Objective: The United Kingdom is highly unusual from an international perspective in being the only country where pharmaceutical heroin has been prescribed for decades in the routine treatment of heroin addiction. Despite its continued use, little has been known about its role in drug treatment. This study examines what influenced the extent and nature of heroin prescribing during 2000 - the last years of “the old British System” - a relatively unregulated and liberal system of prescribing heroin - before the Government recommended its expansion under new medically supervised clinics.
Methods: Contemporary practice of prescribing heroin is examined in the context of policy and research evidence over the last century. National surveys of doctors and analysis of medical notes are used to examine who prescribed heroin, how it was delivered and who received it. Interviews with named key policy players of the time, including those within central government and prominent addiction psychiatrists were used to determine who and what influenced treatment decisions.
Results: In 2000, the prescribing of heroin for the treatment of opiate dependence was rare and did not appear to reflect demand. Pathways into receiving heroin generally included being a long term opiate dependent injecting drug user with a history of failing previous opiate treatments, requesting a heroin prescription, and seeking treatment from a licensed doctor with a personal preference for prescribing heroin.
Conclusions: Levels of heroin prescribing in 2000 are due to historical influences such as the Home Office licensing system restricting the number and type of doctors who could prescribe heroin, and doctors’ decisions in the early 1970s to move away from heroin towards oral methadone and other current factors deterring doctors from prescribing heroin including a lack of national guidance, research evidence and supervision and communities of influence discouraging doctors from prescribing heroin.