Increasingly it seems, politicians, media columnists and other opinion leaders support further liberalisation of recreational drug use. The Utopia they seek is to rid society of the drug pushers and the cartels. The mess drug use creates in any society is unpleasant to say the least and when things are at their worst it is then, in moral panic, we move; creatively, innovatively with much less resistance towards other ways to address the problem. The War on Drugs was lost years ago shortly after its inception in the early 1970s. Peter Hitchens in his 2012 book. The War We Never Fought, makes the case that there never was much appetite by, what he calls, the British Establishment, to take on the social liberals hell-bent on liberalising drug use. How we view drug use in contemporary society has been politicised with the Left supporting a more liberal, health and social care, approach while the Right, support a Draconian, criminal justice approach. Problem is that today recreational drugs are too available and after experimental use those predisposed end up dependent and in need of significant help and support in the long term. Here again the Right and the Left have different views. The Right see the dependent are weak and selfish, the Left see them as victims.
How this plays out in policy is very interesting. As the sides cannot agree things need reframed before being addressed. A key reframing was the promotion of the medical model of addiction now dominant and which defines and directs treatment policy. Another reframing has been harm reduction. Simply put if the drug user does not wish to, or cannot, stop then drug use must be made as safe as possible.
Harm reduction makes obvious sense. Over the past 20 years N. Ireland has introduced; substitution prescribing (methadone and buprenorphine), needle exchange services and naloxone services. Lives have been saved and other health and social harms have been reduced but the problem has grown. Few of those dependent on opiates for example get clean within a year of entering services and most working in the services appreciate that their patients using methadone or buprenorphine are unlikely to get cured of their dependency. Studies suggest only 2% to 5% get clean within a year. Substitutes do not provide the rewards heroin does but reduce withdrawal (and blocks heroin when combined with naloxone) meaning those taking substitutes can live reasonably productive lives and that is an important outcome. But many relapse and some are reluctant to move away from their drug of choice.
A few years ago I attended Addiction NI’s 40th Anniversary event and I was impressed by the strength of the advocacy on behalf of dependent users. Families, advocates, agitators and service users had lots of criticisms of the current services. An emotional presentation from the CEO of the charity “Anyone’s Child” told the personal and tragic story of her son who died of an “unnecessary overdose”. Her son did not want to use methadone and was trying “heroin assisted recovery” but the system did not accommodate him and so he was left to use heroin of unknown strength supplied by dealers and he had to do so unsupervised. He died of a batch of heroin that was too strong. With the wider availability of fentanyl this has become potentially a greater problem.
What she was referring to is now called Heroin Assisted Therapy (HAT) and is the next step in the harm reduction reframing of the opiate epidemic. Scotland has introduced HAT in a limited way in Glasgow and the Scottish Government has long opposed the insistence of the UK Government to retain the legislation that technically makes HAT illegal. We in N. Ireland are moving this way too and I would predict a HAT service in Belfast in coming months as our drug problem has, with recent deaths in the city centre, reached that level of moral panic necessary to support the next step.
I read Theodore Darlrymple’s book Romancing Opiates when it was first published back in 2008. A retired GP with prison work experience Dr Darlrymple offered, back then, an interesting if not simplistic view on drugs and their abuse in modern society. Drugs are not bad he claimed; its people’s behaviour that’s bad. Whereas there might be evidence that people in methadone services commit less crime the evidence he presented indicates that they are still prone to commit crime. Crime does not necessarily stop it just lessens.
In short his thesis is that people, particularly men, do not commit crime because of a drug habit; their propensity to criminality existed before their drug habit began; indeed a propensity to criminality leads to drug experimentation and abuse in the first place. Those who are drug dependent in general, he suggests, are people who abuse the social system to their own gain; they find it easier to be victims of social injustice than finding ways to help themselves. They complain of horrific withdrawal symptoms if they do not get a fix when in fact symptoms of heroin withdrawal are similar to the symptoms from a bout of flu. In a healthy individual this is unpleasant but hardly life-threatening, he asserts.
Addiction, according to Dalrymple, is a social construct that drug users create to ensure continued drug supply and social workers use to keep their jobs and social status. No, he declares, we need to keep the criminal focus on heroin abuse and not support prescribing in “shooting galleries”. His extreme view is that all harm reduction service should be closed down and investment made to support GPs deal with the emerging clinical needs of dependent patients.
Dalrymple’s views are too extreme for my taste, but I do remain to be convinced of the merits of HAT and perhaps time will demonstrate that. How well HAT worked in Portugal and the other European countries now providing this service depends on who you ask. We have moved far into the harm reduction reframing of opiate use and I wonder if we will reach a point where harm reduction becomes public endorsement for the very problem it is trying to address. Advocates will always, off course, say that HAT is only for the treatment of those who are dependent and not heroin on prescription.
I am a pharmacist in Belfast.