Dipipanone

Tighter legal controls on drug prescribing are not the answer

Rising drug related deaths alarm treatment providers, legislators, and society. The recent report from the Advisory Council on the Misuse of Drugs, Reducing Drug Related Deaths, suggests that lax prescribing is responsible for a significant proportion.[1] It supports recent national guidelines on managing drug misuse, emphasising the supervised consumption of controlled drugs.[2] On the same theme, the UK Home Office proposes extending the licensing system for addiction prescribing to cover all controlled drugs except NHS prescriptions for methadone mixture.[3] Yet an expansion in the licensing system is likely to reduce accessibility of treatment and so increase drug related deaths. We believe that a clinical governance based solution would more successfully enhance treatment quality, safety, and accessibility.

Currently Home Office licences cover only heroin, cocaine, and dipipanone, and about 100 doctors (mainly specialist psychiatrists) have licences. The licences encompass prescriptions for about 500 patients, most of whom receive heroin. Monitoring is indirect and low key, aimed at detecting negligently aberrant prescribing and self medication, rather than enhancing quality of care.[4]

For most opiate users the most effective treatment approach is methadone maintenance combined with tailored counselling programmes.[1 2 5] Research also supports the efficacy and relative safety of alternative treatments such as buprenorphine and lofexidine and of injectable formulations in certain circumstances.[5] Such evidence substantiates the continuing development of a modernised "British system," where the approach is to provide a range of management options, tailored to individual need.[6] It has successfully encouraged many patients into treatment,[2] considerably reducing morbidity--for example, from HIV infection. Even though the current hepatitis C epidemic cautions against complacency,[7] mortality and morbidity remain much higher among drug misusers outside treatment.[1 8]

Extending controlled drug licensing will substantially increase bureaucracy without ensuring responsible practice. The inflexibility will cause a range of practical prescribing difficulties--relating, for example, to cover for absent colleagues, continuing prescriptions in hospitals, and diminished access to private health care. Restrictions are also likely to stifle prescribing of methadone alternatives (contradicting the recommendations of the Advisory Council on the Misuse of Drugs[1]) and associated research.

The proposals also convey a negative message about drug misuse treatment, reinforcing the disinclination of generalists to prescribe for drug misusers.[9] Fear of police involvement has already deterred many general practitioners, following recent high profile cases. If drug misuse treatment is singled out as requiring Home Office supervision, many doctors will consider it an optional extra best avoided. Reduced access to services would in turn have a deleterious impact on other health agencies and the wider community and increase drug related morbidity and mortality.

Licensing has failed to improve the quality of diamorphine prescribing to addicts. There are still no treatment protocols or agreed indications for use of this drug, and prescribing practice varies considerably across the country.[4] Supervision by drug control agencies has not worked well elsewhere. In the United States both state and federal authorities closely monitor treatment, but one survey found that 68% of agencies set an upper limit for methadone dose of 50 mg/day, well below the therapeutic range recommended in their own Department of Health guidelines.[10] This type of regulatory supervision tends to deter prescribing of controlled drugs rather than raise clinical standards.

The challenge is to continue developing accessible and effective services, thereby reducing the risks of all opiate related deaths, balanced against measures to reduce treatment related individual and community risks. For example Reducing Drug Related Deaths implicates methadone diversion as an important factor in accidental overdoses and recommends witnessed consumption.[1] This would help ensure treatment compliance, reduce the potential for naive users to obtain methadone, and reassure professionals and communities. Such constraints may, however, discourage chaotic patients most at risk of overdose, have resource implications, reduce treatment retention, and conflict with important rehabilitation goals such as work and family responsibility.[11]

The relation between methadone prescribing and drug related death is complex. Toxicology suggests that fatal overdoses usually involve combinations of drugs, often at therapeutic doses.[1] Further research into diverted methadone is urgently required to establish who uses it and what role it has in overdose.[11]

There is a general acknowledgement that clinical governance, through education, training, audit, and evidence based practice, is the best way to improve standards. This is also a better model for improving drug misuse treatment. Measures based on governance include establishing local shared care monitoring groups, as recommended by the Department of Health clinical guidelines, and reviewing the prescriptions of individual practitioners through the prescribing activity (PACT) system.[12] Studies consistently highlight general practitioners' training needs.[9] The royal colleges of general practitioners and psychiatrists are both currently developing specific training for doctors treating drug misusers. Primary care group and trust developments provide a clear opportunity to harness clinical governance in the cause of more effective drug treatment services. We believe that this approach will lead to sustainable reductions in drug related deaths, by enhancing treatment quality and accessibility.[13]

Mark B Gabbay senior lecturer in general practice University of Liverpool, Liverpool L69 3GB

Tom Carnwath consultant psychiatrist Substance Misuse Services, Trafford, Manchester M33 1FD

Chris Ford general practitioner Kilburn, London NW6 6RR

Deborah A Zador lecturer, University of Sydney, and head Drug and Alcohol Department, Concord Repatriation General Hospital, Concord, NSW 2139, Australia

[1] Advisory Council on the Misuse of Drugs. Reducing drug related deaths. London: Stationary Office, 2000.

[2] Department of Health. Drug misuse and dependence. Guidelines on clinical management. London: HMSO, 1999.

[3] Home Office. Changes to the Misuse of Drugs Legislation Licensing of Controlled Drugs Prescribed in the Treatment of Addiction. London: Home Office, 2000. http://www.homeoffice.gov.uk/ppd/pres0300.htm

[4] Metrebian N, Stimson GV. Heroin prescribing in the UK; lost opportunities for research. Addiction Research 2000;8:305-10.

[5] Ward J, Mattick RP, Hall W, eds. Methadone maintenance treatment and other opioid replacement therapies. Amsterdam: Harwood, 1999.

[6] Strang J, Gossop M, eds. Heroin addiction and drug policy. The British system. Oxford: Oxford University Press, 1994.

[7] Singh S, Miller R, Madge S, Patch D. The impact of hepatitis C in general practice. Br J Gen Pract 2000;50:532-6.

[8] Frischer M, Goldberg D, Rahman D, Berney L. Mortality and survival amongst a cohort of drug injectors in Glasgow 1982-1994. Addiction 1997;92:419-27.

[9] Gabbay M, Shiels C, van-den Bos A. `Turning the tide': influencing future GP attitudes to opiate misusers. Education for General Practice (in press).

[10] D'Aunno T, Vaughn TE. Variations in methadone treatment practices. JAMA 1992;267:253-8.

[11] Gabbay M, Carnwath T A cautious welcome for the new guidelines on management of drug dependence. Br J Gen Pract 2000;50:92-3.

[12] Beaumont B, Carnwath T, Clee W, Ford C, Gabbay M, Robertson R, et al. Alternatives to licensing doctors. Druglink 2001;Jan/Feb:9.

[13] Bell J, Zador D. A risk-benefit analysis of methadone maintenance treatment, Drug Safety 2000;22:179-90.

COPYRIGHT 2001 British Medical Association
COPYRIGHT 2001 Gale Group