TREATMENT
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DOCTOR WARS
What to do about
opiate use and
users has been
discussed,
argued, and
shouted about for more than a
century now to relatively little
positive change. It’s like the opening
song in The Sound of Music – ‘how
do you solve a problem like Maria?’
Only no one ever does solve the
problem of Maria (although I think
it has something to do with finding
love and, of course, climbing every
mountain – a familiar metaphor for
any users).
The same seems true for opiate
users. We dutifully sing the songs
asking for help, but too often
leave disappointed. There are still
hundreds and even thousands of
opiate-dependent users in the UK
and around the world who want
and deserve a safe supply of that
medicine under medical oversight,
and finally some are getting it. And I
use the word oversight for a reason.
It should mean ensuring services are
providing empathic access to a safe
supply with all the social support,
trauma therapies and help with
The running battles between substance
misuse clinicians in the ’70s and ’80s
helped to shape today’s treatment
landscape, says Bill Nelles
housing that we know are essential
to settling down to a life of quality
without the poisons on our streets.
Having all these is what saved
me for nearly 40 years. All were
necessary for me and there should
be widespread shame at the lack of
this joined-up care today.
It wasn’t until the late ’60s that
serious prohibition started in the
UK – largely because young people,
not elderly users and dependent
doctors, were now using heroin
and getting it from doctors famous
for their unusual prescribing
locales like coffee bars and street
corners. Some changes were
understandable as the system was
anarchic and largely unregulated.
But the ‘classic’ NHS clinics
born around 1969 all had differing
attitudes with little agreement on
what to do within the teams formed
to run them. Thus the era of the
‘doctor wars’ broke out – psychiatry
came to dominate treatment in
the UK, leading to psychotherapy
becoming the approach, and in
London high quality Chinese heroin
replaced the state gear. So people
voted with their veins.
‘It wasn’t until
the late ’60s that
serious prohibition
started in the UK...
Some changes were
understandable
as the system was
anarchic and largely
unregulated.’
This was in direct contrast
to Dr Vincent Dole and Marie
Nyswander’s approach in New
York that saw opiate use as a
physically mediated condition that
was treatable but not curable,
and not always responsive to
psychotherapy. Opiate receptors
were identified soon afterwards,
and real research started
uncovering just what was going on.
But the UK’s NHS drug
dependency units were taken
over by psychiatrists, not medical
doctors. With some notable
exceptions, their goals were
abstinence through withdrawal
and therapy. All these psychiatrists
who held the new licences
needed to prescribe heroin hardly
used them, with a few notable
exceptions. People were moved
onto oral methadone or nothing if
your particular clinician wouldn’t
prescribe, or you only had access
to a non-medical community
drug team – tea and sympathy (of
little use) if you were ‘lucky’, but
confrontation if you weren’t.
The fights at the monthly
meetings held at the Home
Office Drugs Branch during
the ’70s to mid ’80s brought
together psychiatrists who hated
prescribing, some of the private
doctors who could still prescribe
some opiates and opioids (but not
heroin or cocaine), and the very
few doctors who did still prescribe
injectables to the few. They were
often vicious and sometimes
very personal – some moderating
influence came from the presence
and later letters and testimony of
dear Bing Spear, head of the Home
Office Drugs Branch the until the
early ’70s. He was replaced by a
warrior who did his best to shut
down even oral methadone.
By 1983 even getting
methadone for more than a short
period became very rare in the NHS
clinics and unheard of in Scotland.
One of the heads of the Royal
College of Psychiatrists held that
‘no one needs more than 40mg
of methadone a day’ – which was
a big reason so many people had
such poor outcomes and used
on top. Most were expected to
and that’s why their methadone
was kept so low. There were no
objective medical tests or practices
used in the UK to ensure patients
had adequate doses to minimise
fluctuation of methadone levels.
Prescribing anything opiate-like
through the NHS to those dependent
had almost completely stopped by
1983. But events were about to take
an unprecedented shift, and that
changed how everything would be
done. I’ll explore this further in the
next edition.
Bill Nelles is an advocate and
activist, now in Canada. He founded
The (Methadone) Alliance in the UK
16 • DRINK AND DRUGS NEWS • JUNE 2020
WWW.DRINKANDDRUGSNEWS.COM