”What are clinical guidelines?” Just what it says, recommendations and advice to clinicians (doctors) from the Department of Health around how patients should be treated for particular conditions. They have no legal status as such. Doctors don’t have to follow them, but if they don’t and they get sued for negligence then they won’t get the backing of their professional bodies (trade unions). The set of clinical guidelines we’re talking about here are called Drug Misuse and Dependence: Guidelines on Clinical Management and, as you might expect, are to do with treating drug users.

We’re not going to go into the detail of these. We’ll give you a list of negatives and a list of positives ; tell you why you shouldn’t worry too much about them and why they demonstrate yet again that the people who design our drug policies don’t know their arse from their elbow.

THE POSITIVES (SO FAR AS THESE GO)

• Big thumbs up for harm reduction and prescribing
  
  
• Message to doctors that it is their responsibility “to provide care for both health needs and drug related problems, whether or not the patient is ready to withdraw from drugs” (p.1). (But remember, these are only guidelines. Basically it needs someone to sue a doctor for not prescribing to really test this advice).
  
  
• For those on maintenance “Random urine checks may be helpful (e.g. at least twice a year)” (p.52). (Try that one on your local clinic)
  
  
• High dose prescribing recommended (maintenance doses should be between 60mg and 129mgs, depending on individual tolerance etc)

THE NEGATIVES

These should only affect new patients. Not those already on scripts

• Prescribing GP’s will need training (3 days in 6 months) and that’s just to dish out oral methadone. (This one’s easy. GP’s haven’t got anything better to do than attend training courses, have they?)
  
  
• New patients should only be prescribed between 10-40mg of methadone. If a low starting dose is used then you might have to go back/hang around the surgery for four hours while they observe the effect. (You can just see GP’s going for this one).
  
  
• New patients should attend daily for the first few days in case they are getting too little or too much. (Another unlikely scenario)
  
  
• Supervised consumption - “In most cases, all new patients being prescribed methadone should be required to take their daily dose under the direct supervision of a professional for a period of time which may, depending on the individual patient, be at least three months, subject to compliance.” (This is the one that’s likely to cause the most problems. Not least because pharmacists stand to make even more cash out of users and so won’t be unwilling to do it. It also creates the illusion of doing something about the illicit methadone market. Needless to say, a market that no one has any hard evidence about).
  
  
• Oral methadone favoured treatment for 99.9% of users. Amps for a few, but only from specialists. Diamorphine gets no brownie points.
  
  
• No real attempt to address needs of stimulant users. A grudging acceptance of dexamphetamine prescribing but only for the short term.

WHY SHOULDN'T YOU WORRY TOO MUCH

These guidelines, if anyone were to take them seriously, would have a really detrimental effect on getting users into treatment and doctors to treat them. Supervised consumption is a bit of a worry, but we don’t expect to see this adopted universally. Our view (prayer) is that these guidelines will suffer the fate of the last two sets, something to hang up in the bog on a piece of string when the Delsey runs out. Most people in the drug treatment field, with the odd lunatic exception, will ignore them and just get on with the business. We’ll hear bullshit phrases like “these are aspirational” (something we should strive for but never intend to reach is what that means here); “something to work for in the long-term” (i.e. when hell freezes over). If these guidelines have any real function it will be to attack the private doctors who supply a significant minority (around 1,000) of London’s drug users. Life is going to be hard for this group of users, no doubt, but the majority of scripted users here in the North shouldn’t see that much change. And why do we think this? Well, read the next section.

ON THE HELPFULNESS OF KNOWING ONE'S ARSE FROM ONE'S ELBOW

These guidelines, believe it or not, are supposed to be a key part of the government’s strategy on drugs. But the central plank of this strategy is reducing the level of drugs related crime. And that, as everybody including the Government knows, means getting as many users as possible into treatment. At the end of the day, anything that interferes with the Government’s vision of a ‘Methadone Millennium’, with every unemployed scally full of slime, eyes pinned and glued to daytime TV, is simply not on. The sheer impracticality of dose assessment processes, observed consumption and training for GP’s are all the things that will make waiting-lists even longer and deter users from coming forward for treatment (plus the sheer cost of all this crap) cutting directly across the government’s aim to reduce offending. The only problem is nobody told the Department of Health that that’s what it’s all about. But, don’t worry, they just haven’t been able to distinguish their arse from their elbow yet.