• Reducing deaths among drug misusers ~ (March 31 2001 editorial published in British Medical Journal)
  • General Medical Council may be destroying the British System ~ Arnold's Response
    • The current state of dependency management in the UK ~ Dr. Byrne responds to Arnold
      • Your letter raises many important issues ~ Arnold responds to Dr. Byrne
  • Standard of care in Britain was not addressed ~ Andrew Byrne's Response
• Authors' Reply

EDITOR Mortality and morbidity of problematic drug users reduce substantially when the users are receiving treatment. ¹ Methadone treatment on the basis of reduction of harm, in which the use of illicit drugs is tolerated, is strongly related to decreased mortality from both natural causes and overdose. ² Any intervention that prevents people who want and require treatment for their drug problem from receiving that treatment is thus likely to be detrimental to their health and fails to address the impact of their addiction on society.

Licensing could act as a barrier to providing readily accessible treatment. We are pleased that Trebach agrees with our view. Byrne has, however, missed this point in our editorial. Byrne focuses his reply on methadone diversion, supervised consumption, and opiate related deaths. These are not the main point of our editorial and would require another article to be discussed fully.

We do not believe that reducing methadone diversion would have a significant impact on opiate related deaths. We believe that supervised consumption has benefits and costs, neither of which has been properly evaluated. Its advantages must be balanced against other important issues such as accessibility of service, retention in treatment, and convenience for the patient.

The United Kingdom has the highest death rate from opioids in Europe because it also has the highest rate of consumption of opioids. Recent figures from the UK's Office for National Statistics show the number of methadone deaths falling for the past three years, with deaths from heroin continuing to rise. The number of cocaine related deaths is continuing to rise steeply, which suggests that deaths are a result of increasing misuse, not irresponsible prescribing.

We do not advocate inadequate dose levels or poor access to treatmentquite the reverse. We hope for a wider range of treatment options, the steady improvement of services through clinical governance, and a wider availability of high quality treatment. Supporting general practitioners through shared care schemes and training, rather than encumbering them with additional bureaucratic mechanisms that do not improve care, will achieve this.

We agree with Trebach that the population using drugs is no more homogeneous than any other group of people with a particular condition, and we treat them as such at our peril. We also agree with Byrne that all patients with a dependency deserve a careful history and examination, and favourable outcomes should follow judicious prescribing when necessary, with appropriate safeguards and psychosocial support. Where we disagree is that licensing will help this process. Prescribing policies for people who undertake problematic drug use should also be supported by available evidence. What little available evidence there is suggests that limiting treatment options and availability through further licensing restrictions will have adverse effects on the quality and availability of evidence based treatments. Furthermore, there is no evidence to support the notion that restricting prescribing in this way will necessarily increase community and patient safety.

Chris Ford, general practitioner. London NW6 6RR

Tom Carnwath, consultant psychiatrist. Manchester M33 1FD

Mark Gabbay, senior lecturer in general practice. University of Liverpool, Liverpool L69 3GB

Competing interests: None declared.

1. Frischer M, Goldberg D, Rahman D, Berney L. Mortality and survival amongst a cohort of drug injectors in Glasgow 1982-1994. Addiction 1997; 92: 419-427[Medline].
2. Langedam W, van Brussel G, Coutinho R, van Ameijden E. The impact of harm-reduction-based-methadone treatment on mortality amongst heroin users. Am J Public Health 2001; 91: 775-780.