British Jourrtal of Addiction (1991) 86, 1355-1356

Letter to the Editor

The editor welcomes all letters whether they are short case reports, preliminary reports of research,discussion or comments on papers ptiblisked in the journal. Authors should follow the same guidelines given forthe preparation and submission of articles on the inside back cover of each issue.

Private treatment for drug problemsSIR—The field of private txeatment for drug andalcohol-related problems is thornier than Cursons'(1991) survey suggests. Many private clinics arenarrow in their approach, advocating the 'MinnesotaModel' for all and offering residential care almost tothe exclusion of treatment in other settings. It isunlikely that such clinics would have proliferated iftheir costs had not been underwritten by the health-insurers, who may not continue with this largesse inthe absence of properly conducted outcome studies.When treatment interventions come to be comparedon the criteria of outcome and cost-effectiveness,the NHS may yet give the private sector a run for itsmoney.

Turning to the treatment of drug-users, this hasunique aspects which are not considered by DrCurson or the subsequent commentators. There ismore to drug-treatment than the simple applicationof the principles of alcohol-treatment to a differentclient group. For example, the assumption that"citizens in a free society have a right to buywhatever they can afford", has powerful implica-tions for drug-users.

The ethical problem can be simply stated. Theprivate treatment of drug dependence has theunique ability to corrupt—both doctor and patient.The corruption for the patient lies in the capacity ofa client-led approach to obtain a prescription, whichin preparation or amount would generally beconsidered inadvisable, or represent a worsening ofthe addictive process. In this scenario the doctor isnow in a dilemma. If he colludes with the patient'swishes and prescribes inappropriately, then fewwould argue that this is bad medicine. On the otherhand, a challenge or refusal is likely to be followedby the patient going elsewhere, and in consequence a

reduced income for the prescriber. The financialpressure to see large numbers of patients can resultin poor quality of care. These are not new concerns.Bewley and Ghodse (1983) found that some privategeneral practitioners were easily persuaded to pre-scribe controlled drugs and asked "if it was everdesirable to prescribe such drugs for a fee?"

While many practitioners in this field are aware ofthese problems, there are however, examples of howdifficult it can be to offer good-quality private carefor drug-users.

A recent study (Strang et al., 1990) of 26'maintained' opiate addicts who had been cared forprivately found that all had been encouraged toreduce their consumption of prescribed opiates, andmany had achieved this, yet none were asked toprovide urine samples after their first visit. Withoutsuch basic checks, the doctor has no way ofascertaining whether his patients are doing well ornot.

By way of illustration from my own clinicalpractice in the London area, I can recall a number ofpatients who considered they were not receivingappropriate prescriptions, and who said that theywould like to transfer their care to practitioners whothey considered to be more obliging. Whether or notsuch disaffected patients manage to find doctorswho are willing to meet their prescribing 'needs', theethical problem remains—do patients have the rightto seek bad treatment?

The statutory drug-services could be exposed tosimilar pressures if the introduction of the NHS andCommunity Care Bill leads to an 'internal market' inwhich drug-units compete for patients.

Is there anything that can be done about thisproblem, apart from relying on the ethical values ofindividual practitioners and peer-pressure? The

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1356 Letter to the Editor

Guidelines of Good Clinical Practice (Report of theMedical Working Group on Drug Dependence,1984) are currently being revised. It is vital thatdoctors who treat drug-users in private or non-statutory settings are given clear advice on appro-priate prescribing. They should be encouraged toharmonize their clinical approach with that ofstatutory services in the same locality and to use theestablished Drug-Unit Consultants for advice onprescribing policies and the care of difficult cases.

Within the National Health Service, DistrictHealth Authorities have a new role of 'purchasing'treatment for drug-users, with the power to specifythe quality of care to be delivered. What constitutesgood-quality care of a drug-user is a matter fordebate, but I would regard the following as compo-nents of a 'five-star' service. All patients shouldhave the benefit of a comprehensive physical andpsychological assessment, and they should be able tochoose treatments which not only meet individualneeds but also operate within locally agreed limits.

To conclude, if the treatment of drug-users is

regarded purely as a business then the customer isless likely to receive good-quality care. Drug-usersin treatment are patients and not a commodity to betraded for profit.

ANDREW JOHNS

St. George's Hospital Medical School,Cranmer Terrace,

Tooting,London SW17 ORE

ReferencesBEWLEY, T . & GHODSE, A. H . (1983) Unacceptable face of

private practice: prescription of controlled drugs toaddicts, British Medical Journal, 286, pp. 1876-7.

CURSON, D . A. (1991) Private treatment of alcohol anddrug problems in Britain (and subsequent commen-taries), British Journal of Addiction, 86, pp. 9-11.

REPORT OF THE MEDICAL WORKING GROUP ON DRUGDEPENDENCE (1984) Guidelines of Good Clinical Prac-tice in the Treatment of Drug Misuse (London, DHSS).

STRANG, J., JOHNS, A. & Gossop, M. (1990) Social anddrug taking behaviour of 'maintained' opiate addicts,British Journal of Addiction, 85, pp. 771-774