractive option to the addict population, and addicts often use their drug of choice to supplement their prescription.
Use of heroin outside the confines of a drug-rehabilitation programme (whilst ostensibly attending it) is, of course, associated with all of the risks of everyday heroin addiction: increased risk of intravenous drug use leading to infection, increased acquisitive crime, poor family relations. More importantly, the chaotic nature of the drug use means that the chances of abstinence after a period of regulated drug use are reduced. Thus use of heroin outside the clinic may be considered one of the definitively poor outcome measures.
However, methadone is also a dangerous drug in its own right: astonishingly, use of methadone has a higher mortality even than the use of illicit heroin, although to what extent is uncertain. For example, in 1992, there were 101 deaths from methadone, and forty from heroin; similarly, from 1982 to 1991 there were 349 methadone deaths and 243 heroin deaths: this is despite the fact that there are far more users of heroin, at every stratum of use, by a factor of at least 3:2, than of methadone.
However, to quantify the mortality requires an accurate denominator (the number of users for each drug), and this, as we have already discussed, can only be achieved indirectly for a covert and underground activity such as drug abuse. Estimates vary widely according to the denominator used, and authors are never so disingenuous as to claim pinpoint accuracy for their figures, but the most recent data to be analysed estimates the risk of methadone-related mortality at around four times that of heroin.
The dangers of methadone have long
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