The UK Advisory Council on the Misuse of Drugs has given the UK’s national methadone programme a bullish seal of approval – it’s not less methadone we need – prescribed to addicts for less time – but more methadone prescribed without time limit. That in a nutshell is the latest recommendation from the ACMD’s Recovery Committee.
To those who have expressed legitimate concern about the UK methadone programme, this report betrays a regrettable reluctance to subject the programme to much needed critical scrutiny. Even within its own report the ACMD acknowledges that 15 per cent of heroin addicts had been prescribed the drug for more at least five years – a finding which once acknowledged is then set aside never to be referred to again.
Within some parts of the UK, methadone is associated with more deaths than the heroin for which it was prescribed as a treatment. An inconvenient fact that does not even get a mention in the report.
Nor does the report give any mention of the finding from research led by one of the UK’s most ardent supporters of methadone (Dr Roy Robertson) who found that addicts prescribed the drug remained drug dependent for decades longer than those who were not prescribed the drug. That finding led those leading the team undertaking this research to conclude that whatever the positive benefits of methadone in reducing drug-related deaths, the drug was inversely related to recovery – in other words those drug users who were prescribed the drug stood less chance of recovering than those who were not prescribed the drug. If ever there was an inconvenient truth for a Recovery Committee looking at the impact of methadone on treating addiction that must surely be it, but this finding does not even get a mention in the report.
The key question in relation to the UK methadone programme is not really about whether addicts should be on the drug for one year or two years, but how to ensure that for however long they are on the drug they are continuing to derive some positive benefit from it. The case for methadone, including the case for how long it should be prescribed, has to be tied to regular, authoritative and penetrating assessment aimed at answering the question of whether this addict or that addict is continuing to derive benefit from the drug. If they are, then continue to prescribe it to them; but if they are not, then the prescription should cease.
Here of course one runs into the difference between the evidence on the impact of methadone derived from research studies and the evidence of its effectiveness at an individual clinical level. The Council refers to research from the US on the benefits of uninterrupted methadone and the dangers of premature cessation of methadone prescribing. That evidence, however, is a long way from determining the benefit of the drug for individual patients and determining how long individual patients should continue to be prescribed the drug. It also goes without saying that prescribing of methadone in the US is a very different beast to methadone prescribing in the UK. Within the US, drug testing and supportive counselling are integral parts of the methadone programme – within the UK drug testing is a relative rarity, while prescribing methadone in the absence of supportive counselling is commonplace.
The Council’s report seems to be infused with a belief that individuals should be prescribed methadone for as long as they want it, or for as long as prescribers are happy to prescribe it. The mindset of unlimited methadone prescribing hardly seems congruent with the reality of scare health resources and economic austerity. Surely we should be undertaking rigorous cost effectiveness assessments of methadone, identifying the length of time over which it remains cost effective to prescribe the drug and ensuring that those analyses contribute to clinical decision-making. The kind of superficial recommendation of limitless prescribing should have no place in a report from the ACMD, which exists to advise ministers on the best available evidence, and to ensure that where the evidence is lacking ministers are charged with the responsibility of ensuring its collection.