More putting out fires with petrol:

There have been many press reports this week of the recent "discovery" that Dihydrocodeine, in the form of DF118's, is at least as effective as Methadone in "treating" opiate dependency. This is no discovery at all - all the addicts that I have mentioned this story to have yawned politely and made comments like "now tell me something that I don't know".

Of course any opiate or opioid drug will serve to assuage the symptoms of opiate withdrawal - whether or not giving an opiate user such a drug constitutes "treatment" is another matter. It seems that if a doctor in a drug service hands out Methadone for example then that is "treatment" - providing of course that reams of paperwork have been filled in and certain procedures have been followed.

If an addict was to buy the same amount of the same drug on the street - then this constitutes dealing and the supplier is liable to lengthy prison sentence - up to life imprisonment in fact!

In other words if a doctor does it then it's treatment, harm reduction etc and a good thing but if I do it then it's a very bad thing. Of course the addict's body would not differentiate between the "good" methadone and "bad" methadone - it would react exactly the same and the effects would be the same.

Coming back to DF118's - Doctors in the UK seem more than happy to hand this medication out like sweeties, I can remember doing a straw poll in a prison where I worked that showed that the incidence of back pain requiring Dihydrocodeine was around 20 times the expected average figure in the community.

On one hand these were young men in their 20's and 30's on the other hand many of them had a long history of drug dependency, however they all knew that Dihydrocodeine was an opiate type drug and they were not taking it to treat their addictions either, more to feed them.

The fact is that these drugs have changed hands on the streets for many years - with most of the supply being diverted from legally prescribed sources. Addicts have known about this, so have many drugs workers, counsellors etc.

I find it rather alarming that a "scientist" discovers what has been obvious to everyone else for years and suddenly it's a newsworthy piece of "new research".

So much for learning from our clients.

Yoof of today!

We definitely seem to have entered the silly season in the run up to Christmas. In the past week I have received several inquiries from the press who all seem to think that I must have some kind of crystal ball or arcane knowledge about "young people". I have been asked about young people and AA/NA - “is it trendy for young people to go to 12 step meetings now that Lindsay Lohan has admitted that she is going to meetings?”

Who cares if it is “trendy” or not, they are missing the point – its about saving lives, not fashion! Is coronary care trendy? Are A & E departments trendy? I have to ask myself what kind of rarefied atmosphere do these guys live in? Have they put something in the water in Wapping?

Lindsay Lohan is living in California, I live in South Yorkshire. Young people in California do lots of things that haven't caught on over here – surfing for one – and there are huge cultural differences in the way addiction and recovery are viewed over here and there.

The end result is that young people do go to AA/NA meetings in the US – especially California, while over here in the main they don't.

Most “addicts” seem to turn up in NA at around the age of 30 and it's around 40 for AA. There are of course exceptions to this rule.

I believe that one of the causes of this is the marked reluctance on the part of treatment providers in the UK to properly diagnose alcohol and other drug use in young people.

In the main the attitude seems to be that alcohol and other drug use is symptomatic of developmental problems rather than a condition that requires proper diagnosis and treatment in it's own right. In fact there are very few services in the UK providing proper addiction treatment for “young people”. Our very politically correct practitioners prefer to treat the age rather than the disease.

Then I would say that wouldn't I? I am a grumpy old addict after all!

The next magic bullet.....

There were several interesting news stories this week:

On Thursday The Guardian run a story reporting that the total social and economic cost of class A drug use is around £15.4 billion a year. The research was commissioned by the Home Office and also reported that 90% of this cost was accounted for by drug related crime.

The Guardian followed this up on Friday with another story which reported that the UK has 327,426 "problem drug users" and that the country spent £5.9 billion a year on illegal drugs.

These figures again came from the Home Office.

What is going on here - there are supposedly 181,000 people in "structured drug treatment" in England and Wales (NTA figures).

This represents around 55% of the Home Offices "total number of problematic drug users" (if the numbers in treatment in Scotland and Northern Ireland were taken into account the figure would be even higher!)

Sorry - but I don't believe a word of it! All the research that I have ever seen suggests that the percentage ""in treatment" at any one time is not likely to be more than 25 to 33 % of the total. If the governments research is right then they aren't commisssioning very effective treatment are they ? I mean if a minimum of 55% of all problematic drug users in the UK are in treatment and its still costing £15.4 billion?

Last year we were being told that each £ spent on drug treatment produced savings of £9.50. On this basis we need to be spending say an extra £1.5 billion a year - on top of the roughly half billion already spent. That would represent a 400% increase!

Spend £2 billion a year and the total cost in theory comes down to zero. Yeah well, thats not going to happen anyway - and it wouldn't work if they did spend the money because there will always be "treatment resistant" individuals.

Interesting to compare the Governments expenditure on drug treatment to the cost nevertheless. Interesting to see that we spend 10 times as much on illegal drugs as we do on treatment!

My final news story of the week was widely reported - the suggestion that we ought to consider prescribing heroin instead of methadone. A senior policeman suggested that this would reduce drug related crime - and guess what, he is right! He is after all a policeman, and it his job to reduce crime.

I suspect that this would be even more successful than he thinks - for one thing the bottom would fall out of the drugs market as the dealers could not compete on price and quality against the NHS!

My job however has always been about treating individuals rather than finding solutions to social problems such as crime and from the treatment point of view I would predict the following:

1. The numbers seeking treatment would greatly increase - many users do not seek treatment because they don't want methadone, it doesn't do what they want it to do. Many users who receive methadone on prescription use on top - for the euphoria that heroin provides and methadone does not!
2. Not many people would ever complete treatment "drug free" - although perhaps a few more would than now as the withdrawals are reconned to be less severe!

Either way don't for a moment believe that the Governments aim is to provide quality treatment for the individual - it isn't and hasn't been for a long while now.

It is to save money, to increase its popularity by reducing crime and to reduce the spread of blood borne viruses associated with drug use into the general community.

They really don't care if individual addicts sit in a corner and dribble while life passes them by if that is what it takes to achieve those goals (which are legitimate goals by the way - but not the only ones!)

To this end I suspect that prescribing heroin will be the next "magic bullet" which is going to achieve these goals!

We have now gone full circle and are rapidly coming back to the point where we were in 1966 - in 40 years there are now around 200 times as many heroin addicts as there were last time that prescribing heroin was official policy.

Prisons and Compensation

I wonder how far back the time frame is for making claims against the Home Office for being forceably detoxed from drugs on admission to prison?

Your author had this happen to him on 5 or 6 occasions while he was using drugs himself. Personally I believe that if I had received the nearly £4,000 compensation that the Home Office has paid out to nearly 200 individuals I would have used it all up on drugs on release and would have probably have killed myself in the process!

I would be interested to see how many of the recipients of this compensation end up dead within a month of receiving their money or their discharge from prison - whichever comes first.

Although this is not a laughing matter I have to admit that I would smirk a bit if their relatives were then to sue the Home Office for gross negligence - I think that most people who know anything about addiction could have told them that giving large sums of money to a using addict is asking for trouble. Like giving them a loaded gun.

Apart from all this I would like to clarify my position on this issue:

I have no problem with the idea of providing addicts (whether to illicit or prescribed drugs) with a proper, medically supervised detox on admission into prison. I do have a problem with the idea of maintaining addicts on methadone while they are in prison. This idea has only come about because some bureaucrat within the NTA and/or the current UK drug treatment mafia decided that giving addicts drugs equals treating addiction. Certainly the figures for those in treatment would show a dramatic fall if all those individuals who are merely given drugs that help maintain their habits were removed from the statistics.

Apparently the individuals concerned also objected to being subjected to "drug treatment programmes" while in prison - they were apparently treated against their wills and this was aginst their human rights!

A little bit of clarification would help here:

Prison drug treatment programmes in England are actually accredited as "offending behaviour programmes" rather than addiction treatment programmes.

Personally I have never liked this as I happen to think it makes for bad addiction treatment which should be about sick people getting well, not bad people getting good - although I also believe that the offending behaviour will inevitably be looked at in the course of any effective treatment programme.

For so long as prison drug treatment are accredited as offending behaviour rather than addiction treatment programmes however then fine, give the prisoners the right to decline them. However the consequence of refusing to do an offending behaviour programme - be it drug treatment, a sex offenders programme, anger management, Enhanced Thinking skills etc - ought to be loss of all priveledges, home leave and parole! We all have a right to make choices in life - but our choices always have a price attached! Why should this be any different?

Personally I can't wait for all the alcoholic prisoners demand parity!

Free booze for all prisoners who can demonstrate an alcohol problem prior to coming into prison! Now there's a thought - the Home Office are discriminating against alcohol addicts!

National Treatment Agency for policy abuse

I have recently been sent an e mail about a forthcoming one day conference in Leicester about future arrangements for Residential (tier 4) treatment here in the UK. All official statements are now pointing to the fact that it is now policy to improve access to residential treatment.

The government’s initial "bright idea" was to give large sums of money to the NHS to open new units, this might sound like a good idea until you realize that all the existing units have empty beds. The Problem is not so much one of capacity as of commissioning arrangements. Whether one gets residential treatment here in the UK seems to depend on several factors, most of which are financial rather than based on any real assessment of clinical need.

The process takes so long and is so convoluted that there are no doubt deaths each year because of either the time it takes or because individuals are so put off that they don't even bother to try to access residential treatment.

I could go on about this - but what struck me about the flyer was that the NTA were asking me to donate a day of my time and pay £165 for the privilege of helping them to save money! As a consultant in the field who actually has many ideas as to how the system could be improved I find this attitude patronizing. Just what sort of business do they think we all run? Do they really expect hard pressed, highly skilled professionals to pay to have their brains picked?

The biggest block to progress here in the UK is the fact that all policy is ultimately driven by political considerations. The NTA and the UK government are only going down this road now because all their previous attempts at "quick fix" treatment approaches have failed dismally and they are now desperate to achieve some real outcomes rather than ending up with 10% of the UK population on methadone for the next 30 years!

Evidence Based Treatment

Evidence based treatment.... how often do we hear the phrase and what does it actually mean? It is supposed to mean that treatment is based on "what works" and that "what works" has been scientifically validated by research. However.....

Here in the UK we consistently ignore evidence that does not suit the political agenda. There is a wealth of research on the effects of addiction on the brain - using various brain imaging techniques - that demonstrates that the effects that drugs have on the brain and which show that the human brain does not show signs of recovery until a considerable period of abstinence has passed. Without going into a small book this research has considerable imlications for the treatment of chemical dependency. Walk into 100 or so alcohol and/or drug agencies up and down the country and ask if any of the staff are even aware of this research and you will find not.

This week an American psychiatrist was quoted as saying that the brains of compulsive gamblers also show similar abnormal scans and it is also a known fact that Naltrexone has been researched in the US as a potential treatment for compulsive gambling.

We also know that there is a distinct correlation between the availability of "addictive" substances and behaviours and the number of people exhibiting problems. Do we take all this evidence into acount? Do we hell - it just doesn't suit the governments agenda! Lets roll out 24 hour drinking and loads of casinos. Then act suprised when the number of people with alcohol and gambling related problems goes up! It will, the all the evidence predicts that it will - but we will ignore the evidence when it doesn't suit us!

Consider the so called "assessment" of individuals with alcohol and other drug related problems. There is a wealth of evidence that shows that there is substance use, substance abuse and substance dependency. The evidence also shows that these are distinct conditions with distinct needs in terms of treatment. Do all alcohol and drug services then actually sit down and diagnose which of these groups an individual falls into? No most do not, and consequently most treatment is inapropriate not to mention ineffective. Why is this? Because dependency requires intensive skilled (and often residential) treatment and the system is generally speaking not geared up to provide this.

It is easier for services to train staff to deliver MET or SFBT (it requires a short 3 day course in many peoples eyes!) than it is to train staff for the year or so required to deliver abstinence based services.

Don't get me wrong - I have nothing against Motivational Enhancement Therapy or Solution Focussed Brief Therapy - with the right individuals at the right time there is no doubt of it's effeciveness. For the rest of the client group however is a sentence to failure and dissilusionment with treatment.

Lets carry on then, blame the clients when treastment fails and concentrate on what is usually economics rather than the real evidence!