I Think You'll Find It's a Bit More Complicated Than That by Ben Goldacre Page B

been recognised. Ghodse et al. (1985) analysed the patient records of notified addicts who died in the UK between 1967 and 1981, and found that among patients using heroin, three quarters of deaths were directly drug related, and ‘most deaths in which a drug was implicated were due to medically prescribed drugs’ (invariably methadone). A retrospective cohort study followed up 128 addicts who first presented in London in 1969, of whom twenty-eight had died, and reported similar findings.
    Reasons for this high mortality have been ascribed to its long half-life: a large number of deaths occur in the first few days of treatment, and this may be due to the chronic accumulation of the methadone in the bodies of addicts with reduced liver function. Other reasons proposed include black-market consumption, which is harder to quantify, and the co-administration of heroin and methadone, for which there is less evidence, albeit that death certificates provide notoriously poor data.
    Clearly there is a paucity of mortality data in the literature on methadone prescription. In 1994, a review of the methodology of drug treatment evaluation found that only four out of seventeen UK studies had used mortality as an outcome measure. To neglect this most ‘ineffective’ of outcomes, in studies of a drug which is prescribed to 17,000 British addicts, in whom it has a demonstrably higher mortality than the drug it is substituted for, seems extraordinary.
    Finally, and perhaps most bizarrely, it is generally recognised that methadone is a more addictive drug than heroin, with a more arduous withdrawal process, and this fact is recognised both among the drug-using subculture and in the scientific literature.
    Heroin on Prescription
    The current situation is that very little heroin is prescribed in the UK: it was estimated that 117 addicts were prescribed heroin in 1992, while 17,000 were prescribed methadone. Maintenance prescription of heroin, the ‘British System’ until the 1960s, is the ultimate extension of harm reductionist philosophy. There are many deductive arguments to support it, but little modern experimental data, and many criticisms that are laid against it. I shall consider these extensively, before examining the few studies of contemporary heroin maintenance programmes which have recently been published.
    The philosophy behind the prescription of heroin owes a lot to the findings of the Rolleston Committee in 1926, is similar to the thinking behind methadone prescription, and is essentially as follows: addiction itself is not something that is readily amenable to medical intervention, and as such opiates are prescribed to the addict for as long as they remain addicted, in order to keep them in a state of good health and leading as normal (and crime-free) a life as possible.
    Addiction has been famously characterised by Vaillant (1991) as a chronic relapsing condition with a spontaneous remission rate of 5 per cent per annum regardless of external intervention. This apparently flippant description is supported by empirical data on long-term follow-up of addicts which show that no external agency expedites the ending of addiction, not even major life events.
    With drug addiction, we are often choosing between problems, rather than solutions, and so heroin maintenance, which is only ever offered to patients who have failed with other modalities of treatment, could be considered the best of a bad lot. ‘With readily available prescribed opiates, there is no need to commit acquisitive crime to buy drugs, to sell drugs to others to finance one’s own use, and to risk one’s own (and others’) health, not to mention life, with adulterated drugs of unknown strength.’ It is also likely to promote attendance at the clinic for intervention when deemed appropriate, and an important side effect is the denial to criminals of a lucrative source of income.
    There are of course a number of criticisms of heroin prescription. The first is