Through the 1970s, consultant psychiatrists in the NHS drug clinics had been moving away from prescribing any injectable drug to oral methadone – and also on a reducing dose basis. But there were still doctors in the community (both private and NHS) willing to prescribe more liberally. The 1982 ACMD landmark report on treatment and rehabilitation came out strongly against private prescribing and battle was joined in the right to prescribe.
The first guidelines of good practice were published in 1984, but like the guidelines that followed in 1991, were little more than the collective opinion and experiences of a small group of London-based consultant psychiatrists with virtually no reference to the (admittedly slim) clinical literature.
The 1999 guidelines were a different beast – a wide range of disciplines were represented on the Working Group, not just consultant psychiatrists – and there was an acknowledgement of a wider clinical literature. Inevitably, though, prescribing was the most controversial area to be tackled; a significant departure from previous guidelines was the endorsement of methadone maintenance as an appropriate intervention for primary care, but tied to much stronger recommendations on daily supervised consumption – were still expressed. Some general reservations about the appropriateness of GP prescribing. Like their predecessor, the 1999 Guidelines were intended de facto if necessary to have the force of law in cases of medical discipline against those believed to be acting outside the guidelines. So, there was a more liberal view taken on prescribing, but still a pretty restrictive view on who best to carry out the work. The 2007 Guidelines will be considered in the next issue, but at the time of writing these too are under review.
What follows is an edited version of the two articles by Mike Ashton which looked at the issues dividing the medical camps in 1986.