I Think You'll Find It's a Bit More Complicated Than That

by Ben Goldacre

  But the most important thing about figures – once you’ve actually got them right – is to put them in their appropriate context. Even if we were generous, would 130kg less heroin make any difference to the UK market? No. We consume tons and tons of heroin every year, and the heroin from Afghanistan, in any case, is going all around the world, not just into the UK.

  More importantly, would this seizure make much difference to the Taliban, whichever figure you use: $126,000, or $3.6 million, or $30 million, or £50 million? Again, that seems unlikely. There are 157,000 hectares (100 metres squared) of opium fields in Afghanistan, producing 7,700 tons (not kilos) of opium, netting farmers throughout the country about $730 million, and that’s real money in their pocket, not made-up UK street prices on the diluted gram. The export value of opium, morphine and heroin at border prices in neighbouring countries for Afghan traffickers was worth $3.4 billion last year.

  Just to remind you: John Hutton is the Defence Secretary, and he said that the seizure of £50 million of narcotics would ‘starve the Taliban of funding preventing the proliferation of drugs and terror in the UK’. That frightens me, because I trust the Defence Secretary to know what’s going on in a war, and you didn’t even need to do the maths on his figure: this seizure was a tiny drop of theatre in a very, very big ocean.

  The Least Surrogate Outcome

  Guardian, 5 April 2008

  There’s this vague idea – which has been going around for the past few centuries – that statistics is difficult. But in reality the maths is often the least of your problems: the tricky bit comes way before the number crunching, when you are deciding what to measure, how to measure it, and what those measurements mean.

  The government’s new drugs strategy has been published, with outcomes that will be measured to see if it works or not. However you cut the cake, we should be clear: measuring drug-related death is difficult. You could look at death certificates to see what’s listed, but they’re often filled out by junior doctors, and aren’t very informative or reliable. You also need to decide where to draw the causal cut-off. Does HIV count as a drug-related death, if you got it from a needle full of heroin? Or from sex work to fund the drugs?

  How about if it kills you ten years after you become abstinent, or you die from chronic, grumbling hepatitis C from a needle? Or chronic, seeping, pus-ridden abscesses bulging deep in your groin from years of injecting your femoral veins?

  And that’s before we get to crack-frenzy violence and drug driving. What if there was no toxicology done? What if there was, but they didn’t test for the drug the person took? What if the coroner finds some drugs in the blood, but doesn’t think they were related to the death? Are they consistent in making that call?

  The new government drugs strategy solves this tricky problem by simply not measuring drug-related deaths as an outcome any more. It was a key indicator in our major strategy document ten years ago, but you won’t see death mentioned once in ‘Drugs: Protecting Families and Communities Action Plan 2008–2011.

  You also won’t see death in ‘Public Service Agreement Delivery Agreement 25’, which includes measured outcomes such as the number of users in treatment and the rate of drug-related offending. A lot of drug users die. Death, even if you don’t like drug users, is important.

  But beyond the disputes over how you collect these figures, there is the interpretation and analysis; and the greatest irony is that the government may have dropped drug-related deaths two weeks ago, simply because it misunderstood that the figures are actually looking quite good.

  Overall, drug-related deaths show no great improvement over the years. But what if older people – over thirty-five, say, users from the great injecting epidemic of the 1980s – were dying at a greater rate, while young people, the target of great effort, are dying at a slower rate? That’s what a recent analysis from the biostatistics unit in Cambridge shows: they presented their findings just two weeks ago, in the same week, by odd coincidence, that the government announced its deathless drug strategy.

  Sometimes people can be so stupid that they don’t even know when they’ve done well.

  Heroin on Prescription

  This is an essay I wrote in praise of heroin prescription, as an undergraduate in medicine, which won the ‘Roger Hole Essay Prize in Medical Scepticism’ at my medical school in 1998. The £250 prize was useful, but winning it also served up an early lesson on the flaws in science and health reporting, and its obsession with ‘authority’. A friend in a thinktank gave my number to somebody working on campaigning journalist Nick Davies’ heroin addiction documentary in 2000. They called, said they’d heard I was a doctor and had researched the issue, and asked if I would do an interview.

  I was happy to help, but explained that I’d only qualified as a doctor two weeks previously, that I wasn’t an ‘authority’ on anything, that I wouldn’t even be fully registered with the GMC for another year, and that I looked about twelve. I chatted through what I knew on the subject, and casually offered to email them an essay I had written as a medical student. I did that, and never heard back.

  A few months later I switched on the telly halfway through a TV show about heroin on prescription. It didn’t occur to me that this might be related to the brief phone call I’d had, but suddenly the screen went black, with a dramatic pause and – if I remember right – a deep bass synthesiser tone in the background. Then, from nowhere, quotes from my medical student essay appeared, in big sombre letters, filling the screen in white on black, ascribed to ‘Dr Ben Goldacre’, as if I was a grand medical authority. I was sat on a mattress on the floor, eating toast in my underpants, aged twenty-five, in a shared flat with no hot water or heating. I’ve never been so embarrassed. I prayed that nobody I worked with had seen it. It’s one reason why I still feel uneasy being described as ‘Dr Ben Goldacre’. Anyway, here’s the essay. Forgive the pompous writing – I was twenty-three.

  Methadone and Heroin:

  An Exercise in Medical Scepticism

  by Ben Goldacre, 1998

  I have often fantasised about living through an age when science was truly adversarial: to have seen Darwin at the Royal Society, or Galileo recant. But the lie of the land, the structure of our scientific territory, and our modes of warfare across it, have become domesticated and tame. Although there may be differences of opinion, we each tend to tinker at the expanding edges of our understanding, and truly mutually exclusive explanatory frameworks for reproducible phenomena rarely co-exist for long.

  If we want to see real friction, some other factor must come to bear on the essentially healthy structure of the mainstream scientific community: a funding issue, for example, might influence the general trajectory of research, but for the most part temporarily; we may be transiently confounded by partisan research from a given drug company, but only in whatever microcosm of physiology their drug acts and, albeit slightly behind schedule, we can be sure that the truth will out.

  But we want the big prize: we want wholesale irrationality, we want to see the axial skeleton of our concepts truly and chronically deformed, and only politics can muster contorting forces of such magnitude. I intend to show how this influence has perverted rationality in one area, our medical treatment of those who are addicted to heroin, to such an extent that our theory and practice is now so polluted as to be scientifically untenable.

  Until recently, it was common practice in Britain to prescribe heroin to heroin addicts. This apparently paradoxical practice was well founded and successful, as we shall see below. However, since the late 1960s, addicts have mostly been prescribed oral methadone, a long-acting opiate agonist with a less euphoriant effect, as a heroin substitute.

  I shall demonstrate that the maintenance of addicts on methadone is less effective at reducing the use of heroin, and the harm that goes along with heroin use, than the prescription of heroin itself. I shall also show that methadone is a more dangerous drug than heroin, and causes more deaths than even adulterated street heroin.<
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  Ultimately, the case I shall make is that heroin prescription is more effective, by all reasonable outcome indicators, than methadone; and that the reasons for its unpopularity have little to do with evidence of best practice, and much to do with our emotional and moral attitudes towards those who are addicted to drugs. To begin, we must consider the history of opiate addiction and its treatment, in order to understand how and why politics intervened, and how we arrived at the state we are in today.

  A Brief History of Opiate Addiction and Rehabilitation

  Heroin, or diamorphine, was first marketed by Bayer in 1898, after being developed as a cough suppressant by the same team who introduced aspirin. Although the use of psychoactive drugs (and specifically opiates) began to be considered as a medical problem in the late nineteenth century, they were legally available until well into the twentieth, and opiates could be purchased from pharmacies with a minimum of formalities up until 1920.

  At this time, the principal medical concern over drug use was the risk of accidental poisoning through the non-medical pursuit of pleasure, and the prevalence of drug addiction (frequently caused by chronic medical use) was so low that its social impact was negligible. The 1920 Dangerous Drugs Act confined the availability of opiates to prescription only and, over the next few years, penalties for offenders against the possession laws were increased, a reflection of similar developments abroad.

  However, where Britain departed from the rest of the world was with the Rolleston Committee report from the Department of Health in 1926. This emphasised that persistent drug use, in line with newly emerging medical and social theory, should be seen as a disease: ‘as a manifestation of a morbid state, and not as a mere form of vicious indulgence’.

  By pursuing this line, Rolleston arrived almost accidentally at the sympathetic modern-day conception of the drug abuser, over half a century before Hartnoll et al. (1980) found evidence of serious childhood disturbance in his patients at a drug dependency clinic in University College Hospital. In many ways Rolleston was the first proponent of the guiding philosophy of most modern drug work, ‘harm reduction’, which I shall later consider in detail.

  The progressive attitude to drug use institutionalised in this report established the framework of public policy for the next five decades, and following 1926 the ‘British System’ prosecuted dealers and dilettantes, but permitted medical prescription of heroin to addicts after ‘every effort’ had been made for the ‘cure of the addiction’, but when the drugs could not be fully withdrawn without ‘severe distress or even risk of life’ or ‘experience showed that a certain minimum dose of the drug was necessary for the patients to lead useful and relatively normal lives … capable of work’. This twin policy of ‘policing and prescribing’ effectively contained the heroin problem (which ran at below a hundred notified heroin addicts) for the next four decades.

  With the sixties came an atmosphere of moral panic at the scale of a well-publicised increase in drug use. Although the drugs in question were mostly cannabis and amphetamines, not heroin, attitudes to drug use and regulation were reappraised: amphetamines and LSD were brought under tight statutory control, and the government began to fear that with a rising demand for drugs, the licit opiate supply system might start supplying the illicit market.

  From 1959 to 1964 the number of addicts notified to the Home Office increased from sixty-eight to 342, and it was noted that an unusually large proportion of these new addicts were of non-therapeutic origin, that is, an unusually large proportion of new users had not come to addiction via chronic medical treatment for physical disease or injury.

  In 1964, the government convened the Brain Committee, an interdepartmental reincarnation of the Rolleston Committee, who found that ‘the major source of supply had been excessive prescribing by a small group of doctors’. They recommended that the prescription of drugs to addicts should be restricted to specialist clinics, ‘Drug Dependency Units’ (DDUs), and although heroin for physical ailments could still be freely prescribed, laws were passed requiring that doctors who prescribed heroin for addicts should be specifically approved by the Home Secretary.

  From the beginning of the seventies, there was a major sea change in the treatment of addicts. This was characterised by an emphasis on abstinence as the primary goal of treatment, and a refusal to prescribe heroin: instead, on condition of abstinence from all other drugs, and under ‘treatment contracts’, heroin addicts were prescribed a new drug, methadone, to be taken orally.

  It has been proposed that the reluctance of doctors to prescribe heroin was probably, in a number of cases, due to the fact that most addicts were so keen to obtain this drug: this made doctors working in the field uneasy, and Glossop (1995) believes that prescribing a medicine which was less desirable for the client was more easily rationalised.

  In the mid-1970s there was an upsurge in the illicit heroin market in London. The factors alleged to have contributed to this include: an upsurge in illicit demand following the change in DDU policy; the end of the Vietnam War, requiring the South-East Asian producers to find new markets after the GIs went home; wealthy Iranian exiles using heroin as a means of getting their capital out of the country after the downfall of the Shah; and political troubles in Afghanistan and Pakistan.

  Over the course of the decade the market ceased to be run by amateurs, as professional criminals extended their interests from the cannabis market to heroin. Driven in part by a pyramid dealing network, where addicts at the bottom of the distribution chain had an interest in selling to fund their own use, heroin use expanded enormously throughout the next twenty years.

  The Contemporary Heroin Problem

  The Home Office were notified of 35,000 heroin addicts in 1994; due to incomplete reporting, and other obstacles in reaching the addict population, this is widely believed to represent between a third and a fifth of all addicts, thus putting the true figure at between 100,000 and 160,000.

  Contemporary heroin addiction is no longer an issue between the individual and their metabolism. The nature of the drug, the scale of its use, and its position in modern society, all mean that addicts experience more diverse problems, and cause more diverse problems, than the heroin addict of the nineteenth century.

  The generally poor health of chronic addicts is usually not a direct result of the opiates as such. Heroin is very addictive but does not in itself cause any serious illnesses, nor does it harm any organs or tissues: the indirect consequences are of course more serious. Pain sensations are suppressed, with the results that certain signals (for example, problems with teeth, infections, cold, heat and hunger) are not noticed. Because opiates also suppress feelings and emotions, the ability to enter into social relations with others is also seriously affected, so not only physical but social functioning worsens.

  Another important issue is how the addict can maintain a supply of heroin. The enormous cost of heroin on the black market is met for the most part by acquisitive property crime. The economics of the illicit market are remarkable: at the farm gate in Pakistan, a kilogram of opium costs $90; when it has been converted to heroin it costs $3,000 in Pakistan; wholesale in the USA it costs $80,000; and its final retail price on the street (at the Drug Enforcement Agency’s quoted average purity of 40 per cent) is $290,000 per kilogram.

  On the streets of the UK, a gram of heroin costs between £50 and £120. The cost of acquisitive crime committed to pay for this heroin has been estimated at £1.5 billion per year. Addicts in the UK generally steal to fund their addiction: thus they risk likely impoverishment and imprisonment. One study showed that 80 per cent of addicts attending a DDU clinic had been convicted of at least one offence in the course of their drug-taking careers. More crucially for long-term outcome, since they often steal from family and friends, addicts risk social isolation.

  Furthermore, since the drug is at such a premium, it will be used in the most efficient fashion possible, which is of course intravenous injection (intravenous use of alcohol u
nder prohibition of alcohol in the USA has also been documented). Intravenous use of any drug carries its own dangers. A large proportion of the morbidity experienced amongst heroin addicts is due to wound infection, septicaemia and infective endocarditis, all due to asterile injection technique.

  Infection is another major cause of morbidity and mortality in intravenous drug users internationally. Heroin addicts tend to lead chaotic lifestyles and have low self-esteem, both of which, along with expediency, contribute to a tendency to share needles with other users. Via this route they become infected with HIV, and hepatitis B and C.

  Ten per cent of UK Aids cases in 1995 were related to the use of intravenous drugs, and it is suspected that the increase in HIV infection amongst non-intravenous drug using heterosexuals is being driven by contact with heterosexual intravenous drug users, and the World Health Organization estimates that 40 per cent of recent Aids cases internationally were caused by drug users sharing injecting equipment.

  It was the spread of HIV through intravenous drug use that led to the reconsideration of heroin addiction treatment in the late 1980s, and was the birth of the new policy of ‘harm reduction’. The HIV seropositivity rate amongst intravenous drug users in Edinburgh, where needle-exchange and maintenance programmes had been vigorously opposed, rose to over 50 per cent in the mid-1980s. By comparison, in Glasgow, where such facilities were available, less than fifty miles away, the level of seropositivity was less than 5 per cent.1