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Transcending methadone
DISSECTING ROOM
Transcending methadone Community Treatment of Drug Misuse: More than Methadone. N Seivewright. Cambridge: Cambridge University Press, 2000. Pp 250. £22·95. ISBN 0521665620. he use of amphetamines, cocaine, and heroin by young people in the UK and other countries has produced a substantial demand for drug-misuse treatment over the past several decades. In Community Treatment of Drug Misuse: More than Methadone, Nicholas Seivewright provides a thoughtprovoking perspective on how to meet this demand in a community setting—a perspective that reflects the evidence but is also tempered by extensive clinical experience in the north of England. The expense and scarcity of treatment and specialist staff for inpatients makes community-based treatment a necessity that also happens to be desirable, according to Seivewright. His patients have to learn to live in communities where illicit drugs are widely available. For most, this is better done in the community rather than in the temporary sanctuary provided by treatment in a hospital or therapeutic community. As the title signals, the author’s aim is to broaden the base of services for community-based drug misuse in the UK. There are two main ways in which he wants to see services move beyond prescribing methadone to opiate-dependent patients. The first is to increase the range of options available for the treatment of opiate dependence. Seivewright believes that the prescribing of methadone has a continuing role in the treatment of individuals who are severely dependent, but he wants to reduce its dominance of the treatment market in the UK, which he fears will be exacerbated by the embrace of evidence-based practice. Because methadone is one of the bettersupported treatments for opiate dependence, there is the temptation to rely heavily upon it. Seivewright argues that community treatment for opiate dependence should include more efficient forms of achieving detoxification from opiates. He favours the ␣-antagonist lofexedine to achieve withdrawal on an outpatient basis, followed by the use of the opiate antagonist naltrexone to reduce relapse to heroin use after abstinence has been achieved. In the case of those who require longerterm opioid maintenance, Seivewright advocates a greater choice of oral opioid agents, including buprenorphine
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THE LANCET • Vol 355 • February 12, 2000
and LAAM (levacetylmethadol). He also sees a limited role for maintenance treatment using injectable short-acting opiates like heroin in a minority of cases. A broader range of maintenance options, he suggests, will increase patients’ choice, reduce the risks of overdose associated with methadone prescribing, and reduce the difficulty that many users experience in withdrawing from methadone. The second way in which Seivewright argues that communitybased services need to move beyond methadone is in providing better treatment for users of cocaine, amphetamines, and other drugs. Problem stimulant users in Britain have challenged drug services that have been primarily oriented to opiate-dependent patients. Seivewright argues that the ease of prescribing methadone has skewed treatment services for drug misuse towards
Belgian artist Jan Fabre’s video installation, A Consilience, at London’s Natural History Museum, UK, is a remarkable encounter between the artist and the museum’s entomologists. Transformed by fabulous costumes, the scientists discuss the nature of insect civilisation. Fabre’s was inspired by the work of his great-grandfather Jean-Henri Fabre, a famous 19th-century entomologist. Shown here is Dick Vane-Wright, Head of Entomology, as A Butterfly.
primarily catering to opiate users who are attracted by this form of treatment. The treatment needs of stimulant users have been neglected as a consequence. Stimulant users are difficult to attract into treatment and they are difficult to engage and retain in treatment when they can be induced to seek help.There are also no pharmacological or other interventions that are as effective with cocaine or amphetamine users as methadone is with opiate users. In the absence of any better treatment to offer, some practitioners have introduced the prescribing of dexamphetamine as a harm-reduction measure. As Seivewright argues, this is not the equivalent of methadone for stimulant users and it is probably only suitable for a minority of cases. He proposes research to find effective forms of treatment for this group of drug users. The book contains some challenging perspectives on the treatment of addiction. Seivewright is honest in describing methadone prescribing in the UK as a medical treatment with social benefits. He also highlights the conflict that service providers experience in prescribing methadone as a treatment that benefits the individual patient when it is publicly funded, because of the benefits it produces for public health (prevention of HIV transmission) and public order (reduction in drug-related crime). A similar conflict was noted nearly 30 years ago among staff in the early heroin prescribing clinics by Stimson and Oppenheimer. Community Treatment of Drug Misuse is a well-written and stimulating book by an author whose opinions are informed by evidence and considerable experience in treating drug users. It is honest in acknowledging the difficult issues faced by practitioners and these are well illustrated in the case histories that show the mixed results often achieved in the treatment of substance misuse.Yet the author leaves the reader appropriately hopeful that medical practitioners and other health professionals can make a difference to the lives of the young people who seek their help in dealing with serious life predicaments exacerbated by psychoactive drug use to which they resort for pleasure and relief. Wayne Hall National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia
585
Transcending methadone Community Treatment of Drug Misuse: More than Methadone. N Seivewright. Cambridge: Cambridge University Press, 2000. Pp 250. £22·95. ISBN 0521665620. he use of amphetamines, cocaine, and heroin by young people in the UK and other countries has produced a substantial demand for drug-misuse treatment over the past several decades. In Community Treatment of Drug Misuse: More than Methadone, Nicholas Seivewright provides a thoughtprovoking perspective on how to meet this demand in a community setting—a perspective that reflects the evidence but is also tempered by extensive clinical experience in the north of England. The expense and scarcity of treatment and specialist staff for inpatients makes community-based treatment a necessity that also happens to be desirable, according to Seivewright. His patients have to learn to live in communities where illicit drugs are widely available. For most, this is better done in the community rather than in the temporary sanctuary provided by treatment in a hospital or therapeutic community. As the title signals, the author’s aim is to broaden the base of services for community-based drug misuse in the UK. There are two main ways in which he wants to see services move beyond prescribing methadone to opiate-dependent patients. The first is to increase the range of options available for the treatment of opiate dependence. Seivewright believes that the prescribing of methadone has a continuing role in the treatment of individuals who are severely dependent, but he wants to reduce its dominance of the treatment market in the UK, which he fears will be exacerbated by the embrace of evidence-based practice. Because methadone is one of the bettersupported treatments for opiate dependence, there is the temptation to rely heavily upon it. Seivewright argues that community treatment for opiate dependence should include more efficient forms of achieving detoxification from opiates. He favours the ␣-antagonist lofexedine to achieve withdrawal on an outpatient basis, followed by the use of the opiate antagonist naltrexone to reduce relapse to heroin use after abstinence has been achieved. In the case of those who require longerterm opioid maintenance, Seivewright advocates a greater choice of oral opioid agents, including buprenorphine
T
THE LANCET • Vol 355 • February 12, 2000
and LAAM (levacetylmethadol). He also sees a limited role for maintenance treatment using injectable short-acting opiates like heroin in a minority of cases. A broader range of maintenance options, he suggests, will increase patients’ choice, reduce the risks of overdose associated with methadone prescribing, and reduce the difficulty that many users experience in withdrawing from methadone. The second way in which Seivewright argues that communitybased services need to move beyond methadone is in providing better treatment for users of cocaine, amphetamines, and other drugs. Problem stimulant users in Britain have challenged drug services that have been primarily oriented to opiate-dependent patients. Seivewright argues that the ease of prescribing methadone has skewed treatment services for drug misuse towards
Belgian artist Jan Fabre’s video installation, A Consilience, at London’s Natural History Museum, UK, is a remarkable encounter between the artist and the museum’s entomologists. Transformed by fabulous costumes, the scientists discuss the nature of insect civilisation. Fabre’s was inspired by the work of his great-grandfather Jean-Henri Fabre, a famous 19th-century entomologist. Shown here is Dick Vane-Wright, Head of Entomology, as A Butterfly.
primarily catering to opiate users who are attracted by this form of treatment. The treatment needs of stimulant users have been neglected as a consequence. Stimulant users are difficult to attract into treatment and they are difficult to engage and retain in treatment when they can be induced to seek help.There are also no pharmacological or other interventions that are as effective with cocaine or amphetamine users as methadone is with opiate users. In the absence of any better treatment to offer, some practitioners have introduced the prescribing of dexamphetamine as a harm-reduction measure. As Seivewright argues, this is not the equivalent of methadone for stimulant users and it is probably only suitable for a minority of cases. He proposes research to find effective forms of treatment for this group of drug users. The book contains some challenging perspectives on the treatment of addiction. Seivewright is honest in describing methadone prescribing in the UK as a medical treatment with social benefits. He also highlights the conflict that service providers experience in prescribing methadone as a treatment that benefits the individual patient when it is publicly funded, because of the benefits it produces for public health (prevention of HIV transmission) and public order (reduction in drug-related crime). A similar conflict was noted nearly 30 years ago among staff in the early heroin prescribing clinics by Stimson and Oppenheimer. Community Treatment of Drug Misuse is a well-written and stimulating book by an author whose opinions are informed by evidence and considerable experience in treating drug users. It is honest in acknowledging the difficult issues faced by practitioners and these are well illustrated in the case histories that show the mixed results often achieved in the treatment of substance misuse.Yet the author leaves the reader appropriately hopeful that medical practitioners and other health professionals can make a difference to the lives of the young people who seek their help in dealing with serious life predicaments exacerbated by psychoactive drug use to which they resort for pleasure and relief. Wayne Hall National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia
585