Friday, 3 October 2014

Medication and Recovery - Magic Pills and Methadone

This week there’s been a lot of media fanfare around the ‘magic pill’ that’s going to save thousands of ‘mild alcoholics’.  I’m not usually in favour of putting things in quotation marks, but in this case it’s almost obligatory because the fanfare is quite clearly over the top.

I don’t particularly want to write about the weaknesses of this approach; that’s been done very well by Niamh Fitzgerald and Matt Field here.  Also, although it’s tempting, I don’t want to analyse all the misunderstandings behind articles such as this by Hugh Muir in the Guardian.

What I am interested in is what the fervour says about how public debate around alcohol and drug use is able to sustain apparent contradictions in understanding different substances.

For the past few years – at least five – the field of drug treatment in the UK has been grappling with the issues of ‘medication’ and ‘recovery’.  What does it mean to ‘recover’ from a ‘substance misuse disorder’ (and what is one of these anyway?) and what role can and should medications like methadone play in that process?

This is the point of the much referenced Strang Report, called, in fact, ‘Medications in Recovery’.  (Though as I said to someone who sat on the panel – though I didn’t know at the time – that was all a bit of a fudge anyway, since although we can all agree that ‘recovery’ is a good thing, the word itself only begs all the crucial questions that still need answers.)

Anyway, the upshot of this great debate is an increased emphasis on the importance of psychosocial interventions – or ‘talking therapies’ as they’re more commonly known – in fostering recovery, and a concern that long-term medication doesn’t really amount to ‘full recovery’.

To add to this feeling of moving away from medication, the trends in drug use – and therefore need for treatment – suggest that fewer people are using opiates like heroin, and there’s an increase the relative importance of drugs like ‘legal highs’ (or ‘new psychoactive substances’) that don’t fit a model of substitute prescribing in the model of methadone for heroin – in fact they often don’t fit any model of prescribing at all.

I’m not saying the shift in emphasis away from methadone maintenance is right or wrong – or that the way this has played out is the same everywhere – but the key point is there’s been a crucial shift in emphasis in public policy debate.

This shift actually ties in quite neatly with broader trends in medical policy so emphasise ‘social prescribing’ rather than imagining medicines can sort everything.  Of course this opens up a can of worms as to whether it’s fair to characterise GPs as ‘pill pushers’, but this is a definite direction of travel in primary care policy discussions, only amplified by current concerns around antibiotic resistance.

You might even make links to broader public policy trends.  Methadone maintenance works on the principle that if you get rid of physical cravings for a drug, someone won’t need it, and therefore should be well-placed to stop using it.  But behavioural economics – which underpins the popular ‘nudge’ theory of public policy – reminds us that we don’t necessarily act on the basis of what we ‘need’ or what’s ‘good’ for us.

It’s in the context of this mood of public debate that Luncbeck has emerged with Nalmefene – or Selincro, as it’s marketed.

It’s worth noting at this point that Nalmefene is actually an opioid antagonist, similar to Naltrexone, which is used to treat heroin users.  That is, it blocks the receptors that give opiates like heroin their pleasurable effects on the body.  It’s precisely this sort of intervention that opiate treatment in Britain is (arguably) moving away from.

One explanation for the fanfare, then, is simple business logic: pharmaceutical companies see an opportunity in the public concern about (non-dependent) drinkers, and so manufacture a relevant product, which fits particularly well with the fact that the UK market for opioid agonists and antagonists is likely to shrink in the coming years.  A ‘pill’ that’s similar to what’s been used for opiate treatment can now be used for alcohol treatment, just at the point when the general feeling is that alcohol treatment services need to be expanded (probably at the expense of drug services designed for heroin users).

I think there’s something more to it than that, though.  This isn’t just about Lundbeck putting out a press release and there being a slow news day.  Nalmefene is genuinely more likely to find favour than similar drugs designed for people with issues with substances other than alcohol.

I think the fact we’re so interested in this ‘magic pill’ at the same time as think tanks as varied as Demos and the Centre for Social Justice talk about the importance of ‘character’ and how drug users ‘have a responsibility to work towards their own recovery’ to take ‘responsibility’ for their own recovery, and the Conservative Party announces the idea of ‘benefits cards’ for those with substance misuse issues, points to a distinction made between alcohol and other drugs.

This distinction is also infused with a notion of class – as the idea of benefit cards makes clear.  It might be worth asking whether – if the aim of these cards is to protect families from the impact of parents diverting resources ‘to feed their destructive habits’ – the same protection should be afforded those in families not receiving benefits.

Regardless of this policy question, though, there is a difference in who is expected to show self-reliance and not be medicated by the state, and who we think might benefit from the ‘magic pill’.  The latter are drinking half a bottle of wine a night, apparently – and the very choice of drink to illustrate the problem says something about the way it is understood.

If we think back to the idea that the shift away from methadone maintenance might dovetail with the principles of behavioural economics, in fact the opposite could be true: you could argue that a pill to deal with cravings fits perfectly with the idea that we’re weak-willed, irrational beings – we can’t be trusted to moderate our drinking simply through reason and self-control, so we need a pill to do it for us.

The question is: who gets a magic pill and who has to demonstrate self-reliance?  I’m not sure the answer doesn’t depend on the substance being used and the status of the user.

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