ABSTRACT
This chapter reviews the current practice of injectable opiate treatment (IOT) in the UK, i.e. the ‘British system’ of prescribing injectable heroin and methadone, and considers some of the clinical and ethical issues it raises. There is only very limited research evidence supporting either the safety or effectiveness of IOT as practised in Britain. In particular there is almost no evaluation of long-term outcomes of IOT which is of potential concern given the possibility of some patients remaining indefinitely in IOT, the risk of vascular complications, and its higher cost compared with oral maintenance. It would be easy to assess this controversial intervention as in need of further research. However, striving towards best practice in IOT involves more than generating evidence. The likelihood of a patient receiving IOT in the UK appears to be influenced more by the personal inclinations of prescribers than by outcome data (if any), or identified community needs for access to IOT. Is this good clinical practice and is it sustainable? The British system needs to modernise itself, consistent with international paradigms of continuous quality improvement and with the NHS’s own agenda of clinical governance. The UK differs from most other countries by including injectable heroin and injectable methadone in its range of opiate substitution therapies for heroindependent users. A small number of licensed medical practitioners, usually specialists in drug dependence, can prescribe heroin to any dependent heroin user who is assessed to be suitable for this intervention. No licence is required for parenteral methadone. Currently, to the surprise of many addictions specialists and their patients, pharmaceutical heroin does not actually have an approval licence for treatment of opioid drug dependence, and parenteral methadone is not licensed for intravenous administration.
