Battersby, Malcolm, et al, "Horse Trading: Prescribing Injectable Opiates to Opiate Addicts - A Descriptive Study." Drug and Alcohol Dependence. 1992: pp. 35-42.
Abstract The clinical audit of 40 opiate-dependent individuals who were prescribed injectable drugs (heroin or methadone) between June 1987 and June 1989 is described. These subjects were characterized by the chronicity of their injecting and dependent opiate use, and by their refusal to comply with a treatment programme involving oral-only prescribing. The key aim was to attract entrenched injectors into contact with treatment services and to promote movement away from injecting drug use and reduce HIV risk behaviour. On review 35 of the original 40 were either still receiving an injectable prescription or injecting illicit drugs. Despite this 14 (35%) were rated as making positive life changes. Nine (22-5%) had been admitted to the in-patient unit and became drug free during their stay. The stability of the lives of eight (20%) had deteriorated. The benefits and drawbacks of this form of intervention are discussed with comparison to the other studies of injectable drug prescribing. [Battersby M, Farrell M, Gossop M, Robson P, Strang J. 'Horse trading': prescribing injectable opiates to opiate addicts. A descriptive study. Drug Alcohol Rev 1992; II: 35-42.] Key words: heroin, injectable, methadone, prescribing. Introduction At first glance, prescribing injectable drugs to injecting opiate addicts seems entirely counter-productive in treatment intended to lead them away from injecting. It is certainly highly controversial. Nevertheless, in the UK the Advisory Council on the Misuse of Drugs [1] recommended that the prescribing of injectable drugs may be appropriate ". . .in the most exceptional cases", for which individuals "the aim will be to: (a) move away from sharing equipment; and (b) provide treatment (in the broadest sense) which may facilitate a gradual change away from injecting use"; and that, when provided, ". . . such prescribing of injectables should normally be undertaken for short periods only (rarely more than 3 months)". This retrospective study examines the injecting behaviour of a group of London opiate addicts presenting to an NHS clinic for whom a primary aim was to use injectable opiate prescriptions to help these long-term injectors to stop injecting. All of these addicts had long histories of dependent injectable use of opiates, often including short or longer periods of supply of injectable opiates from private doctors. None was willing to comply with a treatment programme which did not initially include a prescribed supply of injectable opiates. Some drug addicts are unable or unwilling to make the move as a single step from injecting their blackmarket heroin to swallowing prescribed substitute drugs such as oral methadone. For such patients it could be argued that it might be appropriate to prescribe part injectable, part oral prescriptions in the first instance as a stepping stone between the injectable blackmarket heroin use and the future oral-only methadone use. Through a series of intermediate goals [1,2], it was intended that the patient would be assisted to reduce then cease injecting behaviour en route to the eventual goal of ceasing drug use. This approach aims to engage and retain the more entrenched injecting drug addicts whilst constantly coaxing and cajoling the patient to make significant changes in his/her continued drug use: this is deemed important to prevent inadvertent endorsement and institutionalization of the injecting drug user. This approach was recently described in the British newspaper The Independent as the "Softly softly catchee monkey" approach [3]. Basic harm reduction and health promotion information can be given [4] and injecting and sharing behaviour may be reduced. Information was given on the local and systemic consequences of injecting, on correct injecting and needle-cleaning techniques and on the local availability of clean needles and syringes from needle exchanges and community pharmacists. Provision of the injectable prescription was seen as the 'hook' to catch and hold the patient (as previously described in the UK by Connell [5], and it was possible that patients could avoid contact with drug dealers and other users and therefore move away from injecting illicit drugs. It was hoped that this 'weaning off' approach from illicit drug contacts in a controlled and predictable manner, might lead to both a period of stability and an opportunity to cease injecting behaviour. This form of prescribing constitutes part of a pragmatic approach in which it is recognized that it may be the only way to engage some drug takers in a treatment programme which aims to promote movement away from the injecting of drugs. Thus it is qualitatively very different from the maintenance prescribing of injectable drugs where there are unlikely to be any explicit short-term goals about movement away from injecting. This has involved clarification not only of the intermediate goals but also of the broad time scales within which they should be achieved. An approach involving movement through a series of intermediate goals constitutes an attractive way of working so as to accumulate progressive benefit, but it has not yet been established whether it is possible to maintain progress or alternatively whether more entrenched addicts will be unwilling and/or unable to initiate and continue to change, so that in effect the treatment becomes 'maintenance by default'. Prescribing injectable drugs to drug addicts is by no means a new practice in the UK. Indeed it has long been a subject of lively debate within the UK and has been a source of endless fascination to advocates and critics of the 'British system' [6]. The reports from the Advisory Council on the Misuse of Drugs [1,7] recommend the re-examination of the partial benefits which may be accrued from interventions which focus on changes in the drug-taking behaviour which fall short of abstinence, benefits such as those previously reported in various studies which have included the prescribing of injectable drugs. Hartnoll et al. [8,9] described their study of the different benefits of either injectable heroin maintenance or oral methadone maintenance with random allocation of the injecting heroin addicts presenting to their service. Prescribed injectable drugs have also been available to addicts in other countries. In Queensland, Australia, a small injectable methadone clinic has operated for several decades; and in the late 1980s, an experimental scheme for chronic addicts was introduced in The Netherlands which involved the prescribing of injectable morphine [10]. In the early twentieth century, as control legislation began to be introduced into the USA, many narcotic clinics were briefly established (a total of 44 across the USA [11]) dispensing both heroin and morphine, initially on a maintenance basis, and subsequently on a rapid reduction as anti-maintenance regulations were introduced (for review, see Ref. 12). For a brief period of time, these state-run clinics were widespread (1919-23) but were closed down as a result of the activities of the Federal Narcotic Division of the Prohibition Unit, not as a result of any scientific findings of the benefit/harm balance [11,12]. Goldstein [13] proposed a STEPS programme in which a hierarchical approach might be adopted with the provision of injectable morphine during the early stages, leading to eventual oral-only prescribing. An Australian study is currently being considered which looks at the reductions in HIV risk behaviour which may be associated with sharing of injecting equipment which may result from the prescribing of injectable drugs such as morphine ampoules (G. Bammer, personal communication). Throughout most of this century, the prescribing of injectable drugs such as heroin and methadone has been part of the practice in the management of opiate addicts in the UK, but the total number of patients receiving such treatment in any year has always been small due to the small scale of the British drug problem up until the 1960s and the more cautious prescribing of injectable drugs since the 1970s. By the 1980s, it had become extremely rare for any newly presenting opiate addict to receive a prescription for injectable drugs, except for addicts attending a small number of prescribing private doctors mainly in the London area as has previously been described [14-16] and the subsequent resurgence of interest in injectable maintenance from some NHS drug consultants [17]. The progressive move away from the prescribing of injectable drugs appear to have occurred as a result of increasing disillusionment on the part of the new drug clinics with the first 5-10 years of their operation (1968 onwards) during which period many of the addicts taken on for injectable maintenance appeared to become entrenched in their continuing drug use and injecting behaviours. This paper reports on 40 patients who received an injectable opiate prescription during the period from June 1987 to June 1989 at a NHS out-patient drug-dependence treatment service. The 40 patients represent less than 10% of the total number of patients who presented for assessment during this 2-year period. Methods Subjects The subjects in this study were 40 opiate addicts to whom injectable opiates were prescribed. All were physically dependent upon opiates and attended the Drug Dependence Clinic of the Maudsley Hospital in London. Selection of these patients did not occur by means of a predetermined operationally defined set of criteria. For the majority, assessment involved two or three interviews, which included physical examination and urine testing for drugs of abuse. In some cases it also included a test dose response to oral methadone, before a final decision to prescribe was made by the psychiatrist who was to manage the case, and the consultant in charge of the clinic. Twenty of the patients presented after abrupt termination of their injectable prescriptions from a private-sector psychiatrist, and the social and drug-taking behaviour of this group has been previously described [16]. Of the 20 subjects not referred from the private sector psychiatrist, 8 (20%) had previously attended other private psychiatrists, and 12 (30%) were self-referred, five via voluntary agencies. Twenty-five (62.5%) of the subjects had received previous NHS out- patient treatment whereas only (27.5%) had had previous NHS in-patient treatment. Procedure One of the aims of the initial assessment and negotiation of the therapeutic alliance or contract was to establish what dose is sufficient to prevent withdrawal symptoms and to reduce the likelihood of recourse to extra illicit supplies. In view of the explicit intermediate goal of reducing and then stopping injectable drug use, the clinician attempted to secure the patient's agreement to abstain from any additional drug use while receiving prescribed drugs. The management plan included drugs prescribed, dosage, and a provisional time scale for stopping all injecting of drugs. These were the subject of explicit negotiation and were recorded in the case notes prior to any prescribing in most cases, or prior to any long-term commitment to prescribing, in others. Patients were encouraged to participate in the negotiation and clarification of treatment goals, with the result being the initial plan was to start on a mixed oral and formulation of individual 'treatment contracts'. During the 2- year study period, management of the 40 patients was mainly undertaken by the consultant or senior registrar (i.e. rarely by more junior medical or non-medical staff). Results The sample of 40 injecting opiate addicts comprised 27 men and 13 women. The average age of the subjects was 35.4 years (range 42-60). The mean duration of injectable opiate use was 15.7 years (range 4-43). These subjects were therefore not typical of new patients taken on by this UK treatment service, for whom the mean age is 27 years and duration of opiate use is 6 years [18]. The 20 patients referred from the single private- sector psychiatrist were dependent on prescribed methadone, and the majority of the remaining 20 were dependent on heroin as their main daily drug. Case note data were incomplete for one subject. The average duration of attendance at the drug dependence unit from the time of commencing the injectable prescription to last formal contact with the clinic was 45 weeks (range 1-104). Initial request Twenty-nine (72.5%) subjects requested an injectable maintenance prescription. To the patient this meant that they would receive an injectable prescription of a stable dose for an indefinite period, or until such time as the patient chose to reduce or cease the prescription. Six (15%) subjects for an injectable prescription over a period of more than one year; three for a period of less than one year, and two requested an injectable prescription as a short-term measure prior to an in-patient admission. Initial treatment plan For the majority of patients, the treatment on offer did not match their initial request or expectation. From the outset, it was made clear that long-term injectable maintenance would not be provided although the interim (and probably reducing) prescribing of injectable drugs might be considered if this constituted a stepping-stone towards oral maintenance. For 24 (60%) subjects, the initial plan was to start on a mixed oral and injectable component would be steadily reduced and cease in 6-12 months. For 10 (25%) subjects, the plan was to maintain an injectable prescription until admitted for in-patient detoxification and treatment. Four subjects received an interim injectable prescription until they were seen by a doctor or clinic other than the Maudsley. The remaining two patients attended the clinic for 3 weeks or less and no formal management plan was completed. Initial and final drugs, dosages and injecting behaviour For 31 (77.5%) subjects, the first prescription consisted of combined injectable and oral methadone. Five patients received injectable heroin only and four patients injectable methadone only. The mean combined oral and injectable commencing daily dose, in methadone equivalents, was 70.25 mg. The drug(s) and doses prescribed on the day of final contact were recorded for those subjects who had left the clinic. For those patients still in clinical contact, the case notes were reviewed, and the prescription received on that day was recorded. Where patients had transferred to the in-patient unit, they are included in the data and recorded as receiving zero medication and dose, thus contributing to the final mean score. Using these operational criteria, at the time of review 18 (45%) patients were receiving a combined injectable and oral methadone prescription, three were receiving injectable methadone only, five (12.5%) injectable heroin only and eight (20%) were receiving oral methadone only. The mean combined oral and injectable dose at last contact, in methadone equivalents, was 50 mg. This decrease in mean dose from initial dose to dose at last contact is statistically significant (t=3.72, p<xml>.</xml> The injecting of drugs other than those prescribed was also determined. This was recorded in the case notes by the prescribing psychiatrist and determined on the basis of self-report from the patient, backed up by reference to weekly urine testing and physical examination, looking for injection marks in those who had moved to oral medication. Of the 14 (35%) patients not receiving an injectable prescription at last contact, nine patients were clearly injecting non-prescribed drugs, four were not injecting, and for one it was uncertain as to whether he was injecting illicit drugs. Combining the two sets of data, 35 of the original 40 were either receiving an injectable prescription or injecting illicit drugs at last contact with the clinic. Of the four not injecting, three were in the in-patient until and one was in a residential rehabilitation facility at the time of the outcome review. Where did they go? Of those who ceased to attend the clinic, 17 (42.5%) subjects had transferred to a private doctor, six (15%) subjects to a general practitioner, and for two cases, there was no information. Of the 11 subjects who continued to attend the clinic, 10 were receiving an injectable opiate prescription, and one an oral opiate prescription. Four patients were attending in-patient or rehabilitation units. Physical complications For those who had ceased attending the clinic, no data are available regarding physical complications. However, it is known that after leaving a drug-free rehabilitation facility, one subject died from an overdose. Shortly after admission to an in-patient unit, one subject was transferred to a general hospital with osteomyelitis of his cervical spine resulting from his intravenous drug use despite his previous supply of pharmaceutical injectable methadone and supply of clean needles and syringes. He remained critically ill for many weeks, but survived, and has subsequently made a good recovery. During the prescribing period, two patients were known to be injecting methadone linctus into their femoral veins, and several others used the inguinal area to inject prescribed injectable methadone. Life changes By using information from the case notes, combined with the clinical impression of the treating psychiatrists, a 'life changes' rating was made for each patient. A global rating of occupational, social, intimate relationship and criminality factors was made. Fourteen (35%) subjects were rated as making positive life changes during their period of contact with the clinic, eight (20%) patients had deteriorated and 18 (45%) showed no change. A comparison of 'improvers' versus the other patients showed that the improvers were younger with an average age of 31.5 years compared to 37.5 years (t= 2.45, p<xml>.</xml>x=44 mg for both groups). Treatment compliance We reviewed the quality of the treatment compliance between each patient and doctor. Treatment was undertaken by the prescribing doctor and was broadly directed to achieving change by predominantly cognitive behavioural techniques including goal setting, problem solving and interpersonal strategies such as negotiation, bargaining, reinforcement and cajoling or 'nudging', as described elsewhere [2,19,20]. A rating was made by each doctor of the quality of the therapeutic alliance as characterized by compliance with or resistance to the original treatment plan. Sixteen (40%) subjects were rated as complying with this plan and participating in treatment, 24 (6o%) were resistant to the plan and the therapeutic process. Selection factors No predetermined criteria were used to select patients. However, patients in this study were chronic injectors who refused to accept a prescription for oral opioids and who may be regarded as having a poorer prognosis than patients assigned to other forms of treatment. An attempt was made retrospectively to categorize the factors which contributed to the decision to prescribe an injectable prescription. More than one of the following factors may apply to a single patient. - Common to all 40 patients was their request to be given an injectable prescription; indeed, no patient would have received an injectable prescription unless they had asked for it. For five patients, the knowledge that the clinic was able to prescribe injectable opiates as a treatment option, led to an outside non-statutory agency referring patients with a request that consideration be given to injectable maintenance prescribing.
- For 20 patients, having already been in receipt of an injectable prescription (in excess of 12 months for most cases) added strong weight to their request for a similar prescription.
- Thirteen subjects were categorized as having a history of many years of injecting, with little or no history of abstinence and claiming 'needle fixation', i.e. that the act of injecting itself was associated with an irresistible compulsive urge to inject.
- For eight patients, a combination of chaotic life-style and polydrug abuse with evidence of either ongoing physical sequelae, e.g. the injecting of Diconal tablets (dipipanone/cyclizine) in the femoral vein at the inguinal site, with frequent hospital admissions for deep vein thrombosis, and/or high risk behaviour, e.g. through sharing of needles or prostitution, constituted a major factor in the decision to prescribe injectables.
It should be emphasized that all patients were encouraged to consider out-patient or in- patient detoxification as an alternative to an injectable prescription. In several cases, this option became the goal of therapy, particularly when it became apparent that the original planned graded reduction was unsuccessful. In total, nine (22.5%) subjects had in-patient admissions during the period under review. All of these subjects became drug free whilst in the in-patient unit. Subsequently, some patients returned to drug use and were either attending the clinic and receiving prescriptions, or had severed their contact with the clinic. Discussion The group of subjects described represents a highly selected subgroup of patients attending an NHS Drug Dependence Clinic in London. Their demographic data indicated that they are older, have been using illicit drugs and injecting longer than the typical drug user described in reviews of patients attending NHS clinics. In addition a sizeable proportion of the subjects were polydrug abusers, leading chaotic life-styles and/or were at high risk from serious physical illness including HIV infection. They were also 'treatment-wise' with all patients having asked for injectable prescriptions and the majority having had NHS out-patient or in-patient treatment, and 28 (70%) having received treatment from private sector doctors (psychiatrists). It was hoped that there might be a reduction in HIV risk-taking behaviour such as frequency of injecting and sharing which would be promoted by this prescribing approach. The aims of this open clinical trial were to bring about a shift away from injecting behaviour, by initially attracting and then retaining patients in treatment services. From the measures of outcome described, it would seem that the latter, but not the former was achieved. Patients stayed a mean of 45 weeks in treatment, but at last contact with the clinic, 35 out of 40 subjects (80%) were still injecting. During the prescribing period, one patient developed a life-threatening illness (cervical spine osteomyelitis) and survived. Several others were known to be injecting prescribed medication, including methadone mixture, into the femoral vein at the inguinal site. This is a highly undesirable and dangerous practice. In addition, the stability of the lives of 8 (20%) subjects had deteriorated. The near-death of one patient highlights the high-risk nature of this prescribing practice, where short-term benefit and consumer satisfaction may need to be balanced against the possibility of adverse consequences in the longer term. However, it is not possible to determine the nature of risk-taking that would have occurred in the absence of the present treatment interventions. Despite these negative findings, the results indicate that there were some positive outcomes in the group described. The mean dosage prescribed, in methadone equivalents, had reduced from 70 to 50 mg. Nine (22.5%) patients had attended the in- patient unit, and became drug free during their admission and 14 (35%) were rated as making positive life changes during the period under review. It is interesting to note that there was a relationship between age and improvement with the older addicts being less likely to respond positively to treatment. However, the initial selection of patients to this study might itself be seen as a clinical attempt to identify a group who might benefit from this intervention. Overall the results do not provide conclusive evidence of either benefit or harm as a result of this intervention. Information on injecting frequency is not available but the overall impression was that there was substantial reduction in injecting frequency. Whilst these positive outcomes are important, it cannot be assumed that they are primarily attributable to the prescribing of injectable opiates. This is only one possible factor affecting the outcome. It could be argued that if injectable opiates were not an option, many of the 40 subjects may have accepted oral opiates, and their injecting ceased as a consequence. Indeed there has been argument as to whether the local availability of injectable drugs from private doctors may even have contributed to the flow of patients out of treatment when the transfer from injectable to oral drugs began to occur [21-24]. On the other hand, 26 (65%) subjects left the clinic to find an alternative source of opiates as their prescribed dosage decreased. Perhaps they would not have engaged with the clinic if injectable opiates had not been available. This study is a descriptive one and cannot provide answers to questions of cause and effect. It does, however, highlight a number of points relevant to clinical practice in a climate where the advent of HIV/AIDS has prompted debate on the role of prescribing. The Government and the public expect treatment services to provide effective intervention for intravenous drug users and to combine this with a public health role in reducing the risk of spread of HIV to other drug users and to the wider public. Treatment services similarly wish to fulfil these roles. These expectations have led to a range of new strategies at all levels of service from 'low threshold' access to services, to the prescribing of injectable opiates. Thus it is appropriate for high and low thresholds to exist simultaneously in the same network of services with thresholds, safeguards and degree of monitoring being different for different types of service. In the Netherlands different thresholds between oral and injectable maintenance have been applied with more stringent entry criteria for the Amsterdam injectable morphine study than their oral methadone maintenance programmes [20]. The Maudsley programme had defined pre-set goals within which the time-limited prescribing of injectable drugs was employed in an attempt to lead entrenched injectors away from continued injecting drug use. This regime was presumably unsatisfactory in some respects to the 65% who departed to other doctors. This contrasts with the reported high satisfaction rate for the Amsterdam morphine dispensing programme. Nonetheless in that programme six of the original 37 patients died during the study period [10]. It may perhaps be that the greater availability of injectable drugs from private practitioners in the UK than in the Netherlands led to a climate where the patient may be drawn away to other prescribed sources as soon as difficulties are encountered in treatment--the intra- professional competitive prescribing to which attention has previously been drawn [21]. The Amsterdam study focused on more detailed aspects of psychosocial functioning. Overall they conclude that the programme resulted in more progress than deterioration. Similarly Hartnoll and Mitcheson [8,9] obtained inconclusive results when comparing maintenance with either oral methadone or injectable heroin. Oral prescribing resulted in higher attrition but also in higher abstinence rates. Those with a prescription of injectable drugs did not improve in health in either the Amsterdam or the Hartnoll study. In view of the limited gains seen in this group of patients, particularly in injecting behaviour, and the considerable risks taken to achieve these gains, the authors see only a very limited role for the prescribing of injectable opiates. It is possible that further research into this question might be useful but much more stringent controls and better measures would be needed. It is, however, unlikely that research findings would substantially alter existing attitudes and policies toward prescribing practices. More careful consideration needs to be given to the role of injectable prescribing in the case of the entrenched drug addict if the drug worker is to avoid complicity with continued high- risk behaviour behind a presumption of health promotion and harm minimization. | 
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