MEMORANDUM 60
Submitted by the Royal College of Psychiatrists
1. BACKGROUND
The Faculty of Substance Misuse, Royal College
of Psychiatrists, represents Addiction Psychiatry throughout the
British Isles. Addiction psychiatrists are qualified psychiatrists
who undergo additional training in substance misuse. Addiction
psychiatrists play a lead role in specialist treatment centres
and have contributed substantially to developing the evidence
base on which modern practice is based. There is a growing consensus
among specialists as the optimum approach in the treatment of
drug misuse. We are committed to driving forward this agenda.
We have not dealt with the issue of decriminalisation
in depth. Evidence to date indicates that substance misuse will
increase if there is decriminalisation, as will health problems
and demands on health and social care services. It is a socio-political
decision as to whether there are compensating social and personal
advantages, and we consider that decision lies outside our area
of expertise.
We have focused on current drug policy. We believe
the Government's ten-year plan was well conceived and has already
brought considerable benefits. It is now in danger of being undermined
by three major problems, which need to be addressed urgently.
The treatment element of the ten-year plan
has been distorted and rendered less effective by criminal justice
priorities.
Training, recruitment and retention are grossly
inadequate. A new human resource strategy is required.
Research at all levels is massively underfunded.
This includes evaluation of current practice.
We welcome the establishment of the National
Treatment Agency. It is vital that its policy is based on advice
from addiction specialists in all professions, rather than opting
for politically attractive quick-fix solutions.
2. HEALTH POLICY
VERSUS CRIMINAL
JUSTICE
We are alarmed at the expansion of Criminal
Justice priorities over drug addiction treatment. This should
be a key issue for the newly formed National Treatment Agency.
The National Treatment Agency aims to establish
standards for treatment services. It is of the utmost importance
that specialists in the treatment of addiction (doctors, nurses
and psychologists) play a key role in the development of this
new initiative.
We believe that Criminal Justice initiatives
are in conflict with health priorities.
Recent initiatives include Treatment and Testing
Orders which are expensive and of uncertain benefit. Funding would
have been better spent on reducing waiting lists generally and
reducing caseloads.
We do not believe that evidence supports the
efficacy of coercive treatments. In the final analysis, successful
treatment requires co-operation. Behavioural modification based
on compulsion engenders resistance rather than lasting positive
change.
In some districts, the quickest way to access
treatment is to commit a serious crime. Criminals overtake patients
with more serious health needs eg. AIDS, hepatitis or pregnant
users. The current Hepatitis C epidemic is a major public health
problem, as it will lead to a large increase in cirrhosis and
cancer. The drive to soften its impact may be undermined by misguided
prioritisation of patients and fear of coercion if they are identified
as drug users.
The Home Office focus on illicit drugs ignores
the more important contribution of tobacco and alcohol to the
burden of sickness. Alcohol is also a major cause of crime. As
a result we still await a National Alcohol Plan, and tobacco treatment
remains absurdly underfunded.
We recommend that the National Treatment
Agency make health issues its top priority, and scrutinise Criminal
Justice initiatives to ensure that there is no conflict with this
objective.
3. TRAINING,
RECRUITMENT AND
RETENTION
It is estimated that addictions account for
over a third of the health problems treated by the NHS Treatment
of addiction is cost-effective.Smoking cessation interventions
costs between £212 to £873 per life year gained, compared
with £17,000 median cost for 310 other common medical interventions.
The treatment of both opiate and alcohol misuse saves about
three times as much as it costs.
In spite of this compelling data, training
in addiction is grossly inadequate. On average medical students
receive less than six hours of relevant education. Over the last
10 years this minimal input has diminished, despite the increase
in addiction problems. Most GPs and hospital doctors receive no
further training. The situation is no better for nurses, psychologists
and social workers.
Due to the neglect of addiction training, there
is an alarming lack of trained professionals to deliver the Government
drug strategy.
Most clinical areas demand increased training
to improve clinical practice, service delivery, organisational
standards and commissioning.
We recommend that addiction training throughout
health education from undergraduate to postgraduate level be dramatically
increased.
We recommend that the Specialist Training
Authority recognise Addiction Psychiatry as a Specialty, as
is already the case in the United States and many European countries.
This will increase the status of this field of medicine, aiding
recruitment and retention, and extending the quality and quantity
of specialist multidisciplinary service provision.
We recommend that recruitment and retention
be enhanced by adding a "specialty lead uplift" to the
salaries of suitably qualified professionals in the field (eg
nurses, psychologists).This strategy has already reaped dividends
in the field of forensic psychiatry.
4. RESEARCH AND
EVALUATION
Policy development should follow evidence. This
remains inadequate, particularly that derived from national research.
The UK relies almost entirely on research from the United States
and Australia, even though their drug problems and policies differ
substantially from the UK. Both countries spend much more than
the UK on drug research. Recent figures indicate that the US Government
spends 4 per cent of its total drugs expenditure on drugs compared
to 0.02 per cent in the UK. Until we have a systematic national
strategic research programme, policy makers must base their recommendations
on impressions, anecdotes and prejudice rather than on facts.
As a starting point, we recommend that 1
per cent of the annual drugs budget would inject £14 million
a year into addiction research.
Multidisciplinary research groups with consistent
core funding should be established. These should include basic
and theoretical research eg in neurosciences, genetics and psychology,
as well as applied research which is multidisciplinary and multicentred.
Evaluation of current practice is also essential.
Too many new initiatives are introduced without adequate evaluation.
Examples of necessary research that will impact
on practice:
— Criminal justice initiatives there
is scant evidence about the cost effectiveness or efficacy of
enforced treatment.
— Innovative medications: what is the
best way to combine pharmacological and psychosocial interventions?
— Best models of service delivery eg
impatient versus outpatient treatment.
— Reducing the impact of the current
Hepatitis C epidemic.
— Understanding drug use in the very
young.
— Reducing drug-related deaths.
— Harms associated with cannabis compared
with other substances.
September 2001
REFERENCES
Parrot S, Godfrey C, Raw M, West R & McNeill
A (1998) Guidance for commissioners on the cost effectiveness
of smoking cessation interventions Thorax 53 Supplement
5 S1-S36.
Gossop M (1999) NTORS: two year outcomes.
The National Treatment Outcome Research Study.
Changes in substance use, health and crime.
Department of Health, London.
Society for the Study of Addictions (2000) Tackling
alcohol together Free Association Books, London.
Crome IB. (1999) The trouble with training:
substance misuse education in British medical schools revisited.
What are the issues? Drugs: Education, Prevention and Policy
6: 111-123.
Working Party of the Royal College of Psychiatrists
and the Royal of Physicians (2000) Drugs.
Dilemmas and Choices London: Gaskell
224-226.
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