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Spectacular results or spectacular spin behind Jack Straw’s call for heroin prescribing?

Source: by Kathy Gyngell, Centre for Policy Studies
Posted on: 27th September 2009

“I ask myself this question: if there had been legal shooting galleries with free heroin in the UK years ago would I have ever got clean and sober. The answer to that is a categorical no.” Steve Spiegel, CEO, The Providence Project, 16th September 09

‘Clamour grows for heroin on the NHS’ shouted the Independent last week. This was news to me, as I imagine it was to the rest of that morning’s readers. A group of nameless government appointed drug experts were, I read, calling for a nationwide network of prescribing centres. A pioneering heroin prescribing programme trial had shown “major benefits in cutting crime and reducing street sales of drugs” it was claimed.[1] The article, an exclusive from health editor, Jeremy Lawrence, quoted the trial’s ’study leader’ Professor Strang, as saying: ‘the findings have sent a ripple of excitement through the addiction treatment community, which is unused to seeing progress with hard core addicts.’ By Sunday the ripple had reached Jack Straw, reported in the Sunday Times as calling for heroin prescribing on the NHS

The ripple that reached me however was of disbelief and frustration. Steve Spiegel, a former ‘hard core’ addict now long term director of the Providence Project – the hugely successful abstinence based, low cost rehabilitation centre for those the system has failed, emailed me: “Next they’ll be prescribing alcohol to alcoholics and crack to crack addicts! Who are these so-called experts? I’m not sure where they get their facts from regarding heroin users being the hardest to treat. This is certainly not our experience.” For Theodore Dalrymple this was “the latest expensive scheme to avoid admission of the obvious, that we have been barking up the wrong tree for years.”

Sadly the main body of the media had not shared his scepticism. On Tuesday morning, embargo raised, this ’success’ story led the news. On BBC Online, Home Affairs Correspondent Danny Shaw wrote ingenuously, ‘Heroin Supply Clinic Cuts Crime’. Radio 4’s Today programme ran his sympathetic news features through the morning and gave a platform to Professor Strang to assert: “The reductions in heroin use were spectacular, and those are validated”. Would people get this detail later in the day, he was asked. “Yes” came the reply, “later in the day and later, in proper scientific publications.”

Hmm. My suspicion that this was a case of the media cart before the academic horse was confirmed: “The next stage is for us to make our results publicly available and it’s a great privilege to be doing it on the programme today,” the Prof added.

More a case of spin and announce than of publish and be damned and never mind the principle of independent peer group review and only then to be followed by publication. And so it proved.

Kings College Institute of Psychiatry, the umbrella institution for the trials, had also lost its academic inhibitions – its website displayed the banner: ‘RIOTT a success for chronic heroin addicts’ but gave no link to a publication or a report, only to details of the aim and method of the project. ‘Headline results’ it said, had been presented that day to a conference organised by the charity, Action on Addiction. To their website I duly proceeded, to find ….. no report, not even any headline results.

Yet Kings College does not have to be told that it is a long established tradition in scientific research to release research findings to the media only after the process of anonymous and independent peer review. A principle of fundamental importance, not least because hot house reporting of dramatic research findings in the media is not the forum to objectively consider the accuracy of the results or indeed the robustness of the methodology. In fact it is a principle that provides just the corrective for any temptation researchers have to use the media to influence professional and political opinion, confident that they are right but unwilling to subject their research to independent assessment. Professor Strang knows this as does any researcher worth their salt.

Yet in this instance he has clearly chosen to sacrifice it in favour of securing widespread media coverage. He has indicated that he will seek independent peer review and publication of the results of the heroin prescribing trial later. But he can save himself the postage of sending his research papers to the British Medical Journal or the Lancet – both of these internationally recognized medical journals exhort researchers not to release findings for public discussion before they have been assessed independently and published within the journals concerned. As a member of the editorial staff of another academic journal, Addiction, Professor Strang has shown a remarkable disregard for this principle of due process. Judging by the media response to whatever ‘results’ press release or briefings he selectively gave, he has indeed achieved the aim he may have set himself – of influencing public, professional, and political opinion in the direction of supporting heroin prescribing.

For this reason alone his research findings should be regarded not with uncritical enthusiasm but with considerable caution. It is notable too that the last substantive Cochrane Review of four such randomised trials to test the efficacy of heroin maintenance versus methadone or other substitution treatments published in 2005 for patient treatment retention, reducing illicit use and for improved health and social functioning concluded: ‘No definitive conclusions about the overall effectiveness of heroin is possible’.

Until that due process is completed we have to accept as an act of faith that Professor Strang’s small sample will tell us something quite different. We may have to wait. In response to my request for a publication, report or research evidence to the Institute of Psychiatry I received this from Nicola Metrebian, PhD, a Senior Research Fellow, RIOTT trial coordinator at the National Addiction Centre, Institute of Psychiatry, Kings College London: “Thank you for your interest in RIOTT. The findings have not been published and are not yet in the public domain”.

Her reply begs the question of when is research in the public domain. Not evidently for the Institute of Psychiatry when it appears on their website, as front page newspaper headlines and is flagged up on the BBC with the full cooperation and appearance of the research ’study leader’.

Jack Straw should be aware of this and of the as yet very flimsy basis of his dramatic and potentially dangerous policy development. The facts gleaned from ‘the public domain’ are overwhelmed by those that remain unknown:-

* 127 subjects across 3 sites were randomly assigned to oral methadone, to injected methadone and to injected heroin – subjects described as ‘having failed’ all other treatments. (Unknowns: Assessment according to the internationally accepted ’severity of dependence’ criteria; Prior treatment experience or psycho social or follow up support. Data on age, life histories, co-morbidity. Data about programme retention and drop out, etc).

* The ‘heroin group’ subjects with up to three diamorphine injections a day were still in the main street heroin dependent, 75% had reduced their use of street heroin as a result, but only 20 % per cent of these now ‘abstinent’ from illicit street heroin (Strang on Today). ‘The rest’ still ’scoring’ 4 to 5 times a month (The Independent) despite the high levels of heroin provided. (Unknowns: Continuing dependence on other substances including alcohol; prescribing patterns, continuing street dependence patterns for the two other groups etc.)

* Subjects self report drops in their criminal offences from 40 to 6 per month. (Unknowns: Which? Variation across the three groups? Reliability? One magistrate commented, in the absence of objective evidence this would be thrown out of court.)

The crime reductions and the speculated cost savings led the headlines. Journalists betrayed a disturbing credulity. None asked about the ‘Hawthorne effect’. Yet had any asked to visit the trials, as I did at the start of the project or how much it was costing (I was told some £500,000 to set up and administer the Darlington site for their thirty subjects alone) they might have noted the stark contrast between this gleaming new clinical setting, the attractive and sympathetic fully trained nurses devoted exclusively to them, with the dilapidated drug services centre on offer to every other addict down the road.

With short policy memories too none remembered that similar self report claims for crime costs savings – estimates that have continued to be effectively spun – for methadone prescribing were made ten years ago, by some of the people involved in this latest project ….

If Jack Straw thinks this amounts to sufficient evidence for heroin prescribing – the inevitable abuse of which was the start of the country’s drug problem in the 1960s – then we have to assume that whatever powers of analysis and critical thought he ever had, have now totally deserted him.

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