Tuesday, February 03, 2009

Addicts’ adventures in wonderland

The following editorial by Danny Kushlick was published in the the journal; Addiction Research and Theory (15(2): 123–126) in April 2007*, and is reproduced here as much of it seems relevant to current debates, both on this blog and in the wider drugs field.

Addicts’ adventures in wonderland

Viewed from a public health and wellbeing perspective, you could be forgiven for thinking that drug policy is developed at the Mad Hatter’s tea party. Huge numbers of legal drug users are effectively ignored, whilst relatively tiny numbers of illegal users have enormous time and resources spent on stopping them using.

I am going to suggest that policy is not rationally based upon sound public health or harm reduction principles, but rather that it is skewed to the point of ridiculousness by the Government’s denial of the counter-productive effects of drug prohibition.

What is the drug problem?

The drugs in the UK that contribute overwhelmingly to public ill health are tobacco and alcohol. Both are legal, with tobacco sales oddly, legally sold to those over the age of 16, as opposed to 18 for alcohol. There are over 10 million regular tobacco users and 40 million alcohol users. Alcohol is implicated in about 40,000 deaths per year, with 120,000 for tobacco. Tobacco products carry a health warning but no ingredients list, whilst alcohol products carry neither.

Cocaine and heroin also contribute to public ill health but at much lower levels of use. Both are illegal and consequently there are no controls on their production, sale or use, apart from the blanket prohibition that aims, fantastically, to eliminate them from society. There are an estimated 340,000 problematic heroin and crack cocaine users in the UK and much of the ill health associated with their use is directly related to their illegality.

Within the national ‘drug’ strategy there is no discussion of the needs of our 10 million plus tobacco users, four million problem drinkers or our one million prescribed tranquilliser users. The reason: our commitment to drug prohibition (and the orchestrated demonisation of illegal drugs that has gone with it) has blinded us to the fact tobacco, alcohol and tranquillisers are drugs. And more importantly, that the use of licit drugs constitutes by far the bigger public health problem.

Messages on ‘Addiction’

What does the Government’s Talk to Frank website say about cocaine and alcohol ‘addiction?’ Under the heading ‘Chances of getting hooked’ it says: ‘Coke is very addictive. It can be difficult to resist the craving and strong psychological dependence due to changes in the brain. Recent evidence suggests possible long-term changes to the nervous system’. And under the same heading for alcohol: ‘For most people, if you drink within the sensible limits for regular drinking, that’s OK. But for some people drinking gradually gets out of control and results either in regular binge-drinking, heavy harmful drinking or alcoholism (alcohol dependence)’. But, note not ‘addiction’ and no long-term changes to the nervous system.

So, different messages for each drug. But what about the response to those who do develop a ‘drug problem?’

Treatment – voluntary and coerced

As a result of our long-standing ‘war’ on illegal drugs, an enormous amount of resources are skewed toward ‘treating’ people who commit acquisitive crime in order to support their habits. One of the consequences of the prohibition of heroin and cocaine is that the price of a daily habit is hugely inflated. Consequently low income dependent users resort to crime to earn money and collectively commit anything up to half of all property crime. A Government that is keen to be seen to be ‘doing something about the drugs problem’ must try to ‘get addicts off ’ their drugs. Because if they don’t, ‘addicts’ will continue stealing things and prostituting themselves in public and generally proving how counterproductive prohibition is. The problem is that we have an apparent crime problem, that appears to be a drug problem, for which ‘treatment’ would appear to be the solution. When in fact, it is a self created prohibition problem (an attempt to eradicate a symptom of lack of wellbeing),underlying which are unaddressed wellbeing problems.

A Drug Rehabilitation Requirement (DRR) is a court-ordered treatment condition handed out for those who are convicted of offences related to their illegal drug use, usually acquisitive crime. But, remember it is our commitment to the global prohibition of drugs that create the high prices, that cause the offending to support a habit in the first instance. Interestingly, there are very few orders given for those whose violent offending is related to their alcohol use. You might wonder if the Government is more committed to addressing problematic drug use that creates property crime than that which creates horrible violence against other people.

Within a prohibitionist paradigm it makes perfect sense for Home Office-led interventions to force heroin ‘addicts’ to overcome their ‘addiction’. Whereas for the Department of Health: ‘Alcohol drunk in moderate amounts in appropriate circumstances is not a danger to health’. Perhaps we need a Drug Policy Rehabilitation Requirement for politicians in denial of the unintended consequences of enforcing prohibition.

Imagine someone walking into his or her local drug project seeking help to get into residential rehab for tobacco ‘addiction’. Why does this seem odd, funny even? The fact is that it even if it were to be possible for them to get funding for rehab, most centres allow residents to smoke tobacco.

Think about the number of smokers you know who are in ‘recovery’ from ‘addiction’, having assiduously gone through a twelve-step programme. (Both the co-founders of AA died of smoking-related disease.)

Our anomalous attitude to drug ‘treatment’ is not unlike the Caucus Race that the Dodo organised in Wonderland:

‘What I was going to say’, said the Dodo in an offended tone, ‘was, that the best thing to do to get us dry would be a Caucus-race’.

‘What is a Caucus-race?’ said Alice . . .

‘Why’, said the Dodo, ‘the best way to explain it is to do it’ .. . .

First it marked out a racecourse, in a sort of a circle, (‘the exact shape doesn’t matter’, it said,) and then all the party were placed along the course, here and there. There was no ‘One two three and away’, but they began running when they liked, and left off when they liked, so that it was not easy to know when the race was over. However, when they had been running half an hour or so, and were quite dry again, the Dodo suddenly called out ‘The race is over!’ and they all crowded round it, panting, and asking, ‘But who has won?’

This question the Dodo could not answer without a great deal of thought, and it sat for a long time with one finger pressed upon its forehead . . . . At last the Dodo said, ‘Everybody has won, and all must have prizes’.

Except that those illegal drug users who are not ‘dry’ after half an hour might well find the Queen shouting at them, ‘Off with his head!’

A public health and wellbeing approach

The recent report from UNICEF put the UK at the bottom of the table of 21 countries for child wellbeing in industrialised countries, with the United States 20th. The UK and US also have some of the highest levels of drug use and misuse in developed countries and both also enforce some of the harshest drug laws on earth. The UK has the highest prison population in Europe, the US the highest in the world. Perhaps this is what is meant by the ‘special relationship?’

These laws conform to neither legislative nor public health norms when compared to other social issues (imagine criminalising tobacco use, gambling or teenage pregnancy). The criminal justice system should be used as a last resort, not a starting point in dealing with public health problems.

A drug policy based on a public health and wellbeing paradigm would be truly comprehensive, cross-departmental and tick all the right boxes with regard to social determinants of health and wellbeing. It might look something like the text below, adapted from Tony Blair’s forward to the Alcohol Harm Reduction Strategy of 2004. I have swapped the words ‘drugs’ and ‘drug use’ for ‘alcohol’ and ‘drinking’. It speaks for itself:

‘Millions of us enjoy drug use with few, if any, ill effects. Indeed moderate drug use can bring some health benefits. But, increasingly, drugs misuse by a small minority is causing two major, and largely distinct, problems: on the one hand crime and anti-social behaviour in town and city centres, and on the other harm to health as a result of binge- and chronic drug use.

The Strategy Unit’s analysis last year showed that drugs-related harm is costing around £20 bn a year,and that some of the harms associated with drugs are getting worse.

This is why the Government has been looking at how best to tackle the problems of drug misuse. The aim has been to target drug-related harm and its causes without interfering with the pleasure enjoyed by the millions of people who use drugs responsibly.

This report sets out the way forward. Alongside the interim report published last year it describes in detail the current patterns of drug use – and the specific harms associated with drugs. And it clearly shows that the best way to minimise the harms is through partnership between government, local authorities, police, industry and the public themselves.

For government, the priority is to work with the police and local authorities so that existing laws to reduce drug-related crime and disorder are properly enforced, including powers to shut down any premises where there is a serious problem of disorder arising from it. Treatment services need to be able to meet demand. And the public needs access to clear information setting out the full and serious effects of heavy drug use. For the drugs industry, the priority is to end irresponsible promotions and advertising; to better ensure the safety of their staff and customers; and to limit the nuisance caused to local communities.

Ultimately, however, it is vital that individuals can make informed and responsible decisions about their own levels of drug consumption. Everyone needs to be able to balance their right to enjoy using drugs with the potential risks to their own – and others’ – health and wellbeing. Young people in particular need to better understand the risks involved in harmful patterns of drug use. I strongly welcome this report and the Government has accepted all its conclusions. These will now be implemented as government policy and will, in time, bring benefits to us all in the form of a healthier and happier relationship with drugs’.

The health and wellbeing approach will become reality within a decade, but for now unfortunately, Mr Blair and his colleagues prefer Wonderland.


Danny Kushlick is Director of Transform Drug Policy Foundation**

* note that some of the content is out of date
** Danny Kushlick is now head of policy and commincations


Anonymous said...

Education on drugs is certainly the right way to go, may i recommend reading through the Drug Free International website and their Unite Against Drugs campaign, it is also targeted at the education point. When people know the truths about drugs, their harmful effects and dangers, people stay well clear. Drugs are drugs, legal or illegal. Cheap or expensive, over the counter or not and there are dangers with all of them, that is the plain truth. Drugs are dangerous, people shouldnt be so eaasily fooled by a drug being sold legally in shops...some of them are just as addictive as illegal street drugs!

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