I once carried out a general practice surgery where the first two patients requested opiates but for entirely different reasons. I was struck at the time by the difference in my response. The first patient was an elderly man with pancreatic cancer. He came for a repeat prescription for a concentrated morphine solution to control his metastatic pain. I gave it to him willingly, and told him he could take it as often as he needed. I reminded him that, when necessary, I would be very happy to organise a syringe driver for him at home, so he could receive a continuous infusion of diamorphine intravenously. The next patient, however, had an entirely different presentation. She was a young woman from outside the area who had asked to be seen urgently. She told me she was recovering from heroin addiction and was on a methadone programme to aid her withdrawal. She said her handbag was stolen the previous day, with her prescription in it. Would I please issue a replacement? I politely refused. I explained that, like most surgeries these days, we had a firm practice policy, restricting such prescriptions to patients who attend our substance misuse clinic. She left with little protest.
A visitor from another planet, observing these two consultations, might have been puzzled as to why I was so relaxed and generous with one person, and so strict with the other, when they were asking for similar drugs in almost identical doses. I would have had to explain that, sadly, consultations like the second are about 10 times as common as the first in inner city practices: the first patient's request was legitimate, while the second was almost certainly deceitful, and driven by a helpless craving for the drug itself.
For patients and doctors alike, opiates are a blessing and a curse, a source of angelic relief from suffering and a diabolical cause of it. Morphine and heroin draw their users into the same polarisation as the drugs themselves. We admire one group as moral heroes for taking these as they face the ultimate challenge of their lives. We approach the other group too often as moral failures—with suspicion at best, rejection at worst. No other class of drugs has such powerful physical and psychological effects. None has such a Manichean image in our society, culture or political debates.