Answering the cries of anguish and helplessness

On her knees before me in my windowless consulting room, the woman wailed and screeched with anguish, tears streaming down her face. She was begging me to treat her son. “Please, I beg you, you must do something for him, he is going to die and I am going mad”. 

A week earlier a mother and daughter had broken down in the same airless little room. With wringing of hands and flowing tears they had beseeched me to treat their daughter and older sister who they believed was on the verge of death. An epidemic which had already caused the deaths of dozens of young people in our community was reaching a crescendo of suffering .It seemed incongruous in the last days of the 20th century in a developed country. Heroin was stalking inner city Dublin and its deprived suburbs resulting in death, anguish and misery.

A treatment for this epidemic had been pioneered 30 years earlier in New York by Dole and Nyswander and reported in a paper in JAMA in 1976. By 1997, GP colleagues in Scotland had successfully created a treatment programme using methadone as an opiate substitute using the term ‘harm reduction’ to describe the management strategy. In early 1997 we had no such programme and no guidelines, protocols or legislation to guide us in answering this therapeutic challenge.

Into this therapeutic vacuum had stepped some very unscrupulous characters... The rogue prescribers of methadone! These doctors (few in number but very damaging in effect) preyed upon heroin addicts like professional vultures. Disgracefully, they took advantage of the lack of regulation and prescribed for cash to any addict who came to them. No other care and no other service was provided except a private script for methadone whenever the fee was forthcoming. This was not ‘harm reduction’ but medical drug dealing. The addicts’ families loathed these practitioners and we powerlessly witnessed the effects of their evil trade.

A number of very concerned and ethical colleagues were so alarmed at our paralysis in the face the heroin epidemic in Dublin that a number of GPs began to seek knowledge and evidence from abroad. Scotland, where GPs had commenced a structured harm reduction programme using methadone, was our main source of expertise. Several workshops were held and in a short time a body of evidence and knowledge was created. Though not among the vanguard myself, I clutched the coattails of the innovators and gained enough confidence to prescribe methadone to a small number of heroin misusers.

Strictly tentatively and for no fee, we prescribed and monitored and recorded and gained experience. To our delight, many other health needs (other than opiate substitution) emerged and were addressed for this small cohort of patients who fitted well into the run of general practice.

The tide had turned and the ICGP, the Drug Treatment Services and the Department of Health were energised to regularise and legislate for a methadone protocol. Privileged to be on the working group which advised the legislators, I was delighted when the methadone protocol for treating opiate addiction came into being in 1998. This is predicated on the principle that heroin misusers are best treated in general practice where a holistic and continuing approach to all their health needs should be their right. It is now 16 years old and has stood the test of time quite well, but the protocol does require some revisiting. In 2010 Prof Joe Barry and Prof Michael Farrell led a review of the methadone protocol which published an extensive review informed by many submissions: The Introduction of the opioid treatment protocol which has yet to be implemented in practice. Amongst other conclusions this recommends a structured detoxification system and much more multidisciplinary cooperation.

Treating opiate misusers, in general, has been a therapeutic joy. Methadone is only part of the equation and while not curing the addiction, it dramatically reduces harmful activity and allows other health promoting measures such as management of hepatitis C and HIV. Relationships have been restored, families have thrived, healthy babies have been born and many people have returned to work and education.

A criticism of the methadone protocol is that the drug is very addictive and difficult to wean off. This is true and my practice has a cohort of people who have been treated for more than a decade. However, in the main they are stable and undoubtedly many are alive because of the harm reduction resulting from their treatment. Every year several people in our practice do detoxify and leave the programme becoming drug free. This is one type of successful outcome and it is always a pleasure to sign an exit form.