Home Affairs Committee - Drugs: Breaking the CycleWritten evidence submitted by Anonymous (DP186)

My M.P., Dr Julian Huppert, tells me you’re still accepting late submissions. If so, I hope you will consider the following.

I’m over 60 and my earlier life went quite down the toilet as a result of illegal drug addiction. At age 42, I finally qualified for a diamorphine prescription and have been employed, housed, law-abiding and a relatively productive and contented citizen ever since. I’m just one of a number of examples of lives recovered by an intelligent maintenance policy and now find myself a reluctant commentator on the subject of addiction from a concern those “in charge” tend to overlook the obvious and compound an already alarming and unnecessary “drug problem”. With drugs as elsewhere, one size does not fit all and present “encouragement to abstinence” policies can do more harm than good unless account is taken of individual circumstances.

I avoid broader comment on the “war on drugs” to focus exclusively on heroin addiction and its treatment.

1. The importance of the Select Committee in this area is not be underestimated. There are over 300,000 heroin addicts on UK streets tonight. As I write, local radio pundits debate whether the increase in “drug related” crime in Cambridgeshire is the exception to a general decrease in offences is because of “proactive policing”. Drug gangs and drugged thieves are major social problem on inner cities and council estates.

It’s quite remarkable just how little addiction realties are generally understood. Here, one of the major UK Drug Service Providers elected to impose a policy that would have had disastrous consequences for a number of their patients simply because they knew no better; and because a determined minority were able to exercise undue influence. It offered a fitting climax to 40 years of canard, misinformation and indifference that has turned the British Drug Treatment System from the envy of the civilised world to its sick relation. To understand how badly treatment has failed its mandate, one must only look around.

2. Addicts are overwhelmingly unpoliticised, uncommunicative and liable to tell “authorities” whatever best suits their immediate self-interest. There’s little outside scrutiny of an unattractive area of medicine and addiction myths pass from patient to doctor and back again. What’s best described as drug law sociology further contributes to a communications breakdown. I now witness a preposterous situation of avoidable dependencies while a minority for whom opiate drugs fill a genuine need are unable to access the appropriate medication

3. Addiction is essentially a solitary business. The addict gets on and comes off alone, of his own volition. The opinions of close family may be heard but those of strangers repeating dubious mantras are unlikely to be. A slightly higher percentage of heroin addicts “got clean” within three years during the Rolleston years than do today via “rehabs” or legions of paid helpers, which rather says it all about the reality of the thing. The present structures could be dismantled and staff reduced to doctor and receptionist tomorrow and it would make very little difference to the “drug problem”.

The Blair government, typically, used treatment as a job creation scheme and “key workers” and DSP staff are often poorly trained and lamentably ill-informed. A national standard of qualification is probably more politic than casting middle class voters into the dole queues. An unwieldy structure and considerable local autonomy gives rise to widely differing standards of treatment and allegations of a “postcode lottery”.

4. The Drug Laws uniquely criminalise not an act but a state of being. There are obvious implications and drug policy operates in a number of grey areas. Nonetheless, the decision to abandon Rolleston may rate as the single most disastrous social policy decision of modern UK history. In an era of no drug gangs, crime, violence or billionaires narcoterrorists and a maximum of 1,500 addicts, the anxieties expressed to the hastily commissioned 2nd Brain Report appear positively frivolous compared to what we face today. Brain’s worry about “juvenile delinquents” is paralleled by present-day warnings about an underclass on drugs. Like much of the “drug debate”, this is a fear based irrelevancy. Nobody is a long term heroin addict if they can help it. Addiction realities are the same for all classes. New “underclass” dependents may not be the same as the predominately middle-class Rolleston users but their addictions will be. There will be no new drug epidemic if treatment accepts its responsibilities and no longer seeks to divorce its own expedient interests from the wider problem.

5. There are, I believe, two causes of addiction. There is no “addiction gene”. A minority find it the best or only treatment for a psycho-spiritual condition that has yet to find DSM diagnosis. This group are often set back by the demands of UK guidelines that they first fail on every other treatment option. The introduction of methadone—apparently for its non-euphoric properties—failed to satisfy the “consumer base” and about half the recipients of methadone linctus buy street heroin on top. The first black market heroin appeared in the UK two years after the introduction of the clinic system.

Now, with heroin on every bored corner, a majority of users stumble into addiction needlessly and almost by accident, often in consequence of rebellious fashion. Criminality creates glamorisation and over-enthusiastic drug education actually inclines impressionable youth to drug use. The “gangs” afford social credibility and a certain adrenalin. All this is quite separate from any therapeutic or health concerns. It’s worth noting there is no methadone chic. If heroin were available on prescription, most of this group would fall by the wayside. Switzerland has fewer user numbers and in Sweden there’s an increase. Again, it’s the reality of the thing; drug “epidemics” result from prohibition, not liberalisation. I’d privately estimate up to 90% of present heroin dependents would never have developed addictions were it freely available on prescription.

6. Any “recovery” agenda ought to involve the dictionary definition of the word and an appreciation that abstinence is neither always possible nor the best course of action for all drug users. The reality of “withdrawal” is of unpleasant physical symptoms compounded by a strange “state of mind” that, until neurological changes take place way down the line, is nonetheless manageable when the incentive is there. There follows a period of low mood and an paralysing lack of energy that lasts roughly six weeks for every year of addiction. In the last 10 years of Rolleston, a majority surrendered their prescriptions within two to three years. Without distraction of supply and economic and social considerations, this was long enough for most people; able to get enough, they’d soon had enough.

7. “Drug crimes” come from those left outside the system; without the “I had to do it to get drugs” excuse, it’s simply crime. The seven diamophine-maintained patients in Cambridge accrued nearly 50 criminal convictions between them before their prescriptions; in the 15–30 years since, none. Yet the present guidelines recommend RIOTT style supervision for all new diamorphine prescriptions. No dsp can afford the costs and diamorphine is effectively taken off the menu. It would seem the government is in terror of pharmaceutical diamorphine seeping onto the street. An estimated 30 tonnes of adulterated product is consumed annually and “drug gangs” ensure its freely available. Police efforts and other considerations have left the quality of street heroin at an all time low but buyers remain abundant. Permitting the lower orders effectively unimpeded access to poor, but not pure drugs is dubious politics.

8. Restrictions on prescribing gave the “drug gangs” power in the UK and their removal would largely take it away again. An unglamorous prescription would accommodate patients for whom it fills a need and remove the mystique for those who do not. It will result in less, not more new users and those who are still attracted will be able to sort out their problems without distraction and diversion, It would save lives and improve the “quality” of life for residents of drug blighted areas. It is as simple as that. All else is politics and the illusion of “public opinion” manufactured by incessant fear mongering and inaccurate information.

The Swiss experience serves as a guide—and as an indication of how voters may react. A recent German trial, in which diamorphine was made available to all comers not only methadone failures, is also of relevance.

9. It is difficult to know what to recommend for the other major problem group, the crack cocaine users other than to make psycho-social interventions accessible. Cocaine as well as heroin on prescription has not been tried for some years and further investigation is appropriate.

10. The arrival and impact of the Voluntary Sector’ merits careful scrutiny. There was concern in the Blair era the VS would serve as a covert arm of government; now the fear is government serves a corporate hegemony. Drug users have a poor grasp of treatment politics and many assume their corporate provider is, in fact, the government. What’s reported to government as most appropriate may be what best suits the provider, not the situation. Major drug service provider board members come from corporate backgrounds and may have political aspirations of their own; the interests of their user “clients” should not be seconded into their service nor should they be considered a commodity akin to canned goods. The similarity of the ideas of the major providers and degree of substance behind their cosmetic claims may also be of note.

There are also business links between the VS providers and the rehab industry. While it is right and proper every assistance should be available to empower users to kick the habit, Treatment should not serve as a rehab waiting room nor for the primary benefit of the corporate whole. Weekend dabblers and “marijuana addicts” should not be cajoled into residential rehab to boost the success figures. Post detoxification, the user is at their most vulnerable; safeguards are needed to prevent rehab personnel in effect abusing their considerable power to push their particular social credos onto their susceptible, captive audience as “rehabilitation”. As with treatment in general, care must be taken to avoid a specious social engineering. Again, standards in detox and rehab centres are often abysmal and far different from the claims of their brochures or reception areas.

11. Any competent pharmacist may make up dosage from powder at a fraction of the cost of the presently available “freeze dried” ampoules. The influence of pharmaceutical multinationals on government advisory committees and excessive pricing ought to be examined. The practice of “supervised consumption” may also be of concern. At present, chemist chains are paid large sums of taxpayer money to ensure, in practice, new clients acquire a methadone dependency; after three months, the user is allowed to “take home”; (and, frequently, exchange their methadone for street heroin) and the dsp endeavours to help them kick their new addictions. There is a considerable place for methadone among treatment options but, for those who continue to use heroin, a new initiative is appropriate.

12. It may be thought a vast drugs bureaucracy employed to keep government informed is also unnecessary and the concern is more for the employment figures than addiction realities. Common sense is often missing; those who worry about drug use if it were legal invariably contemplate “other types” as the ones open to temptation. Equally, a certain fashionable liberalism espoused by “celebrities” may be more concerned with their own “image” than the reality of life for a drug user on a council estate.

My suggestions, in summary:

(a)An immediate consideration of a wider diamorphine prescription base, not exclusively with an obligation first to fail elsewhere. and of less costly but no less effective ways than RIOTT style dispensation or “supervised consumption” to police and minimise any potential “seepage”. Results to be closely monitored for a pre-determined period of trial.

(b)An emphasis on harm reduction and accuracy of drug information and education. Users not to be pushed out of treatment and to be given the same consideration as other patient groups.

(c)A national qualification standard for drug “key workers”.

(d)A standardisation of services on a national level. Inspection to ensure “rehabs” act as advertised and a scrutiny of their efficacy.

(e)A closer supervision and greater accountability for Drug Service Providers. If the present “payment by results” is maintained, checks and balances to ensure “successful discharges” are as claimed and have not simply been criminalised.

(f)Note should be taken of the particular constituency of drug patients and occult drug law sociology and effort made to ensure accurate reportage of what’s happening on ground level.

(g)An emphasis on common sense and improved communication at every stage.

Good luck with your work in this area.

February 2012

Prepared 8th December 2012