• 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

Dear Arnold,

You may not be aware of the current state of dependency management in the UK. Even from my distance in Australia (and currently in NYC) it is unenviable ... although as you imply, and the BMJ authors would have us believe, it is POTENTIALLY the best in the world. But more people are reportedly dying from methadone than from heroin in the north of England. They do not usually supervise it. Mean doses are usually less than 50mg daily, about half what it should be. They often give more than 50mg as a starting dose and there are often no urine tests, examinations or regular counselling sessions. We might cope without one or some of these, but to have a "treatment service" which often offers NONE of the above is an invitation to disaster ... and that is just what they have got ... unlike their Scotch colleagues who have been doing it 'by the book' for a decade or more. They have GPs, pharmacists and specialists all cooperating in a manner that JAMA researchers found beneficial, and possibly a useful model for the US. Nobody in their right mind would want to copy what the English have (or haven't) done. And the EEC monitoring people in Lisbon say that the UK has the highest opioid overdose death rates in all of Europe (22 per million per year).

Few would argue with your statement "the judgment of an individual physician should be trusted in tailoring treatment for each patient". However, in a condition like dependency where few doctors have any training in diagnosis, let aside treatment, this is inevitably going to lead to problems initially. What we need when such a situation arises (as with HIV, TB and other 'epidemics') is a 'cook-book' approach using simple guidelines (such as Strang's masterly work). Then 'normal medical practice can take over when we have sufficient physicians familiar with the field to allow what you so rightly hope for 'individually'.

On the point of addiciction, Connell is incorrect in my opinion. For one of the commonest and most serious drug use presentations, opioid addiction, there is a time honoured and proven strategy that saves lives and reduces complications: methadone and other agonist treatments. For alcoholism, there are behavioural approaches and, where these are found wanting: a variety or proven or recommended pharmacotherapies. So why would an experienced person like yourself make the quite unsupportable and incorrect assertion that "there is no specific treatment of drug abuse"? It is certainly true that with benzos and stimulants and non-dependent drug use we are in less charted waters, but by no means does every little GP have to 'experiment' with their patients as there are reasonable protocols to try and referral mechanisms to use as with every other difficult medical condition.

I hope you will take this message as a stimulus to discussion and NOT as an invitation to internal warfare. There are so few people genuinely involved in their field as I know you are. I have contacted such names as Millman, Maslansky, Kreek, Newman, Joseph, Drucker and Dole in New York and try to keep abreast of moves. I have recently prescribed buprenorphine for (possibly) the first 5 private heroin addicts who were 'treatment refractory' in Australia - each happily with very positive outcomes. I would be pleased to share the case histories with you in due course if you are interested.

You will find that there is no such thing as 'the British system' any more and has not been since the 1960s unless you can define it for the field yourself. Individual clinical decisions are either good practice or they are not and excuses about various 'systems' is a diversion from this Hippocratic responsibility borne by all doctors.

Yours sincerely, and with respect and admiration for your important contributions to this field,

Andrew Byrne ..

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   Dr Andrew Byrne,
   General Practitioner, Drug and Alcohol,
   75 Redfern Street,
   Redfern,
   New South Wales, 2016,
   Australia
   Tel (61 - 2) 9319 5524  Fax 9318 0631
   Email  ajbyrne@ozemail.com.au
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"Addict in the Family" http://www.csdp.org/addict "Methadone in the Treatment of Narcotic Addiction" http://www.drugpolicy.org/library/byrne_contents_methadone2.cfm