To treat or not to treat (Part 2)

Wednesday, December 5th, 2012

Sorry I went off on one a bit yesterday. I was in a vile mood. And sorry to mental health nurses in Community Drug Teams, I do recognise there are some of you out there who are very committed to working with drug users and aren’t just in it for the supervised urine tests.

The point I actually intended to make before I got side-tracked by my own negativity and social bitterness was – who should receive drug treatment, and who shouldn’t? The political back-drop I outlined yesterday does have an impact on this, as there are trends, depending on who is in power, how they feel about drug users, and how much money is available. However what I want to briefly consider here is a more clinical perspective.

When I first started as a treatment worker many years ago, prescribing methadone was perceived as an additional risk factor. The logic was that if someone was taking central nervous system (CNS) depressants, such as heroin, alcohol, benzodiazepines such as Valium, (all of which, may I add, are widely sought-after by engrained heroin users, and a combination of which is almost always present in cases of fatal overdose), and now the new wave of nerve painkillers such as pregablin and gabapentin, then adding another CNS depressant such as methadone would increase the risk of overdose.

Buprenorphine (Subutex) therefore became a popular choice – another opioid but which only works on two of the four opiate receptors in the brain, and so stops withdrawals without sedating. Subutex also blocks opiate receptors, making it difficult to get any effect at all from heroin when taking a regular, reasonably small dose of Subutex. It is brilliant stuff. However, in order for it to work, no heroin can be used for 12 hours before taking the first dose, and of course little effect can be gained from further heroin use – so needless to say, it is not a popular choice amongst the old hardcore. (Now in prisons, where it is crushed and snorted to get a buzz… that is a different matter.)

So, imagine that you are assessing someone for treatment – they come in and tell you that they are using heroin every 6 hours and their mental health isn’t great. Subutex might not be appropriate as they want the sedation provided by heroin to manage their mental state, so you decide together to opt for methadone. But this person has no intention of stopping heroin use at present because it is the only way they can block out the trauma they experienced as a child, which they do not feel ready to address until they have somewhere stable to live.

So the question is – do you offer them treatment?

In the olden days, the answer would have been “No”. People had to say they had no intention to continue using heroin once receiving a prescription, and this was monitored through regular drug tests. Any heroin-positive urine samples sent heads spinning, and would probably result in being given an ultimatum, and possibly no prescription (ouch). The logic behind this was that dual use would increase overdose risk.

The harm reduction movement changed that – once people had dared to continue to prescribing to those still using heroin, research showed that high doses of methadone not only ‘drowned’ opiate receptors and so also had a blocking effect, making it more difficult to experience the euphoric effects from taking heroin – but the surprise conclusion was that people were actually LESS likely to overdose when taking heroin on top of methadone. This was because people’s tolerance to opiates was so high that risk of overdose was greatly reduced, as long as they took their prescribed dosage daily to maintain their tolerance at this level. (If you imagine an alcoholic, who is used to supping a bottle of whisky a day, drinking half a Carling… if you want to try this experiment at home, get yourselves down Wetherspoon’s with a £1.40 in your pocket and talk to anyone sitting alone at the bar.) Plus, taking a decent dose of methadone meant no withdrawal symptoms; and so less frequent injecting, less dodgy, desperate injecting, and so less hepatitis C, HIV, deep vein thromboses and cellulitis. And so the answer back then would have been, “Yes, treat, and keep treating until they get bored with paying for something they aren’t getting an effect from”.

So how would the question be answered today? Well although methadone in itself is pretty cheap, and Subutex not unreasonable, the cost of these medications often lies in the level of monitoring that is required, because they are ‘controlled medications’. This often means paying the pharmacist to dispense it in single doses and supervising its ingestion each day. It also means more frequent monitoring by doctors and drug workers to ensure that prescribing is safe and to reduce extraneous risk factors such as mental health problems and homelessness.

The truth is, as the money dries up, doctors and mental health trusts are going to be significantly less interested in working with heroin users. Half of those still walking around have got bits dropping off them – open abscesses you could fit your fist in at the top of each thigh and swollen, purple legs, from injecting into the femoral vein and irreparably damaging the blood supply to the legs; terrible general health from years of poor diet and jabbing bacteria-laden substances directly into their blood vessels; and quite probably hepatitis C. To treat, they are expensive and time-consuming. And so, I fear, the answer to the question will increasingly be, again, “No”. And doctors can be extremely eloquent and creative when it comes to finding justifications for why someone is ‘not appropriate for treatment’.

Oh god, I’m having a go at doctors now, what is my problem?! I’d better go before I piss off the whole medical profession and start making wild claims like “All radiologists are gay”…

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