Prescribing Policy in the UK: A Swing Away from Harm Reduction?

Introduction

This paper is going to take a long view of prescribing policies in the UK, looking at the situation over the last 25 or so years. At present harm-reduction prescribing policies are reasonably well established and there are factors that continue to promote them. However, at the same time there are a number of influences which are working against harm reduction as the principal focus of prescribing policy. UK prescribing policy over the last 25 years will be briefly outlined, a description will be given of the situation today, and influences that may undermine harm reduction in the future will be discussed.

Prescribing Policies and the Setting Up of Drug Clinics

The drug clinics began in the UK in 1968. They were set up to bring the treatment of heroin addicts under stricter control than had existed previously, when it was thought that the over-prescribing by a handful of doctors had been responsible for the increase in the number of young heroin addicts. Heroin was the main drug prescribed and the aim was to prescribe sufficient to eliminate the need for the addict to buy black market drugs, but not more than was needed so as to feed the black market. The hope was that contact with clinic staff would lead to the addict developing motivation to come off drugs in due course (Connell and Strang, 1994).

Already in the early days of their operation harm reduction was one of the stated aims of the clinics. By more controlled prescribing of pure drugs it was hoped to undercut the black market and thereby lead to its shrinkage, and also to reduce the necessity for addicts to be involved in acquisitive crime. To quote Connell (1969) writing at the time the clinics were first set up:

Heroin provided free at special treatment centres will obviate the need for the addict to commit crimes to obtain money for the drug. The pure, British-made heroin which the addict will receive is less likely to cause complications and death than the impure material which circulates in a criminally organised system.

As the clinics developed in their early years other harm-reduction practices were apparent. Although addicts were encouraged to think about coming off their drugs, there was no coercion applied. In effect, for those who did not wish to consider coming off, or who had tried and failed, maintenance prescribing was available. As Edwards (1969) wrote:

There are believed to be some patients who cannot — or cannot for the time being — function without the drug, but who on a regular maintenance dose can live a normal and useful life as a 'stabilized addict'; such patients will be maintained on heroin rather than have their drug withdrawn.

Gradually injectable methadone began to be prescribed instead of heroin in the early l970s; the rationale here was that addicts would not need to inject so frequently with the longer-acting drug, but prescribing an injectable drug was still viewed as good practice.

As well as prescribing heroin or injectable methadone, clinics provided clean needles and syringes and sterile water for preparing heroin tablets (the form in which they were first dispensed) for injecting. Some clinics also gave advice on clean injecting techniques, and provided 'fixing rooms' for addicts to inject in with clean equipment available (Stimson, 1973). All good harm-reduction practices.

The Years 1975-85

A number of factors led to the reversal of these early harm-reduction policies during the decade 1975-85 (Mitcheson, 1994).

First, the continued prescribing of injectable drugs began to be questioned. Heroin had been prescribed in the first place when the clinics were set up partly because of the experience of prescribing the drug in the decades before the 1960s to small numbers of more stable, middle-aged, middle class addicts — the original 'British System'. It was becoming clear that younger users were not necessarily becoming more stable on prescriptions of heroin. In 1976 the first results of a random controlled study in London (Hartnoll et al., 1980) of prescribing heroin against oral methadone were becoming available. These results were interpreted by many (though not the authors) as indicating that oral methadone was the treatment of choice. As a result the prescription of heroin and later of injectable methadone was replaced by oral methadone as the drug of choice prescribed by the clinics.

A second factor was that clinics were gradually becoming silted up with long-term patients, and staff were beginning to get demoralised. Counselling, originally seen as a means of promoting motivation for change, was more often an argument about dosage of drugs. Towards the end of the 1970s with an influx of new addicts the system became overloaded.

Thus disenchantment with long-term prescribing and increasing pressure on the clinics led to the abandonment of previous policies and the introduction of time-limited prescribing programmes. In these, new patients would be put on oral methadone which after a period of stabilisation would be reduced and stopped, the programme lasting typically 6 months. What happened in many cases was that, as the dose of methadone was reduced, the addict would go back to using street drugs; usually he would have to wait 3 months before being considered for a further programme. This led to a revolving door situation with addicts going through several reduction programmes. It also led to an increase in addicts going to private practitioners for treatment where they could often get the maintenance prescribing they were seeking (Dally, 1990).

The Years 1985 to Date

The last 10 years have seen a redefinition of harm reduction in the UK prompted by the emergence of HIV (Stimson and Lart, 1991; Malinowski, 1993). At the same time there has been a considerable expansion of services for drug misusers which has led to a new generation of drug workers unencumbered by the attitudes of a previous generation. The influence of doctors has lessened as multidisciplinary community drug teams have developed. Articulate commentators on drug issues from a range of disciplines has resulted in the doctors' views being challenged (Stimson, 1987).

The Advisory Council on the Misuse of Drugs, an independent Organisation set up to advise the government on drug issues, has brought out three influential reports on AIDS and drug misuse (ACMD, 1988, 1989, 1993). In the first of these, published in 1988, the guiding principle was that AIDS was more of a threat to individual and public health than drugs. In the most recent report, published in 1993, methadone maintenance programmes were acknowledged to be beneficial in both individual and public health terms.

There is increasing concern at the high crime rate associated with drug misuse (Mills, 1994) and the large number of drug misusers who are in the criminal justice system. This has led to the police often taking a more liberal attitude to prescribing than previously. It is not uncommon to hear a policeman arguing for easier access to treatment and a prescription and even arguing for heroin prescribing (Payne, 1992).

These various influences have led to a number of changes in practice which can be viewed broadly as extending the range of treatment available to drug misusers and altering the focus of intervention to that of harm reduction. These changes include the following:

1. Needle and syringe exchange schemes first set up on a pilot basis in the UK in 1987 are now widespread and accepted as an integral part of a comprehensive drug service. Such schemes are operated from a variety of sources including drug agencies, retail pharmacies and outreach workers.
   
2. Longer-term methadone prescribing is much more widespread although some prescribers prefer not to use the term 'methadone maintenance'.
   
3. The prescription of injectable drugs, principally heroin and methadone, continues to occur and anecdotal evidence suggests that there has been some increase in such prescribing, although it is still on a very small scale. The prescription of oral amphetamines to dependent amphetamine users is gaining ground as a harm-reduction measure (Fleming and Roberts, 1994; Pates, 1994).
   
4. General practitioners are being encouraged to treat drug misusers in partnership with community drug teams (Department of Health, 1991).

Influences That May Compromise Harm Reduction Prescribing Policies

There are a number of influences which I believe may alter the present direction of drug policies away from harm reduction as the priority:

The development of a Government strategy on drug misuse. A consultation document was issued in the latter part of 1994 (Tackling Drugs Together, 1994) as a first step in this process. This document was notable in having no mention of the term 'harm reduction'. Many of those working in the drug field noted this absence and in the revised strategy (Tackling Drugs Together, 1995) there is a section in one of the appendices explaining the Government's stance towards harm reduction:

The Government starts from the basis that the ultimate goal of its drug policies must be to ensure that people do not take drugs in the first place, but if they do they should be helped to become, and remain, drug free.

In relation to 'primary prevention' (stopping people from taking or experimenting with drugs in the first place), the Government would not support any initiatives that could be interpreted as explicitly condoning drug taking. Nevertheless, the Government acknowledges that there will be those who, through ignorance or for other reasons, will misuse drugs whatever the consequences. For these people, information and facilities aimed at reducing the risks should be provided because this may save lives. However, such information must be coupled with the unambiguous message that abstinence from drugs is the only risk-free option.

Readers must judge this statement for themselves, but in my view this is a very parsimonious interpretation of harm reduction with priority being given to abstinence.

NHS and Community Care Act 1990

Recent changes in the National Health Service organisation (NHS and Community Care Act 1990) have lead to the separation of those who purchase health care (purchasers) from those who provide it (providers). Health Commissions have been set up is to assess the health needs of the local population and to purchase appropriate health care for that population. Health Commissions are finding that alcohol problems are much more numerous than drug problems and that services are much less for this group. New funding thus tends to be directed to improve services for those with alcohol problems. Commissions are keen on prevention generally and are tending to emphasise education and prevention and early intervention, especially with young people. All this means that there is less funding available for prescribing programmes.

Methadone prescribing programmes are costly and purchasers are casting a critical eye on these costs. They are questioning the effectiveness of such programmes and are looking at the outcomes of individuals under treatment. There is a danger that 'Costs as much as research will shape the future of methadone maintenance in Britain' (Mason and Marsden, 1994). For example, in many areas put, chasers have already put a limit on the funding available for methadone programmes. This means that the only way to make places available for new opiate users on such programmes is by moving people through. In some places this has meant a return to enforced reduction programmes. This pressure on prescribing budgets will increase as more referrals come to drug agencies.

Alternative strategy

An alternative strategy has been to try and encourage GPs to take on stable methadone clients. However, it is proving more difficult to persuade OPs to do this nowadays (Greenwood, 1992). Such shared care spreads the increasing burden of treating addicts in terms of both professional time and cost. It also normalises such treatment making it part of the general practitioners' duty of care for his patient rather than being the prerogative of the 'specialist'. However, there is a danger that less control will exist over doctors' prescribing activity leaving the way open for excessive or idiosyncratic prescribing to occur — the very reason the clinics were set up in the first place.

HIV-positive cases

The proportion of new HIV positive cases caused by transmission by injecting drug use seems to have peaked and is falling in the UK (Report of Working Group, 1993). One result of this success is that AIDS funding is being directed away from drug services to target more at-risk groups, which is a further restriction on funding.

Effectiveness in health care

Last but not least purchasers (encouraged by the Government) are looking for effectiveness in health care generally (Hayward, 1994). The Government has set up a Task Force to review services for drug misusers which is due to report in early 1996. The terms of reference are as follows:

To conduct a comprehensive survey of clinical, operational and cost effectiveness of existing services for drug misusers; to review current policy in relation to the principal objective of assisting drug misusers to achieve and maintain a drug-free state, and the secondary objective of reducing harm caused to themselves and others who continue to use drugs; to make recommendations where appropriate and to report to Ministers.

Once again abstinence has displaced harm reduction as the principal objective of policy. However, there is much to commend in this initiative; the Task Force has commissioned a number of pieces of research which is to be welcomed. The Department of Health itself has commissioned some research into the effectiveness of oral methadone maintenance programmes, although this is an area where effectiveness has already been demonstrated (Farrell et al., 1994). There are other areas where effectiveness or non-effectiveness has yet to be shown, for example, in the prescription of injectable drugs (Battersby et al., 1992) and the prescription of amphetamines. The conclusions the Task Force reaches are going to have a major influence on purchasers in the future and indeed will form the basis of guidance to them to be issued by the Department of Health. Purchasers are likely to take the attitude that in the absence of any evidence for the effectiveness of a treatment they will not buy it. Thus prescribing of injectables and amphetamines is at risk.

Conclusion

We have reached a point in the UK where harm reduction policies are widely accepted in the drug field. As far as prescribing is concerned, methadone maintenance is now an acceptable treatment for opiate addicts who are unable or unwilling to stop using opiates, where 10 years ago it was not.

However, there are a number of influences that are beginning to undermine this situation. Some of these are directly the result of changes in government policies. But it is the indirect effects of local purchasing policies that are going to have the greater influence. There has always been a tension between harm reduction and demand reduction and between public health considerations and the treatment of individual patients (Stimson and Lart, 1991). I see a swing in the UK to prevention and early intervention and the concentration on outcome for individual patients. The treatment of long-term addicts will no longer be a priority and harm-reduction prescribing is likely to be a casualty of this swing.

Dr Philip M. Fleming, Consultant Psychiatrist, Northern Road Clinic, Northern Road, Cosham, Portsmouth, Hants P063EP, UK.

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