The Heat is On – Doctor Wars (part two)

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In the second part of ‘Doctor Wars’, Bill Nelles describes the tumultuous days of the 1980s.

Read part one here.

By 1983, the cold war among doctors treating drug users was becoming a lot hotter, and there was still no public health response to drug use.

The Home Office consultants still met regularly, and included private doctors as well as NHS consultants. The NHS doctors felt the private doctors prescribed overly generously, didn’t demand reductions, left their patients ‘still addicted’, and even charged them fees. The private doctors felt the NHS doctors were too rigid and their patients poorly treated. Guidelines on the treatment of drug misuse (‘orange guidelines’) were the first national guidance issued by this group in 1984 – they pleased few. For instance, the guidelines considered that medically supervised detoxification was a ‘simple and short-term process with spontaneous remission possible’, and also stated that maintenance was not acceptable. ‘Evidence-based treatments’ didn’t really exist in addiction medicine at that time.

Ironically, the main use of the orange guidelines was as evidence in 1986 at Dr Anne Dally’s General Medical Council (GMC) hearing. She was a feisty senior private doctor on the working group and one of the signatories of the 1984 guidelines. I gave testimony supporting her at her GMC hearing, having become the drug education officer at the Terrence Higgins Trust (THT) a year earlier, but her verdict was guilty of maintenance! While she was able to still be a doctor, she was never allowed to prescribe controlled drugs again. Her practice evaporated almost overnight.

Because of its policy of avoiding methadone and arresting users for the possession of syringes alone, Scotland was one of the first parts of the UK to see the unusual and mostly lethal illnesses associated with AIDS and injecting drug use. Cheap heroin from Iran and the easy availability of Temgesic, (ironically, an early sublingual form of buprenorphine) had vastly increased the number of people injecting opioids, and police pressure had made clean needles impossible to obtain.

But two factors had yet to reveal themselves. The first was, of course, the AIDS epidemic, with the first Scottish drug user dying in Scotland in 1983. The second was the growing involvement of general practitioners in providing services to drug users and their influence on practice. Britain had not made methadone a drug needing a Home Office licence, and thanks largely to the efforts of dear Dr Tom Waller – an ACMD member who batted it back every time it was put forward – it was never adopted as policy.

These trends intersected in early 1985, when a young GP in Edinburgh published a paper in the BMJ which galvanised me, and many others, into serious action. Dr Roy Robertson, (now the Queen’s physician in Scotland and professor of addiction at Edinburgh University), had been seeing drug users for some years, and maintaining some with dihydrocodeine. He was able to obtain HIV test kits in advance of their national availability, and in late ’84 had taken blood for HIV antibody assay from around 160 patients. He knew they shared used needles, and the paper showed that 51 per cent had already been infected by HIV.

The effect of this news cannot be exaggerated. Research testing in London was showing rates of under 5 per cent positive, so we realised we had a short window to make a difference if we moved fast. By the summer of 1986, teams in London, Liverpool, Edinburgh and Amsterdam and, of course, the US were working very hard to understand what they were facing, and the UK and Holland had already implemented needle exchanges to stop sharing and prescribing to reduce injecting.

But there were still battles to be fought over clean injecting equipment. I had been seconded to the Standing Conference on Drug Addiction (SCODA) from the THT to write a booklet about AIDS for drug users, but in February ‘86 I spoke at a large National Haemophiliac Society meeting in Newcastle at which I represented SCODA and called for a serious examination of supplying clean needles.

This was picked up on Newsnight, and on Monday I found myself called to the office of the director. In fact the Friday before, after six months of abstinence from opiates, I had engaged a private doctor to look after me so that I didn’t resume injecting. He strongly objected that I had supported needle exchanges. I was also told that I ‘looked stoned’ and under no circumstances could someone work in a drugs agency even on legal methadone. That same day I returned to the THT where we concentrated on reducing the risk for drug users through advocacy with politicians, speaking engagements, and writing leaflets. By 1988, the McClelland report in Scotland and the ACMD special report chaired by Ruth Runciman gave the green light to access to clean needles, setting up 15 pilot schemes in England and Scotland. These were quickly expanded when the pilots reported favourably and both reports called for an immediate re-evaluation of methadone prescribing.

GPs had also become more independent and proactive especially if they had no specialist prescriber. West Berkshire Health Authority under Ailsa Duncan, their drugs coordinator, engaged me in 1988 to train a group of around 15 GPs to prescribe methadone. It was a five-day course with a written handbook. Apart from Ailsa, none of the doctors were aware they were being trained by a methadone patient!

I have great respect for all evidence-based treatment including non-prescribing approaches when it’s what the patient seeks. But present policies that deny people such approaches are shameful and should not be tolerated. In the last part of this series, we will look at the golden age of drug services – the first eight years of 2000. And how it all collapsed and we ended up where we are now.


 

Gavin Strang MP (Edinburgh, East),
Gavin Strang MP (Edinburgh, East), House of Commons debate 31 March 1988

‘We know that the main method of transmission [of AIDs] among drug takers is the sharing of dirty needles… It was clearly documented in a paper produced by Edinburgh professionals in February 1986. The Scottish Office commissioned a report from a committee chaired by Brian McClelland published in September 1986, which recommended decisively that the government should bite the bullet and provide clean syringes at an exchange centre, where drug injectors would be able to obtain free needles and syringes.

‘The government’s response to that call has been so inadequate as to be positively irresponsible. They sat on the McClelland report for months. Eventually, they announced 15 pilot schemes, 12 in England and three in Scotland. Of course such projects involve problems – the minister may wish to comment on them – but we must make the projects work.’