The Big Question: Is methadone being over-prescribed as a treatment for drug addiction?

Jeremy Laurance
Thursday 10 December 2009 01:00

Why are we asking this now?

A dispute has erupted over the treatment of drug addicts in prisons. According to the former government drugs tsar, Mike Trace, the Ministry of Justice and the Department of Health are battling to impose their differing approaches. The Ministry of Justice is said to favour pushing addicts towards abstinence, while the Department of Health is understood to back the "maintenance" prescribing of methadone to keep addicts stable.

Isn't this a long-running argument?

Yes. The debate over the best way to manage drug addicts has been going on for decades. There are an estimated 330,000 drug users in the UK, most taking heroin and crack cocaine, of whom 180,000 receive treatment each year and 2,500 die. Drug addicts commit three-quarters of all acquisitive crime in the UK, official figures show. In addition to the crime they commit and the damage they do to themselves, they cause harm to their immediate family and friends as a result of their chaotic lives.

So what's changed?

The charge in this case is that the needs of drug-addicted prisoners to kick their habit are being neglected in favour of keeping them on a drug – methadone – which makes them easier to control. Latest figures show the number of prisoners put on methadone increased by 57 per cent in a year. With prison overcrowding at record levels it might appear an attractive option to prison governors to keep inmates subdued with a "liquid cosh" so they are less likely to cause trouble, rather than to put them through the challenge of an abstinence programme which is likely to have unpredictable effects on their behaviour.

Is it true that methadone is used as a 'liquid cosh'?

Not according to the Department of Health and the Ministry of Justice. In a joint statement they said: "It is categorically untrue to say methadone is used as any sort of control mechanism. Decisions regarding treatment are clinically based. The programme includes abstinence, but all treatments are aimed at getting the person off drugs. The rise in prisoners getting methadone treatment means more prisoners are getting the treatment they need and there has been significant investment in prison clinical drug treatment to help this happen."

Who gets methadone in prison?

About 20,000 inmates in England, according to Mr Trace, who is critical of the Government's approach. He says the numbers are too high. The Government says prescribing methadone in prison is mostly for detoxification not maintenance. This means the drug is prescribed by a prison doctor for a pre-set period, with the goal of becoming drug free at the end of it. Latest figures show that in 2007/8 detoxification made up 79 per cent of prescriptions and methadone maintenance 21 per cent.

So whom do we believe?

Tricky one this. Mark Easton, the BBC's home affairs editor, says on his blog that he met many former prisoners in a rehab centre in Burton on Trent "all telling a similar story – that prison doctors are 'doling out' heroin substitutes and making it less likely they will get off drugs". So there is a straight conflict of evidence. The Government highlights the 79 per cent in detoxification programmes while the Burton on Trent rehab centre wheels out people who were among the 21 per cent on maintenance programmes.

What is methadone?

It is a heroin substitute. It does everything that heroin does except deliver the "hit". A non-opiate that removes the craving for a fix, it is taken orally and is easier to control than heroin, allowing addicts to stabilise their lives.

When combined with cognitive behaviour therapy or counselling, the benefits can be greater. Methadone is regarded as easier to come off than heroin so is a first step to becoming drug free.

What happens to drug addicts outside prison?

Much the same as inside, but with more variety. Those who want help, can get it – from long-term maintenance to rapid de-tox. But increasingly it has been recognised that you cannot force an addict to become drug free. They have to want to do so. As a treatment, forced abstinence has proved disappointing with a high rate of relapse. Instead, the treatment approach has to be carefully calibrated according to where the addict is on his or her journey to becoming drug-free.

How does an addict give up drugs?

With great difficulty. For long-term addicts it is a matter of growing up, gaining insight and acquiring the desire for an ordinary life. That takes maturity and cannot be rushed. While waiting for it to occur, addicts may need maintenance treatment for a time, then a period of gradually reducing doses until they arrive at a point where they can give up drugs altogether.

Can giving drugs to addicts be counted as treatment?

This is what worries a lot of doctors – how handing out hard drugs such as methadone free to people who were previously scoring them on the streets can be termed "treatment". Especially when patients in other NHS specialties – cancer, for instance – can't get the drugs they need. But addiction experts say this is about "harm reduction", not cure. Long-term heroin users are among the hardest addicts to treat and impose huge costs on the medical and penal systems.

Does treatment work?

Yes, according to findings of the largest-ever study of heroin and crack cocaine treatment programmes, published in The Lancet in October. The study involved over 14,000 patients from 1,000 community treatment agencies across England who received at least six months' treatment in 2008. The findings showed 42 per cent of the heroin users reported having stopped using the drug and 29 per cent reduced their use in the month prior to their assessment.

Is it expensive?

Treatment with methadone costs £3,000 to £5,000 per year per addict and the average period in the programme is 10 months. The total national cost is £800m a year. Treatment has expanded hugely in the past eight years and waiting times have plummeted from over a year to a few weeks.

Can we trust the results?

The findings came with caveats over the robustness of the results, because of the absence of a control group. There were also doubts over the length of time the benefits were expected to last. But there are few alternatives – and a solution to the problem is still desperately needed. Drug addiction typically follows a relapsing and remitting course and many addicts take years to shake the habit.

Is methadone the best treatment for drug addiction?


* It is the first step on the way to weaning addicts off heroin

* It helps addicts stabilise their lives before they give up drugs

* Research shows almost half of those treated give up within 10 months


* Substituting one drug of abuse for another is not "treatment"

* Addicts who are not reducing their dose are not making progress

* At up to £5,000 per patient per year treatment is expensive

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