To the NHS Grampian conference in Aberdeen last week where the subject was “Belt & Braces – the Importance of Support in Many Forms”.
The keynote speaker was Dr. Bruce Davidson, a Consultant Psychiatrist in Substance Misuse Services at Royal Cornhill Hospital Aberdeen. His talk was called “Methadone and Substitute Prescribing – Exploring the Facts”. From the beginning of his talk he described himself as someone who prescribes a lot of methadone.
His justification for systematic methadone prescribing was the Road to Recovery (2008) document which says “Methadone has a key role to play in treating opiate addiction.” And an SACDM (2007) report which states “Methadone is the most cost effective treatment available…” the NICE guidelines were also mentioned.
Harm reduction vs. ‘real treatment’
The main thrust of his talk was that “methadone prescriptions stop people dying…. methadone is not a great tool to help you become abstinent but we don’t have alternatives…”
Further points he made were that: “Methadone is not a drug treatment per se but the background…harm reduction …” and that the wrap around services (i.e. continuous support services within the community) were the real treatment. He further stated that “The evidence base for metahdone is NOT as a tool for detoxification but only for maintenance.” As a doctor, he said, you cannot ever take people off methadone.
Abstinence and maintenance
One of the most interesting points from his talk almost slipped by unnoticed. He pointed out that most patients who came looking for a methadone prescription had previously tried quitting heroin use, before almost inevitably failing, putting their hands up and saying ‘HELP’.
What this seems to be is an admission that the goal for most methadone users is in fact abstinence, but doctors are nearly always prescribing methadone which is a drug which has an evidence base for maintenance, not abstinence.
Locally Dr. Davidson referred to the steady increase of methadone scripts and users in Grampian and Aberdeen. There are now 2,000 users in Aberdeen and 2,500 in Grampian. 95% of substitution prescriptions are for methadone.
Very exact figures. It is a shame that no-one ever has such reliable and impressive figures about participation in wrap around services, or the provision of regular counselling. If methadone maintenance is just the ‘background’, and the wrap around / community services are the actual treatment then we need to know more about how these services are being used and how they are performing.
Risks of long-term methadone use
At the end of Dr. Davidson’s talk I asked him a question: in his talk he had referred to the supposed improved physical and psychological heatlh of users as being an effect of methadone treatment.
In light of this claim I asked him to comment on the increased risk of cognitive impairment and osteoporosis, as a result of prolonged methadone use. I asked whether enough was being done to warn patients bout the dangers of methadone.
I was surprised by how frank and straight forward the answer was… He said my point was very valid, and that there are long term side effects of very serious concern, and that “from the inform and consent point of view, doctors are not doing enough to inform patients.”
This seemed to be an admission that physical and psychological improvements as a result of switching from heroin to methadone are only noticeable in the short term – but the long term effects are plainly negative. Doctors must do more to ensure that service users know about these risks before they start a methadone maintence programme.