Prescribing Heroin and Other Injectable Drugs

Introduction

For years, prescribing injectable heroin to opiate addicts has been unique to the UK. Indeed prescribing any injectable agonist as part of the treatment for opiate addiction occurs only in the UK, apart from a few experimental schemes with injectable morphine which have been mooted (Goldstein 1974) and implemented in The Netherlands (Derks 1990a,b) and three patients who are the rump of 27 heroin addicts who were started on injectable methadone in 1977 in Queensland, Australia (Reynolds, A., personal communication, 1993).

At first glance (and for some, at second and third glance also) there is something inherently paradoxical in an approach which involves the prescribing of the very drug of addiction as part of the treatment of addiction. For any consideration of this approach, a particular clarity is required with regard to the goals of treatment. Is it the containment of the 'epidemic' to those already 'Infected'? Is it the overcoming of the dependence? Is it the protection from, or muting of, the associated harm? These options will be considered in more detail later in the chapter.

The prescribing of injectable heroin is perhaps the most famous characteristic of the 'British System'. And yet, at the time of writing, it is probably only I or 2 per cent of the estimated 75 000- 150 000 heroin users who receive a prescribed supply of any injectable drug-and only a small proportion of these will be receiving injectable heroin. In 1990, the total number of addicts who received a prescribed supply of injectable heroin was approximately two hundred, with a few thousand receiving injectable methadone. In truth, although this practice may attract considerable local and international attention, the prescribing of injectable drugs is numerically of small significance in the overall UK response-even though the continuity or cessation of the practice may be a subject of great concern to the practitioners and patients for whom it forms the basis of a current treatment.

Commentators from abroad, and perhaps especially the USA, are fascinated by the extraordinary clinical freedom which is given to the medical practitioner in the UK with regard to the prescribing of drugs to the opiate addict. As Connell (1975) commented in his review of methadone maintenance schemes, 'each physician in charge of a special drug dependence clinic is a law unto himself as to how he treats and manages patients'. Whilst the prescribing of heroin, cocaine, and dipipanone (Diconal) is now restricted to those doctors who hold a special licence (in practice, the doctors who work in National Health Service (NHS) drug treatment centres), any qualified medical practitioner can prescribe oral or injectable methadone, morphine, or any other available pharmaceutical drug. However, despite this extraordinary clinical freedom, the majority of general practitioners choose not to exercise this right so that, paradoxically, the average UK doctor is extremely conservative in their prescribing to the addict, with three-quarters of a recent national sample of general practitioners reporting that they would not be willing to prescribe oral methadone-even if provided with shared care and support from a local specialist team (reported in Advisory Council on the misuse of Drugs, 1993). Thus a strange situation has developed, where a small number of general practitioners develop a degree of quasi-specialist expertise in the management of opiate addicts (e.g. Robertson 1987; Banks and Waller 1988; Dally 1990), whilst many other general practitioners react hostily to the more modest proposals in guidelines from the Department of Health (1984, 1991) that they should be involved in the prescribing of oral methadone for at least the purposes of detoxification. A similar opposition can also be seen in the hostile response from police surgeons (who are mostly general practitioners who do additional sessional work visiting police cells) who reacted angrily (Davis et al. 1992) to the suggestion [in the Department of Health (1991) guidelines] that they should be willing to give oral methadone to established opiate addicts who are detained in custody (Department of Health 1991; Strang 1992a; Ghodse 1992; Green and Drennen 1992).

Great variability in prescribing habits results from this lack of central direction and the accompanying individual clinical freedom of medical practitioners in the UK. There is probably no prescribing whatsoever of any injectable drugs to addicts in the whole of Scotland, Wales, Northern Ireland, and much of England, whereas some other areas (most famously Liverpool and other parts of the Mersey Region, and also to a lesser extent parts of London) have NHS drug specialist doctors and other doctors who include the prescribing of injectable heroin or methadone as part of their overall prescribing response. Nevertheless, despite periodic calls for the introduction of controls, the prescription of the injectable drug of main use (or an injectable substitute) continues to exist as a tool within the armamentarium of every doctor in the UK.

The hypodermic syringe was extensively developed by Alexander Wood in Edinburgh in the middle of the nineteenth century. However, its early use was for intrarnuscular administration of drugs. In his account of the history of injecting, Kane (1880) describes accounts from his colleagues of some of the first few intravenous administrations of opiates-which had occurred inadvertently during an intended intramuscular administration. Although it was initially thought that the habitforming naturenature of such drug use might be avoided by circumventing the oral route,; it soon became clear that injectable drug use might also be habit-forming, as had become the case for many soldiers who had regularly used their supplies of injectable morphine during the American Civil War.

By the early twentieth century, the international anti-narcotics movement was becoming influential, and, with the lead taken by the USA, both national and international legislation was passed. After a period during which injectable opiates were prescribed in the USA, the Harrison Act was passed and all prescribing of pharmaceutical opiates to addicts was soon stopped. In contrast, the UK establishment chose not to criminalize but to 'medicalize' the problem, following guidelines from the influential Rolleston Report, which had been prepared as an interministerial report under the chairmanship of Sir Humphrey Rolleston (Ministry of Health 1926). In essence, this report established the right of the medical practitioner in the UK to prescribe regular supplies of an opiate drug to an addict in the following circumstances:

(i) where patients were under treatment by the gradual withdrawal method with a view to cure;

(ii) where it has been demonstrated after a prolonged attempt to cure that the use of the drug could not be safely discontinued entirely on account of the severity of the withdrawal symptoms produced; and

(111) where it has been similarly demonstrated that the patient, while capable of leading a useful and normal life when a certain minimum dose was regularly administered, became incapable of this when the drug was entirely discontinued.

Thus it was established that the doctor might legally prescribe injectable opiates to an addict provided this was "treatment" rather than the "gratification of addiction" '.

The next 30 years were a period during which there was no significant problem of injectable opiate use in the UK (for further discussion UK. see Chapter 1). However, although some commentators have eulogized about the effectiveness of the British System during these years, the direction of causality between policy and lack of problem is not clear.

The date when intravenous injecting became established in the UK is not documented. It would appear that the injectable opiate use under consideration by the Rolleston Committee (1926) was subcutaneous or intramuscular, whereas the new opiate injectors in the 1960s (see next section) were using the drug intravenously. In the US, over this period, there had been a steady spread of the intravenous habit, and this diffusion has been described in some detail (O'Donnell and Jones 1968).

As cracks began to appear in the 'British System' during the 1960s, there was a temptation to look back on what appeared to be the success of the previous decades, identifying characteristics such as the absence of any illicit traffic in drugs, the absence of an addict subculture, and the absence of any young users. However, other commentators suggested that the previous decades had merely been 'a period of non-policy' (Smart 1984) in which '... there was no system, but as there was very little in the way of misuse of drugs, this did not matter' (Bewley 1975).

As Downes concluded, the British System had perhaps been ' well and truly exposed as little more than masterly inactivity in the face of what was an almost non-existent addiction problem' (Downes 1977).

In the late 1950s and early 1960s, there was an influx of a new type of opiate addict to the UK-a North American (mainly Canadian) addict with an established criminal history. Several hundred such addicts entered the UK during these years, attracted by the accounts of prescribed supplies of injectable pharmaceutical opiates -alongside a lack of immigration restrictions. Some caught the boat to Liverpool and then a train straight to London. For others, the transfer was more direct: 'I got a taxi from the airport to a GP in the Holloway Road, and got an immediate prescription for heroin and cocaine.' (For further discussion see Chapter 1.) Up until this time, the opiate addict population in the UK had been substantially middle-aged and middle class, with a high representation of doctors and of patients who became dependent oil their analgesic drugs. Thus, as a result of the prevailing patterns of prescribing of analgesics, heroin itself was rarely prescribed. For example, during the 1940s and 1950s, the total number of known opiate addicts in the UK never exceeded 500, of whom only about 10 per cent had been using (i.e. were prescribed) heroin.

The interpretation of the events during the 1960s varies greatly, with some observers concluding that the growth of a new drug culture was caused largely by the overprescribing of a handful of doctors (Second Brain Report (Interdepartmental Committee on Drug Addiction) 1965) whilst others suggest that the lax regulations and generous prescribing potential of UK doctors was a system waiting to be bust open by the newly arrived North American junkies (Blackwell 1988). Whatever the explanation, a youthful hedonistic drug using culture became established in the UK during the 1960s -particularly in London. The use of injectable opiates involved prescribed pharmaceutical opiates (particularly heroin) which was prescribed by a small number of doctors in or around London, and from whom the daily doses prescribed rose steadily: for example, some of the opiate addicts steadily increased their daily intake from about one to 40 grains of injectable heroin daily (60-2400 ing daily). The dependent status of some of the high dose users was confirmed by occasional clinical observation of them as they injected these large amounts (Gossop 1987).

NHS drug clinics were established for the first time in 1968. They were expected to address multiple agenda, which included the need to provide treatment to the new addicts, and the need to contain the spreading 'epidemic'. More immediately, there was a need for them to take over the care of more than 1000 addicts who had been receiving their heroin (and sometimes cocaine) from doctors who were no longer allowed to prescribe either of these two drugs. In practice the majority of these patients were taken on by the clinics on prescriptions very similar to those which they had previously been receiving-at least in the first instance. (For further details on the changes at this time, see Connell (1991) and Chapter 12.)

During the early months of operation of the new drug clinics, the new NHS heroin prescribers also took over responsibility for prescribing injectable cocaine-almost exclusively to a population of injecting drug users who were taking both heroin and cocaine. For patients who received both drugs, doses of cocaine were either equal or lower than the dose of heroin prescribed. However, within a year, an informal agreement was reached amongst London doctors working in the drug clinics to stop the practice of prescribing injectable cocaine: this practice subsequently stopped abruptly for most such patients, since which time only a handful of addicts in the UK have received prescribed supplies of injectable cocaine.

After 18 months of operation, some degree of stability had developed in day to day clinic practice. Home Office data are available on the drugs being prescribed to the 1466 known addicts at the end of December 1969-499 were receiving prescribed supplies of heroin (of whom 295 were also receiving methadone), 716 were receiving methadone, and 251 were receiving other opiates (usually morphine or pethidine). (Note: Most methadone prescribed to addicts in the UK at this time was in the form of injectable methadone ampoules, with only small amounts of oral methadone linctus being prescribed-see Chapter 13; however, the exact breakdown of the prescribed drug by route of administration is not provided in the Home Office data.)

During the late 1960s and early 1970s, the new drug doctors (the NHS doctors in the drugs clinics) began to switch their prescribing habits from injectable heroin to injectable methadone (see Chapter 13). Nevertheless, returns to the Department of Health showed the continued dominance of injectable opiates in the prescriptions to addicts attending NHS hospitals in England and Wales. Examination of the total quantities of injectable heroin, injectable methadone, and oral methadone (the three main forms of opiates prescribed to addicts) prescribed reveals a gradual change during the decade after the opening of the clinics, with annual figures of 17, 11, and 3 kg, respectively, being prescribed in 1970; 15, 21, and 8 kg, respectively, in 1974; and 9, 14, and 17 kg respectively, by 1978 (Department of Health data published by Edwards 1981).

Prescription of injectable methadone steadily increased to a mid-1970s peak, after which the trend appears to have been away from any injectable prescribing, with an increased reliance on oral methadone. These data accord with the findings of Blumberg et al. (1974a,b) who reported on the slightly greater obtainability of injectable methadone than injectable heroin in the early 1970s. It is also interesting to note from Blumberg's work that injectable methadone and heroin are accorded similar scores by the addict for liking and need as measured on a fivepoint and four-point scale respectively (Blumberg et al. 1974a).

This potential conflict is explored by Stimson and Oppenheimer (1982). If clinics were to be given the twin aims of medical care and social control, could these aims always be met together, or might they sometimes be in conflict? 'For example, the social control of addiction might be best pursued by a maintenance-prescribing approach, but this might not be the best treatment for an individual patient The social control of addiction was usually seen as the primary task of the clinics. This conflict was also considered by Mitcheson and Hartnoll (1978) in one of the early considerations of their study of prescribing injectable heroin versus oral methadone. They observed that

... overall, prescribing heroin can be seen as maintaining the status quo with the majority of heroin-maintained patients continuing to inject heroin regularly: prescribing heroin is not associated with an improvement in social functioning or a reduction in consumption of illegal drugs, as is sometimes claimed. It may reduce the degree of involvement in criminal activity, especially in terms of arrests and conviction rates. Refusal to prescribe heroin, while offering oral methadone, constitutes a more confrontational response by the clinic and results in a higher abstinence rate. On the other hand this treatment is less acceptable to the client and the clinic fails to maintain a regular contact with the group of clients who continue to use illicit drugs ...

What was behind the move from prescribing injectable heroin to injectable methadone? No doubt it was partly influenced by the increased public and professional anxiety about prescribing heroin (in the public's eyes, a drug of abuse) compared with methadone (in public and professional eyes, a medicinal drug). However, other reasons were also articulated. The long half-life of methadone meant that it might be a drug which was more conducive to social and occupational stability, as it need only be administered once or twice a day.

There were also concerns about the safety of injecting heroin: pharmaceutical heroin was prescribed in the 1960s and 1970s in the form of tablets known as pills or jacks, which the addict (or nurse or doctor) would then dissolve in water to make the solution ready for injecting. As Bewley (1975) said

We tend to prescribe methadone because it comes in an ampoule and it won't be mixed with water from the kitchen sink or whatever: also because it's a more long-acting drug. There is no evidence that it is better than heroin in one way or another but because it is more long-acting and because people can inject it in a cleaner way, we believe that there is an advantage.

In the same proceedings, Haastrup reports on interview research with heroin users in England which showed that '... in one week, half of the addicts used normal water from the kitchen and one in ten had used water from the lavatory' (Haastrup 1975). Bewley went on to explain how clinical practice in his own clinic in London included not only the provision of clean needles and syringes, but also advice from the clinic nursing staff so that patients can be instructed on how to inject themselves. The study to which Haastrup referred may well have been the study by Stimson who reported on the extent to which addicts mixed up their heroin with either Apyrogen (ampoules of sterile water), liquid methadone (Physeptone ampoules), boiled water, tap water, or lavatory water; whilst only 12 of the III subjects reported use of lavatory water the majority of use was of uncertain cleanliness status (Stimson 1973).

Methadone has a hedonistic appeal and black market value which is similar to heroin when both drugs are compared in their injectable forms (see Blumberg et al. 1974a). Internationally, methadone is often considered only in its oral form, and observers mistakenly attribute properties to the drug itself when they are in fact confusing the drug with the formulation. In clinical practice with the prescribing of these drugs to opiate addicts, the committed injector seeking a prescribed supply of injectable drugs would usually be quite amenable to moves between heroin and methadone in injectable form-in sharp contrast to the determined opposition which may be encountered to suggestions of moving from injectable methadone to its oral form. In an interview with one such addict receiving injectable methadone in Amsterdam, the addict is quoted as follows: 'I have been taking it for half a year now, it's far out: they can take anything from me, my beer, my wife-so long as they keep their hands off my injectable methadone' (Kools 1992).

The debate about prescribing of injectable drugs to addicts is usually dominated by consideration of prescribing opiate drugs. However, other drugs of dependence have also been prescribed in injectable forms, although this practice has become extremely rare.

When the new NHS drug clinics were established in 1968, many of the patients who were taken on from the private practitioners were already receiving prescribed supplies of intravenous cocaine alongside their prescribed intravenous heroin. Initially the doctors in the new drug clinics continued this prescribing of cocaine-up until a consensus was reached amongst these doctors to cease all such cocaine prescribing (in late 1968), which appears to have been implemented extensively with little or no evidence of the promotion of a black market in imported cocaine. A small number of doctors continued to prescribe injectable cocaine to extremely small numbers of addict patients (usually in conjunction with injectable opiates), but only a handful of such cases continued through to the 1980s. More recently Marks and Palombella (1990) have argued for the prescribing of cocaine 'reefers' as a possible 'harm reduction' approach, with the cocaine being added by the pharmacist to herbal cigarettes. However no useful data have yet been presented on this practice, and it is not even clear whether the drug is effectively or reliably absorbed from these 'reefers'.

An intravenous methylamphetamine epidemic occurred during 1967/68, when a small number of private doctors (whom the new regulations banned from prescribing heroin or cocaine) began to prescribe methylamphetamine ampoules (Methedrine) with a resulting epidemic of chaotic use (James 1968; Hawks et al. 1969). One London centre began an experimental programme of prescribing injectable amphetamines to these drug users, but this was soon abandoned when an agreement was reached between the Ministry of Health and the manufacturers to withdraw supplies of the drug to retail chemists (hence closing off its availability via private doctors) (Mitcheson et al. 1976).

Whilst the interruption of cocaine prescribing (see previous paragraph) might have been linked to the development of this methylamphetamine abuse (in that the methylamphetamine was being prescribed by many of the same private doctors who were no longer able to prescribe cocaine), the co-ordinated control strategy of removal of supplies of the drug from retail pharmacists would appear to stand as an example of a successful control-based intervention.

The debate about the appropriateness or otherwise of prescribing injectable drugs continued as a background debate during the early 1980s, but shifted from being a debate within specialist clinic practice to being the battleground between NHS and private doctors. However, it remained an extremely rare form of clinical practice in most areas, so that by the mid to late 1980s there were probably still less than 1000 addicts in receipt of injectable drugs (mainly injectable methadone) from amongst the estimated 75 000-150 000 opiate addicts (ACMD 1988).

Acquired immune deficiency syndrome (AIDS) brought a fundamental re-examination of drug policy and the goals and methods of drug treatment in the UK (Advisory Council on the Misuse of Drugs (ACMD) 1988, 1989; Strang and Stimson 1990; Department of Health 1991). The prescribing of injectable drugs was back on the main agenda-not necessarily as a recommended practice, but certainly as an option to be considered. Prescribing of any drugs to the drug user was reformulated as a possible '... useful tool in helping to change the behaviour of some drug misusers either towards abstinence or towards intermediate goals such as a reduction in injecting or sharing' (ACMD 1988). A hierarchy of acceptable goals was identified:

(1) the cessation of sharing of equipment;

(2) the move from injectable to oral drug use;

(3) a decrease in drug use; and

(4) abstinence.

For this consideration, any prescribing could be judged and compared according to its effectiveness/ ineffectiveness in bringing about the desired changes.

The prescribing of injectable drugs was included in this consideration, but with the caveat that such cases should not be managed by the general practitioner and required input from specialist drug services. The ACMD (1988) went on to state that

In some cases----a small minority-prescribing of injectable drugs may be necessary to keep the individual in treatment and/or to ease the change from injecting the drug of dependence to taking a substitute orally. Where this is so, such prescribing of injectables should normally be undertaken for short periods only (rarely more than three months) ... the prescribing of injectable drugs in this way will be an important element in helping some injecting drug misusers to move gradually away from injecting. Such cases will be exceptional ... (and) should be managed by, or with guidance from, the District or Regional specialist team.

Thus the ACMD endorsed the view that interim prescribing of injectable drugs might be considered legitimate medical practice if it was found to bring. about a move to oral-only use which might otherwise not have occurred: in these circumstances, the end would have justified the means. There has been insufficient study of this approach for robust conclusions to be reached, but preliminary reports show a disappointing lack of evidence of extensive achievement of these intermediate goals: rather, what is seen is a drift away to another source of prescribed or black market injectable drugs as the change over to oral drugs begins (see, for example, Battersby et al. 1992). The issue remains unresolved at the time of writing, but as various commentators have observed, the potential for serious error is much greater in view of the direct physical complications and supply to third parties (the black/grey market) if injectable drugs are prescribed when oral drugs would have been sufficient (Strang 1990; ACMD 1993). This debate re-emerged in the 1990s in the UK, with arguments about the relative importance that should be assigned to the debate on oral methadone versus injectable methadone (Brewer, Marks, and Marks 1992; Strang and Farrell 1992). As Dole has recently observed, whilst UK practitioners may see great advantage to the preservation of their considerable clinical freedom, there may also be disadvantages of the 'cafeteria approach' to drug treatment for the opiate addict who wishes to exercise freedom of choice when he/she may otherwise have been satisfied with a single available product (namely oral methadone) (Dole 1992).

The introduction and spread of needle-exchange schemes in the UK since 1987 (Stimson et al. 1988, 1990) represents not only a new service to the actual or potential clientele of the drug clinics, but it also provokes a widening of the constituency of concern. The needle-exchange schemes may provide needles and syringes to the established addict (who may or may not be known to drug treatment services), but they may also provide needles and syringes to the non-dependent injector.

What should be the response of drug treatment services to this new wider constituency -the non-dependent injector? Although some drug doctors and drug workers would argue that the next logical step is to provide free supplies of the pharmaceutical drugs to put into the free needles and syringes, this could be seen as a naive and ill-considered position which fails to appreciate the fundamentally different nature of the strategies behind drug treatment services and needle and syringe services. At the heart of the debate is a different view on the role of the doctor (or other health-care worker) in providing drugs to the drug addict. Certainly the recent considerations of the ACMD have seen prescribing as a treatment for the individual- admittedly an unusual treatment by medical standards, but a treatment nevertheless- which is provided in order to bring about benefits in physical and psychological well-being of that individual which would not have been accrued (at least, not to the same extent) if the treatment had not been given. On the other hand, the case for considering the public health and individual health needs of the wider constituency of injectors is evident in the encouragement of over-the-counter sales of needles and syringes from pharmacies (Glanz et al. 1989) as well as the needle-exchange schemes.

But should the doctor then feel obliged to prescribe the drugs to fit inside the needle and syringe? If they were to do so, it would be far from clear whether the doctor was still providing medical treatment to the individual, or might alternatively be an overpaid grocer whose only task was to provide the products as requested (perhaps with some safety cut-off limits). Self (1992) has described this as doctors acting as 'dealers by appointment to H.M. Government'. This confusion between the availability of drugs as treatment and the availability of drugs as commodities is evident in some of the calls for legalization of drugs, where many of the points made relate to the provision of treatment to addicts (and could hence be considered in a different context). However this concerns an altogether different legitimizing ideology behind the provision of drugs to drug users, and is not considered further within this chapter.

The option of prescribing heroin or other injectable drugs has long been a distinctive feature of the 'British system'. In practice, this authority to prescribe injectable drugs is rarely exercised-at the level of the specialist, as well as the generalist doctor. Nevertheless the very existence of this prescribing tool within the armamentarium has a profound influence on both policy and practice: it may well be simultaneously good and bad-good in so far as it may draw the reluctant or ambivalent drug addict into treatment at an earlier stage, and bad in so far as it may obstruct progress to a non-injectable treatment option which would have been acceptable in the absence of an injectable alternative.

Perhaps a new discipline is now required in re-examining the role of injectable prescribing. Since the advent of HIV, an old perspective has re-appeared in a new form, with the new attention to 'harm reduction' strategies. In this context, the debate about injectable prescribing has to be re-examined. Can the prescribing of injectable drugs lead (at least on some occasions) to a reduction in risk or harm? If so, what harm, and experienced by whom? And if harm is reduced in the short term, then what will be the overall effect on cumulative harm accrued over a longer period of time (Strang 1992b, 1993)? Moral positions may need to be swept aside so as to permit unobstructed scrutiny of the extent to which injectable prescribing has a beneficial and/or aggravating effect on overall harm.

Regrettably there has been an extraordinary lack of properly conducted studies of injectable prescribing so that any opinions which are formed must rely on partial anecdote in the absence of either proper research or monitoring. As a result, no reliable conclusions can be reached about such prescribing, and the issue is open to hijack by those who wish to reinforce their pre-selected position within the prescribing debate. Despite the media and public fascination with the prescribing of injectable drugs, it is probable that the greatest benefits will be accrued from the prescribing of oral substitute drugs (such as oral methadone), especially when one bears in mind that this form of the drug is prescribed to at least ten times as many heroin addicts in the UK and at least one hundred times as many heroin addicts across the world.

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