How would a prescription model work?

Heroin Assisted TreatmentThe prescription-only model is the most tightly controlled drug supply model currently in operation. Under this model, drugs are prescribed to a named user by a qualified and licensed medical practitioner. They are dispensed by a licensed practitioner or pharmacist from a licensed pharmacy or other designated outlet.

The process is controlled by a range of legislation, regulatory structures and enforcement bodies. These guide, oversee and police the prescribing doctors and dispensing pharmacists. They also help determine which drugs are available, in what form, where, and under what criteria.

As the most tightly controlled and enforced supply model, the prescription model is the most expensive to administer. It is limited to medical necessity, which means it tends to only be used to address the problematic or dependent end of the drug use spectrum. Most commonly, it supports heroin substitute (e.g. methadone) maintenance prescribing as part of a treatment regimen or harm reduction programme. As such it will only ever involve a small fraction of the total drug using population, although it should be noted that this user group is disproportionately associated with the greatest personal and societal harms (especially under prohibition).

While substitute opiates such as methadone are the most commonly prescribed under such scenarios, it is also used to provide prescribed, injectable heroin (diamorphine) in some cases. Heroin Assisted Treatment (HAT) has a long history, and an established evidence base as an effective harm reduction measure for people who have not achieved success with substitute opiates. Less common, although not unknown, is the prescription of stimulants, including amphetamines and cocaine.

  • These long established models serve as an island of regulation for the very same drugs that are prohibited in all other scenarios. They provide a useful, if limited, demonstration of how legal regulation of drugs can help people become prescribed, rather than street, users; a clear example of the benefits of decriminalisation of drug use and regularisation of their supply route.
  • This is particularly important given that such legal models have only evolved within generally hostile prohibition environments. As a rule, they have been minimally funded and politically unpopular. It is hard to know how such services would develop if managed with the latitude afforded to other, less controversial areas of patient care such as, for example, diabetes or mental health.
  • Additional tiers of regulation have often been introduced within the basic prescribing model. These include requirements for consumption to be supervised in a specific venue, for very specific qualifying criteria to be met, or for the prescribing doctor to obtain a special licence. Prescribing is often time limited, administered in progressively reduced dosage, or made conditional on the patient meeting specific rehabilitation milestones.
  • Some prescribing occurs in a grey area, where medical necessity has evolved into what is effectively maintained dependence. This is far more widespread, and includes dependence on various painkillers (e.g. Vicodin, OxyContin) and tranquillisers (e.g. Valium).
  • Maintenance prescribing for dependent users continues to create controversy within the field of medical ethics and practice. It raises some difficult questions for practitioners, as it exposes the grey areas between medical, quasi-medical and non-medical use. There are ongoing controversies and conflicts between the clear need to reduce harms associated with problematic illicit drug use and a reluctance to dispense drugs that are being used in any way non-medically.
  • There are clear benefits of providing a safe and affordable supply of both drug and related paraphernalia. From a medical point of view, these are particularly helpful to those injecting, who are at high risk of contracting blood borne diseases. These benefits are sometimes undermined if practitioners are accused of supporting drug use for pleasure or recreation, while simultaneously ‘failing to treat’—or even ‘endorsing’—dependence.
  • There appears to be a need for this field of care to evolve pragmatically to deal with modern challenges. Specialist training, a specific qualification/licence, or a new specialist prescribing-practitioner professional niche could be put in place. These would be supported by a strictly ethical code of conduct, and clearly defined general guidance. They would potentially be overseen by a new regulatory agency, or equivalent sub-group.
  • Beyond this admittedly European perspective is an extensive, although poorly documented, history of opium registration systems in many Eastern and Middle Eastern countries. Users were registered and managed in Iran until 1953, and then again in the early 1970s (similar programmes are now being cautiously re-introduced); comparable systems also existed in Pakistan and India—where remnants still function—and in Bangladesh, Indonesia, Thailand and elsewhere.