Eleanor Chrispin on methadone prescribing in prison

Ellie Chrispin Former UK drugs tsar Mike Trace spoke out last week about what he perceives to be a territorial dispute between two Whitehall departments over the most appropriate treatment for heroin-addicted prisoners. The alleged in-fighting between the Ministry of Justice (MoJ) and Department of Health (DoH) centres on methadone prescription in prisons and, Trace claims, exposes a desire to control prison drug treatment, via departmental budget lines, rather than a resolve to see addicted inmates become drug-free.

According to Trace, prisoners are being prescribed the addictive heroin substitute methadone because the DoH wants to control treatment, meaning inmates are being diverted from MoJ-funded abstinence schemes. He observed that “When they (inmates) see the healthcare professionals… sometimes the only choice they are offered, is a prescription of some type, which means their motivation to remain drug-free can be undermined.”

A further accusation levelled at the current system is that the genuine needs of drug addicted prisoners are coming second to the need to control them by keeping them on a drug that makes this possible. Abstinence programmes, on the other hand, are likely to have unpredictable effects on inmates’ behaviour.

News of the supposed spat emerged along with reports of a 57% increase in the number of prisoners on methadone “maintenance” programmes between 2007 and 2008, up from 12,518 to 19,632. Of the 140,000 individuals passing through the prison system last year, more than 60,000 would have received the heroin substitute methadone, or an alternative, buprenorphine. This treatment is funded by the DoH and favoured by them, and many drugs experts, as a way of keeping prisoners stable and moving them towards rehabilitation. The substantial leap in the number of inmates receiving methadone has led to concern among those opposed to extensive methadone use. Trace, who heads a charity running drug rehabilitation programmes in England’s jails, and others, argue that, in the absence of sufficient drug abstinence and detoxification programmes, as favoured and funded by the MoJ, prisoners are simply exchanging one addiction (heroin) for another (methadone) with little chance of getting clean.

In a gesture of apparent unity in response to Trace’s comments, the MoJ and DoH released a joint statement saying that: “It is categorically untrue to say methadone is used as any sort of control mechanism. Decisions regarding treatment are clinically based. The programme includes abstinence, but all treatments are aimed at getting the person off drugs. The rise in prisoners getting methadone treatment means more prisoners are getting the treatment they need and there has been significant investment in prison clinical drug treatment to help this happen.”

Given the overt medicalisation of the issue, where do prison doctors fit into the debate? Regardless of whether this instance of departmental infighting is real or imagined, the disputed territory of drug treatment is genuine and has significant consequences for those doctors to whom responsibility for methadone prescribing falls. What role for them amidst the wrangling between those favouring abstinence and those advocating heroin-substitutes?

Ellie Chrispin is ethics adviser, British Medical Association Medical Ethics Department. The views expressed are her own.