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Dear Dr Puff n'Stuff I am writing to you because I am very concerned about some news I recently heard regarding an old friend of mine who has contracted Hep.C. I have never shared injecting equipment with this person and always thought of myself as immune to catching it as I had my Hep. Jabs at the C.D.T. However I have since been told that there is no vaccination against Hep.C. and it was Hep.B. I was immunised against. Not only that but I was told that even though we never shared works I'm still high risk as you can catch it off rock pipes, spliffs, cups etc. Please don't think I am ignorant - I know you can't catch HIV from touching people or sharing cutlery etc. but I don't know that much about Hep.C. and I'm hearing that many conflicting stories that my head is done in - HELP Dear Reader Many people get confused about hepatitis, but the whole issue is really important. The boffins keep discovering new types of hepatitis - I think they've reached Hepatitis G by now - but for a drug user there are really only two big ones they need to know about, hepatitis B (HBV) and hepatitis C (HCV). They are both quite similar. Both are viruses, which are spread mainly by blood. Both can lead to chronic infection, and sometimes after many years to serious liver damage. In both cases it is possible to be infected and infectious without knowing about it. This is particularly likely with HCV, because the initial infection may not even be noticed. Also, long-term infection is much more common with HCV than HBV. HCV is very easily spread by contact with even tiny amounts of blood. In this respect it is much more infectious than HIV (AIDS). We used to advise you not to share needles, so that you wouldn't pick up HIV. Drug users in this country have been very sensible about this, with the result that our HIV rates are very much lower here than almost anywhere else in the world. We must all be grateful for this achievement. WELL DONE! BUTÉwe now realise that just avoiding sharing works is not enough. HCV can be spread by the tiny amounts of blood, which can be found in every item of injecting equipment, for example cups of water, filters, syringes and spoons. Back-loading and front-loading are equally dangerous. The only safe way to inject is to use your own filter, spoon, water, needle and syringe. Best of course not to inject at all. Infected blood is the danger. There is no problem shaking hands, touching or hugging, sharing cutlery toilet seats or smoking equipment. HCV is only transmitted rarely by sex (unlike HBV). It can be passed on by mothers to their babies, but only in about one in twenty infected pregnancies. Sharing toothbrushes scissors and razors should be avoided. It can be passed on by tattoos and acupuncture, if not carried out with proper sterile technique. Before 1991 it could be caught from blood transfusion. Since then all blood in this country has been screened for infection (but not always abroad). American cocaine snorters, who pass round a rolled-up $10 bill, have also picked up HCV. Since cocaine powder damages the membranes inside the nose, the bill inevitably gets smeared with traces of snot and blood. Do not share snorting equipment! Don't be mean - get your own $10 bill. You are right that the vaccination you had was probably for HBV. There is no vaccine yet for HCV. However, HBV vaccination is very useful even if you catch HCV because if you have both illnesses together, things tend to get worse more quickly. All injecting drug users should make sure they get vaccinated against HBV. If you are an injecting drug user, you are at some risk of having already caught HCV. It is well worth asking for a test, after discussing the issue in depth with your worker. If you are clear it will set your mind at rest and you can be very careful in future. (Although remember it can take 6 months for the test to turn positive after infection.) If you are infected, there is still a lot you can do: 1 Stop injecting. There are a number of different types of HCV. Further infection with other types will make things worse. 2 Drink alcohol in moderation only. Liver damage can occur quickly when booze and HCV are mixed together. 3 Get yourself referred for assessment by a specialist. At present almost half of those infected can be cured by treatment with interferon and ribavirin. Treatments are improving all the time. 4 Get vaccinated for HBV if you are not already protected. You will need a booster every five years. 5 make sure you have a healthy diet 6 Get up to date advice from your doctor, or from the British Liver Trust freephone 0808 800 1000
Dear Monkey It has taken me a long time to put pen to paper over my prescribing experiences/treatments. Mainly because I have a fear instilled in me that I would be kicked off my script for speaking my feelings. In short, I am presently on methadone amps daily. My drug of choice is heroin which I used to be prescribed many years ago, in fact the sixties with Dr Swan in Hackney and the odd script from Peter and Lady Franks, as you did then. So I've been using on and off for over 30 years in between bouts of prison, detox, mental hospitals and street agencies who insist they won't prescribe Heroin and in fact denied that anyone did any more. My point is this - I don't want to be on Methadone amps, I want to be on a Diamorphine script. But, I don't want to be using street gear either because of the inevitable crime I'll get back into and from there back to prison, hospitals etc etc, the full circle again. So I feel I am being blackmailed into accepting Methadone amps or even worse for me the oral shit. I do like my needle. I am 50 years old in December, (8th if you wish to send me a card) and what a beautiful present it would be if I could just settle down contented with a Heroin script. I feel so terribly sad and depressed about not being on one. Please can you help, I'm alone here. I hope the powers that be concerning me see this letter and lo and behold the penny will drop, if you print it that is. By the way, Monkey is a real head. Keep it up. Yours truly HC PS - when 'they' finally get to reduce me right down off Methadone, do you think anyone will ever talk to me about heroin addiction? (just a thought) Reply from Dr Puff n' Stuff You are part of heroin history! You say you received a prescription from Lady Isobel Frankau (I guess this is who you mean). She was an eccentric private doctor who almost by her own efforts alone brought about the end of the old "British system", whereby drug users were prescribed what they needed to keep them stable and healthy. She prescribed so generously to so many that the authorities decided something must be done, particularly when Canadian addicts started arriving at Heathrow with her telephone number in their pockets. The result was the Dangerous Drugs Act, and the establishment of special drug misuse clinics. Controlled drug prescription was taken away from general doctors and handed over to specialist psychiatrists. (In the drug field, what comes round goes round. They are now desperately trying to get GPs involved once more, because of the shortage of interested doctors and the dangers of hepatitis and AIDS.) Unfortunately, the new-style drug specialists wanted to appear very scientific, and quite different from the old shower of discredited amateurs. They were most impressed by the data coming from the US about an exciting new drug called methadone. At the same time, a research trial in London comparing methadone and heroin was widely claimed to show that heroin was not effective. Looking back on the results of this trial now, one would beg to disagree with this conclusion. There were all sorts of problems with the study design, and the dose of heroin used was very low. Nonetheless, the trial was very influential and heroin was put on the backburner. Methadone became the standard treatment for opiate addiction. Since that time doctors who wish to prescribe heroin have to get a special license from the Home Office. Only very rarely is this given to anybody else but specialist psychiatrists and doctors working under their supervision. There are at present about one hundred doctors with licenses, and fifty who make use of them. Between them these doctors prescribe for about four hundred patients. Some doctors prescribe much more often than others: ten doctors account for over half of the prescriptions. There are many reasons why most doctors don't prescribe heroin. Some don't think it works. Others are worried that if they prescribe for some they will come under huge pressure from everybody else. Some consider it to be a "form of licensed drug dealing". The predominant reason however is cost. A heroin prescription costs about £5000 a year, as opposed to less than £1000 for methadone. Although £5000 might prove cost-effective in terms of prevention of crime etc, it makes a huge dent into local health budgets. So why can't users pay for their prescriptions privately? Because the Home Office won't license private doctors. All this means that unless you live near one of those ten doctors you are unlikely to receive a prescription. In theory you can ask your health authority or Primary Care Trust to pay for your treatment elsewhere. There are some health authorities who are prepared to do this in exceptional circumstances, but not many. Usually you will come up against a brick wall if you try this angle. But it is the "official" way to proceed, and if you don't get any success it is worth contacting your local MP, and writing to the Drug Czar and Minister of Health (addresses below). They ought to be told if people are not receiving the right treatment. On the bright side, there are trials of heroin prescription being conducted or about to be conducted in Germany, Holland, Switzerland and Spain. If these prove successful, there is more chance of heroin being made more available here, particularly if health and Home Office budgets come together as is being proposed. I suspect that if it is made widely available, there will be a requirement to attend injecting rooms three times a day as happens in the European trials. On the even brighter side, I predict that cannabis will be made legal by 2004 and heroin by 2012. There is not enough room here to give my reasons, but I suggest you lay your bets now. You should get pretty good odds! Mr Keith Hellawell,
Anti-Drugs Coordinator Mr
A Milburn, Secretary of State for the Department of Health
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