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EDITOR - Strang & Sheridan1 complain that despite government guidelines,
inappropriate practices and attitudes surrounding methadone prescribing
have not diminished. In particular, they deplore the continued
prescribing of methadone tablets and of inadequate doses.
Historically, the National Addiction Centre (NAC) has itself ignored
evidence-based guidelines on methadone. Until about 1994, government
guidelines and the NAC were rather hostile to methadone maintenance (MM).
A textbook published in 1991, under the auspices of the NAC, recommended a
maximum methadone dose of 60 mg daily. In 1995, a distinguished methadone
researcher implicitly castigated the NAC for an excessively psychological
approach to dependence which "influenced staff of drug dependence units to
refuse to provide [MM]".2 Are Strang and Sheridan documenting a problem
which partly originates in the NAC itself?
In our reply3 to an earlier NAC paper, we noted that despite very
restrictive attitudes to methadone prescribing in the USA, stable MM
patients could be regularly given a month's supply of methadone (as
tablets, incidentally). We also noted that daily pick-up was incompatible
with continued employment for people who leave home early and return late,
or work for days or weeks at distant locations. Strang & Sheridan
simply ignore these important practical issues. Such patients should not
invariably have to carry around large bottles of 1mg/ml methadone mixture.
A constructive alternative might be to produce tablets containing a small
amount of naloxone, which is not significantly absorbed by mouth but would
produce acute withdrawal if injected.4
Several months ago, you published a letter criticising some NAC staff
for ignoring publications which contradicted their argument.5 In a
politically sensitive area where balance is particularly important, this
further example of academic Bourbonism from the NAC is disturbing. (285
words)
Yours sincerely
Dr Colin Brewer
Director
Catherine Neill
Senior Counsellor
The Stapleford Centre
25a Eccleston Street
Belgravia
London SW1W 9NP
1 Strang J & Sheridan J. Effect of government recommendations
on methadone prescribing in south east England: comparison of 1995 and
1997 surveys. British Medical Journal 1998; 317: 1489-1490
2 Capelhorn J. Methadone maintenance treatment; Britain has been
over-committed to psychological theories of drug dependence. British
Medical Journal 1995; 310: 463.
3 Brewer & Neill Clinical judgment is important. British
Medical Journal 1996; 313: 1482
4 Loimer N, Presslich O, Grünberger J & Linzmayer L. Combined
naloxone/methadone preparations for opiate substitution therapy. Journal
of Substance Abuse Treatment 1991; 8: 157-160.
5 Brewer C. Opiate detoxification under anaesthesia. British
Medical Journal 1998; 316: 1983-4
Possible conflict of interest. Both authors work in a private
addiction clinic which offers methadone maintenance as well as other
addiction treatments.
The effect of government recommendations on methadone prescribing
EDITOR - Strang & Sheridan1 complain that despite government guidelines,
inappropriate practices and attitudes surrounding methadone prescribing
have not diminished. In particular, they deplore the continued
prescribing of methadone tablets and of inadequate doses.
Historically, the National Addiction Centre (NAC) has itself ignored
evidence-based guidelines on methadone. Until about 1994, government
guidelines and the NAC were rather hostile to methadone maintenance (MM).
A textbook published in 1991, under the auspices of the NAC, recommended a
maximum methadone dose of 60 mg daily. In 1995, a distinguished methadone
researcher implicitly castigated the NAC for an excessively psychological
approach to dependence which "influenced staff of drug dependence units to
refuse to provide [MM]".2 Are Strang and Sheridan documenting a problem
which partly originates in the NAC itself?
In our reply3 to an earlier NAC paper, we noted that despite very
restrictive attitudes to methadone prescribing in the USA, stable MM
patients could be regularly given a month's supply of methadone (as
tablets, incidentally). We also noted that daily pick-up was incompatible
with continued employment for people who leave home early and return late,
or work for days or weeks at distant locations. Strang & Sheridan
simply ignore these important practical issues. Such patients should not
invariably have to carry around large bottles of 1mg/ml methadone mixture.
A constructive alternative might be to produce tablets containing a small
amount of naloxone, which is not significantly absorbed by mouth but would
produce acute withdrawal if injected.4
Several months ago, you published a letter criticising some NAC staff
for ignoring publications which contradicted their argument.5 In a
politically sensitive area where balance is particularly important, this
further example of academic Bourbonism from the NAC is disturbing. (285
words)
Yours sincerely
Dr Colin Brewer
Director
Catherine Neill
Senior Counsellor
The Stapleford Centre
25a Eccleston Street
Belgravia
London SW1W 9NP
1 Strang J & Sheridan J. Effect of government recommendations
on methadone prescribing in south east England: comparison of 1995 and
1997 surveys. British Medical Journal 1998; 317: 1489-1490
2 Capelhorn J. Methadone maintenance treatment; Britain has been
over-committed to psychological theories of drug dependence. British
Medical Journal 1995; 310: 463.
3 Brewer & Neill Clinical judgment is important. British
Medical Journal 1996; 313: 1482
4 Loimer N, Presslich O, Grünberger J & Linzmayer L. Combined
naloxone/methadone preparations for opiate substitution therapy. Journal
of Substance Abuse Treatment 1991; 8: 157-160.
5 Brewer C. Opiate detoxification under anaesthesia. British
Medical Journal 1998; 316: 1983-4
Possible conflict of interest. Both authors work in a private
addiction clinic which offers methadone maintenance as well as other
addiction treatments.
Competing interests: No competing interests