The play, the plot and the players: the illicit market in methadone
Jane Fountain and John Strang

Largely unseen and extensively unrecognized, there is a substantial illicit market in the UK of diverted supplies of the methadone prescribed to drug users to treat their drug dependence. Methadone ampoules and unconcen- trated methadone mixture can both be found on the illicit market. Rarer are methadone tablets, which are infrequently prescribed, and the concentrated methadone mixture which is usually administered under supervision.

The play
Reports of the proportion of drug users in treatment who sell their prescribed drugs range from 5% to 34% (Whynes et al. 1989; Parker and Kirby 1996) and studies that ask for the sources of drugs used by misusers support the view that there" is a sul9stantial market in diverted prescription drugs (McDermott and McBride 1993).
The data in this chapter derive from a study by Fountain et al. (1996; 1998; 1999; 2000) on the use of diverted prescription drugs by chronic drug users and the operation of drugs marketplaces in London where these substances are traded. Qualitative methods were used to gather data from a small number of networks of chronic poly-drug users in several drugs marketplaces. In total, the study involved approximately 100 drug users.

The plot
The diversion of methadone may in principle occur at any point in its manu- facture, transportation, delivery, storage, and dispensation. However, studies over many years reveal that drug users in treatment are the primary diverters (Vista Hill Psychiatric Foundation 1974; Burr 1983; Spunt et aL 1986; Fountain et aL 2000). Sales are conducted by a large number of individuals, each diverting some of their own prescribed drugs (Edmunds et al. 1996; Parker and Kirby 1996).
The majority of drug users in treatment who acquire methadone which is surplus to their own requirements use either or both of two methods (Fountain et al. 1998): they obtain prescriptions from more than one drug treatment service ('multiple scripting', often inaccurately known as 'double scripting') and/or they obtain a larger dosage and/or a wider variety of drugs than they use ('overscripting'). Thus they may exaggerate the amount of drugs used in order to obtain a larger prescription for substitutes than needed, use false identities in order to obtain more than one prescription, claim to be a temporary resident to get a 'one off' prescription, or exploit prescribers judged to be 'easy' (Burroughs 1953; McKeganey 1988; Jones and Power 1990; Wheeldon 1992; Seivewright at al. 1993; Fountain et al. 1998).
There appears to be substantial geographical variation in the type and amount of diverted methadone. Major reasons for this are local prescribing policies, the availability of illicit drugs, and the patterns of drug use of buyers and sellers. Over- and under-supply can occur in the same marketplace on the same day, since trade relies on the surplus supplies of many individual sellers; several individuals collecting two-week supplies of methadone from a pharmacy on the same day can create a glut, but a shortage can quickly follow when it is sold (Burr 1983). As the supply of diverted methadone differs between markets, so does demand. In some markets, methadone is not a marketable commodity (Whynes at al. 1989), whilst others trade primarily in it (Edmunds et al. 1996).
'Marketplaces' are central to the distribution of diverted methadone, and typically evolve near drug treatment agencies, needle exchanges, and those pharmacies which dispense prescriptions to drug users in treatment. Drug trading hours often reflect those of these agencies (Burr 1983; Jones and Power 1990). In some areas, methadone and illicit drugs are bought and sold in the same marketplace, whilst in others, they are traded in separate locations (Edmunds et al. 1996). The legality of ownership of the methadone (i.e. by the named recipient) facilitates the operation of marketplaces where they are traded. Potential buyers and sellers can linger with impunity until the point of sale. It has been reported that the police rarely discover diverted prescription drugs because distribution is contained within networks of drug users trading in personal prescriptions (Parker and Kirby 1996). Marketplaces have shown themselves to be remarkably resilient, and their reaction to disruption has often been simply to relocate nearby (Burr 1983; Edmunds at al. 1996).
The price of methadone on the illicit market can fluctuate according to supply and demand, although that for unconcentrated methadone mixture appears to have been stable for many years at £10 per 100 mg. The cost of the larger-than-usual 50 mg methadone ampoules ranges from £8 to £15, and from £4 to £5 for the less widely available 10 mg ampoule. Concentrated methadone mixture and methadone tablets are not available on the illicit market often enough for there to be a standard price. Drawing on data from the London study, it is possible to postulate some general principles about the determinants of the price of methadone on the illicit market:

- Methadone is cheaper than its equivalent in illicitly manufactured heroin.
- Injectable methadone is more expensive than the oral formulations. The relative scarcity of injectables on the illicit market may further add to their cost. in the UK, for example, ten times more prescriptions are written for oral methadone mixture than for injectable methadone ampoules (Strang at al. 1996; Strang and Sheridan 1998).
- High dose units are cheaper per mg than low dose units: thus, a 10 mg methadone ampoule can cost as much as £5, whilst a 50 mg ampoule can cost as little as £8 in times of plentiful supply.

The players
The players in the diverted methadone market can be divided into two groups: sellers and buyers. Many switch roles at different times, or play these two roles simultaneously, most often selling their prescribed methadone mixture in order to buy methadone ampoules.

The sellers
Individuals are likely to change their motives for selling their prescribed methadone according to their current drug-using pattern, treatment status and financial situation. A crude typology of sellers consists of the substitutors, the fundraisers, and the retired criminals.

The substitutors
Substitutors are drug users who are receiving treatment with methadone but do not like it and sell it to buy heroin and/or other licit and illicit substances. Examples of this dissatisfaction can be seen in the quotes from the following clients:

Sarah: It's awful to not give people what they need. I mean I can't understand the system in a country, where it's supposed to work, and people are given this green liquid and told 'This is enough for you, this is as much as we are going to give'. And these people are having to say 'Yes, thank you, but actually I'm a heroin addict'. 1 mean it really does not make any sense, does it?

Harriet:... this green unpleasant-tasting liquid, that is not terribly good for you.

Edward: ...1 told them [at the clinic] I was using smack [heroin] and that I wasn't taking any methadone, but...I've ended up with a methadone script, so by rights they've actually given me a methadone habit. I mean, they could have left me on the smack, but [the doctor] said it was too expensive.

The fundraisers
The fundraisers are drug users receiving private treatment who are raising funds to pay their prescription and dispensing fees. A prescription from a National Health Service practitioner had a standard fee of £5.90 per item (or was free to those on a low income) but the cost of private treatment not only was considerably more but also could vary. In London, where the majority of private treatment was located, the initial consultation and assessment from a private practitioner was typically around £50, plus £25 per week for the consultation that resulted in the prescription. The total cost, depending on the drug, dosage, formulation, and the pharmacy's prices, could reach £125 a week. Herbie and Sally describe how Herbie's private prescriptions could be financed:

Herbie: if I sold the lot I could sell it for say £550 a week...1 pay £100-120 for it - £25 to the doctor, £70 odd...

Sally: ,..to the chemist. So it's costing about a hundred pounds a week to actually buy, but the amount [of prescribed drugs] he's getting, he could go and sell easily down the [marketplace] and make triple the amount easily.

Herbie: It works out cheaper than heroin...

Sally: ...he earns enough to, like, cover his script...

Herbie: ...and I énd up with a little bit of money in my pocket.

The retired criminals
Some sellers can best be described as retired criminals - drug users in treatment who sell their prescribed drugs rather than commit other crimes to fund their heroin use. Their appearance, physical capabilities, and reputations in local shops means that burglary, mugging and shoplifting are not viable income sources, as explained by these two methadone sellers:

Derek: ,..half the people that go to [marketplace] can't go into any of the shops round there... Soon as their faces are seen, the hooter [alarm] goes off - they are that well-known. That did happen to me when I went into Superdrug once...I was told never to go in there again. Another time, my mate went in there and 1 waited outside, but they recognised me from outside and knew that I was with him, so then they slung him out.
Mike:... with a list [criminal record] as long as my arm, my sentences are going up and up and up, so I'm trying not to do any thieving now...1'm not really a violent person - I don't want to be going out mugging and stuff like that...

The buyers
The unknown and variable impurity and the high cost of illicit heroin means that some (but probably not the majority of) drug users prefer methadone, although, as discussed shortly, buyers of diverted methadone usually use it in combination with other drugs to obtain the desired effect. An additional significant attraction of methadone to the purchaser is that it is manufactured in standard doses in recognizable packaging.
The buyers of diverted methadone do not generally use the drug (particularly the oral formulation) for its pleasurable effects. Rather, its main roles in poly-drug-using repertoires are as a cheap, safe and pure medication to reduce withdrawal symptoms and as a base for drug cocktails (Lauzon et al. 1994; Chatham et al. 1995; Rettig and Yarmolinsky 1995). Combinations, about which the user may be discerning or not, can include methadone and other prescribed oplaids, illegally-manufactured drugs (such as heroin and cocaine), alcohol, cyclizine, benzodiazepines, and stimulants (cocaine, amphetamine sulphate, and dexamphetamine sulphate). Some respondents in the London study expressed a great deal of enthusiasm for experimenting with different combinations of substances.
In the UK, the most economical method for a drug user to obtain methadone is to get an NHS prescription. As described above, if the prescribed dosage is less than they are trying to obtain, then overscripting or multiple scripting is another 'cost-free' option. If yet more methadone is sought, two options exist: to buy it on the illicit market, or to obtain a private prescription, which is more likely to be for the preferred variety, dosage, and formulation (Strang et al. 2001; Pharmaceutical Journal 1997). The latter is the cheaper option if an individual can secure a sufficiently large dose to make re-sale realistic in order to raise the necessary fees: for example, in London, the cost of a private prescription for four 50 mg methadone ampoules per day (a frequently prescribed amount) is around £100 per week. On the illicit market, these would cost £224-£420. However, some drug misusers could not accumulate the initial £100 as the single sum every week. An alternative is to buy from the illicit market several times a week, according to the cash available, where they can obtain single ampoules at £8-£15 each.
Patterns of use of diverted methadone are varied. They range from regular and heavy use, to occasional use as a 'treat', an experiment, or in an emergency such as buying methadone to avoid withdrawal symptoms when no heroin is available. Thus buyers are not necessarily regular and the amounts of methadone purchased from the illicit market vary from a single dose of methadone occasionally to two weeks' supply regularly. In addition, an individual is likely to change his or her reasons for purchasing methadone according to their current drug-using pattern, treatment status, and financial situation. Bearing these differences in mind, methadone buyers can be categorized as the supplementers, the treatment avoiders and the substitutors.

The notion that those who buy methadone on the illicit market are engaged in self-treatment is then also considered.

The supplementers
An insufficient dose (real or perceived) of methadone can occur at the start of treatment, particularly if the addict has high expectations that it will address all of their drug needs and will stop cravings for other drugs (Dole et al. 1966; Preston 1996). It can also occur during treatment, if the dosage is reduced too quickly and if tolerance to the drugs prescribed - and/or those used in addition - increases. Two supplementers explain:

Paul: ... they don't believe the amount of drugs you can take these days...like when 1 first got registered...I had to sit in a room with [drugs worker] whilst I did the crossword in The Mirror, The Star etc. I had to take these drugs all at once in case I went clunk. Obviously I didn't. It wasn't half the amount that I wanted or needed. I don't get stoned off my prescription - it just keeps the wolf from the door.

Edward: ...it's a vicious circle in one way, because they don't give out enough for a start. A lot of people are driven onto the streets Ito buy extra drugs] from these demands that the clinics make.

The treatment avoiders
There are several reasons why those who are drug dependent and buy diverted prescription drugs do not arrange their own prescriptions. These include an unwillingness - especially of women with children - to submit to official attention, and their experiences from previous treatment episodes which have left them disillusioned with services (McKeganey 1988; Sheehan et al. 1988; Stimson et al. 1995; Department of Health 1996; Powis et al. 1996). Harriet is one of these:

I would never get registered because I didn't want my name down on any government list - that's another very common thing especially with organized junkies who have got a straight job, like a nurse or something like that, because of all the prejudices that go with it. The reason 1 don't want my name down on that list is partly because i do want a reasonably straight job - that's why I'm doing my degree - and also for my child. As soon as you say junkie' you become a bad, irresponsible parent in the eyes of everybody, even people that should know better like doctors etcetera. I didn't tell them when 1 was pregnant that I was using. I came off on my own rather than say that, because i knew the minute that 1 said i was using, my name would be put down on the lists, and my child's name would be put down.

The substitutors
NHS drug treatment services are reluctant to prescribe injectable formulations to drug users in treatment, and successive-government documents have emphasized the caution that should be associated with the prescribing of such injectable drugs (Advisory Council on the Misuse of Drugs 1993; Department of Health 1991; 1999). However, this policy stimulates demand from the illicit market for injectable methadone, even though buyers may already be receiving a prescribed supply of the same drug in an oral form. The prescription of the client below had been changed from an injectable to an oral formulation of methadone:

Interviewer: So you haven't got any amps on a script now, then?

Maurice: No, but I can get them. But I don't get them legally... That's what I said to them up there [at the clinic] - 'You're just defeating the object. You stop my amps so I just go out and buy brown [heroin] or I go and buy amps off of someone else.'

The self-treaters?
It has been suggested that some of those buying diverted methadone are engaged in self-treatment (Langrod et al. 1974; Spunt et al. 1986; Gossop et al. 1991) and that the benefits of prescription drugs are therefore reaching an out-of-treatment population. However, 'self-treatment' suggests that users are embracing the same therapeutic objectives and are mimicking the therapeutically based decisions of treatment agencies. The supratherapeutic amounts and the combinations of prescription drugs used by some who buy them on the illicit market are not generally purchased with such therapeutic objectives, and would not be available to them in these forms and doses via legitimate treatment sources (Ruben and Morrison 1992; Seivewright and Dougal 1993; Strang et al. 1993). Nevertheless, some users of diverted prescription drugs have assimilated the harm reduction advice emanating from drug treatment services and disseminated by the drug users' grapevine. Ironically, the knowledge that illicit drugs and injecting are dangerous probably increases the demand for the 'safer' methadone from the illicit market (Edmunds et al. 1996).

The finale
It is generally accepted that some diversion of drugs prescribed to drug users in treatment is unavoidable (Department of Health 1996), and the literature on diversion control argues that the energy and ingenuity which some drug users devote to obtaining drugs to divert can thwart control attempts unless all avenues are closed simultaneously (National Institute on Drug Abuse 1993). When restrictions are placed on only one substance or one source of supply, buyers may find a substitute or experiment with new combinations of drugs or routes of administration to achieve the desired effect (Klee et al. 1990; Strang et al. 1992; 1993; Fountain et al. 1999).
Implicit in the UK Guidelines on Clinical Management (Department of Health 1999) is the notion that good prescribing practice minimizes diversion.

However, when substitute prescribing is included as an option for treating drug users, the level of concern and decisions made about the potential for diversion depend on whether the policy-making community is more concerned with treating addicts than preventing them selling drugs. However difficult, the objective should be the identification of the most health-conferring balance between caution against overprescribing (despite the possibility that the patient may sell the surplus on the illicit market) and caution against underprescribing (and maybe prompting the patient to `top up' from the illicit market). The application of this balanced judgement is the challenge.

Acknowledgement
The study and literature review from which the data for this paper were taken were funded by the Department of Health, England. The views expressed, however, are those of the authors.
Some sections of this chapter were first published in Fountain, J., Strang, J., Gossop, M., Farrell, M. & Griffiths, P. (2000) Diversion of prescribed drugs by drug users in treatment: analysis of the UK market and new data from London. Addiction, 95: 393-406.

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