Home Affairs Committee - Drugs: Breaking the CycleWritten evidence submitted by Stephen Dowle [DP196]

There has been much debate recently about the best way to deal with drug addiction. I write to you as an addict in recovery. I was a user of crack cocaine. When I ran out of money I stole from family and friends. I committed crime. At a certain point I decided enough was enough. I walked into a police station and admitted to my offences. The police were excellent. They put me in touch with the right agencies. I’ve been clean ever since.

Whilst I was a user I saw many terrible things. I could never have imagined so much cruelty, depravity and suffering. Women in particular are vulnerable to some of the most disgusting and humiliating exploitation. It is a truly horrific existence; the rules of society are redefined to create a parallel world where the unthinkable becomes the norm. This makes it all the more surprising that so many people relapse, and even find a kind of solace in the suffering.

I was lucky in so far as I was not addicted to heroin and therefore did not have to deal with physical withdrawal. But it is not physical addiction that causes relapse it is the psychological, and that applies across many drugs. However, physical withdrawal receives a lot of attention and is often the focus of debate about drug treatment policy. My belief is that the predominant heroin substitution policy is misconceived. I shall try to explain why this is the case by giving an example drawn from my own experience.

When I was using I got to know a woman, addicted to heroin and a user of other drugs, including crack. Five years ago she got onto a drug programme run by the Bristol Drugs Project (BDP). Starting with methadone and then transferred onto subutex, I believe hers is a typical example of heroin substitution policy at work. Five years later and she is still on a large daily dose of subutex. She is using heroin and crack cocaine. She uses subutex as a fall back when she can’t get anything else; it provides a safety net, giving her the security to keep on using heroin. The subutex she does not use, she sells. She allows a dealer to “cut-up” in her flat. She allows Class A drugs to be sold from her flat and will sometimes act as a “runner” for a dealer, delivering drugs to his customers. All this is done in return for drugs. In addition she “works” as it is euphemistically put, or more plainly, she is prostituting herself.

During these five years she has had brief periods in recovery, but for the vast majority of the time she has been using heroin and crack, and engaging in various illegal or harmful activities whilst continuing to receive a heroin substitute. After five years, missing appointments and failing (woefully infrequently applied) urine tests, the BDP just keep on prescribing. To what end? How long will this continue? The BDP are prescribing subutex that end up for sale on the streets. They are aiding a woman’s decline into hell. They are not reducing harm, they are prolonging it.

I know it is dangerous to generalise from a single example but what I have described is, in my experience, far from being an isolated example.

It seems to me that a policy of heroin substitution has the following disadvantages:

The focus on managing the physical withdrawal can be to the detriment of dealing with the wider issues that ultimately drive addiction and lead to relapse. This creates a classic vicious circle.

Heroin substitution maintains addicts in a dependant relationship with drugs.

Most heroin substitution is carried out in the community, which typically means that addicts remain in the same physical location, mixing with the same people, as when they were using.

Addicts are highly skilled liars and manipulators. They operate by a completely different moral compass. The environment created to manage heroin substitution policy is perfect for them to deploy these “skills” to achieve their own objectives.

As too often applied, substitution based treatment does not really test an addict’s commitment to recovery or challenge their addictive behaviours, indeed it can reinforce them.

All of these factors contribute to the failure of heroin substitution as a treatment option. We need to find an alternative to substitution and I believe the most promising is a policy based primarily on abstinence that starts with a short sharp managed detox. One advantage of this is that, as in the example I gave above, five years (so far) would be reduced to two or three weeks. With that out the way the focus can then be on the key issues relating to addiction, psychological, environmental and social, without any distractions.

I know this requires that sufficient detox beds are available, but this does not mean there has to be a detox bed for every addict currently undergoing substitution therapy. Based on current success rates the number of detox beds initially required to just match outcomes would be quite small.

But detox is only the first stage, the full range of psychological, environmental and social issues that drive addiction and lead to relapse must be addressed. Much of this needs to be informed by recent discoveries in the field of neuroscience. It may well be that addiction cannot be cured; an addict is an addict for life. But it can be controlled by taking concrete actions and the development by the addict of certain tools, alongside the treatment of any specific mental or physical problems. In his book “Memoirs of an Addicted Brain” Marc Lewis describes the relevant neuroscience alongside his own story of addiction and recovery. It has been suggested that addicts in recovery might benefit from some understanding of this latest research as a basis for developing the tools they need to avoid relapse.

Two things are pretty widely agreed:

The addict needs to be removed from the people, places and things that trigger relapse. This normally means relocating to a new area, building new social networks and total abstinence.

The addict needs to unlearn the addictive behaviours that ultimately define addiction. This means using tools such as those provided by cognitive behavioural therapy and developing new interests and activities, work or study.

All the above would need to be intensively supported. This agenda should become the basis for a comprehensive programme to free individuals from the slavery that is addiction. What is the alternative? Continue with a flawed strategy that fails addicts and wider society? The abstinence based approach redirects the focus onto the really important issues and in this way offers the best chance for recovery.

But decisions about drug treatment affect more than just addicts or the society in which they live. The war on drugs has come under scrutiny recently. From an international perspective it is widely seen to have failed. The IISS recently reported that there was growing acceptance that the war will only be won by reducing demand, particularly in the rich developed countries. I believe that an abstinence based programme of drug treatment as outlined above would provide our best chance of reducing that demand.

But in the end it is about people and ruined lives. The life of most addicts is an abomination by all standards of human decency. It is essential that we give our fellow citizens the best chance of removing themselves from this hell.

Stephen Dowle

August 2012