Expert view on methadone a bit blinkered

In a plural democracy, is it unreasonable for people such as Neil McKeganey (professor of drug misuse research at Glasgow University] to ask if the same drug treatment effect might be achieved more cheaply or effectively by doing something else?

While the price of the methadone provided to "substitute" opiate misuse is low, the cost of the army of prescribers, dispensers and support workers required to apply it safely is huge, though justified by the social and medical costs of doing nothing.

The treatment of some of our most vulnerable citizens should not depend on the narrow-mindedness of professionals who enjoy considerable income and status on the basis of a restrictive single therapy.

Evidence presented to challenge the view of the multinational corporation they have become (as demonstrated by the signatories to their letter to The Scotsman, 5 April) is dismissed out of hand on the volume, rather than quality, of their own "evidence base".

Methadone is not the only treatment for opiate addicts; other treatments have been demonstrated to be effective, but may involve different spending patterns, threatening the vested interests of those behind the current approach.

It is beyond question that methadone has a part in treating drug misusers, but why should they be condemned to prolonged (lifelong) palliative care, when curative methods have been demonstrated and warrant further research, rather than unswerving loyalty to a therapy that is becoming increasingly counterintuitive to the voting public, who pay handsomely for a service the "experts" provide?

DR AJ ASHWORTH, MRCGP

Davidson's Mains Medical Centre

5 Quality Street

Edinburgh

Your editorial (29 March) called for new solutions to the drug problem in Scotland, in view of the growing numbers of heroin addicts in spite of present policies based on methadone.

This week, the use of methadone was strongly supported in a letter by a group of experts (5 April), but here are two suggestions which might help to reduce the mounting misery and costs of the present situation.

Firstly, decriminalise possession of heroin, and secondly provide heroin in medical clinics as an alternative to methadone. This is not legalising heroin, for which drug traffickers should be vigorously pursued, but it would detach supply from the criminality which accounts for a majority of an ever-increasing prison population.

Heroin-assisted treatment has been shown to reduce criminal activity and increase abstinence. But such policies would require a change in professional attitudes.

PROF DAVID HANNAY

Kirkdale

Carsluith

It is sometimes said there are three main religions in Scotland: Protestantism, Catholicism and Methadonism. The latter, like the other two, is a world religion and it is perhaps for that reason the letter defending methadone (5 April) was signed by experts from so many different countries.

Although it is true that methadone has evaluated positively in randomised control evaluations, none of those studies have been undertaken in the UK, and we should not assume that the positive results will apply to the same degree in the case of the methadone programme in Scotland.

I have suggested that the numbers on the methadone programme should be capped and that it should be made available for a maximum of two years. My reasons are twofold. First, the effectiveness of methadone is enhanced when it is combined with psychosocial counselling. The capacity to provide that counselling is limited. By contrast, the capacity of doctors to write methadone prescriptions is limitless.

We should only be providing methadone up to a limit that is capped by the resources to provide the necessary additional counselling.

Second, research has shown that addicts in Scotland improve most markedly within the first 18 months of their treatment. Thereafter, they tend to improve to only a limited degree. By limiting methadone to two years, addicts would then be able to move on to a drug-free programme and continue to build on their progress towards full recovery.

The Department of Health in England sent out guidance last week to prison medical services, recommending that prisoners are not placed on long-term methadone maintenance programmes, but instead receive a decreasing dose of the drug with the aim of enabling them to become drug-free. We should look at that guidance in Scotland and follow a similar course towards addict abstinence and recovery, rather than accept the advice of those who favour life-long methadone prescribing.

NEIL McKEGANEY

Professor of Drug Misuse Research

University of Glasgow