Dr Michael Fitzpatrick
The drugs campaign - just say no
'All statistics are imperfect, but those related to drug use are egregiously bad.' This judgement by a commentator on the US drug debate in the 1980s would seem to apply even more forcefully to the discussion in Britain around the government's recent White Paper, 'Tackling drugs to build a better Britain'. Every newspaper and television report features the results of surveys revealing shocking levels of exposure to drugs among schoolchildren and terrifying estimates of the scale of crime related to drugs.
Cursory inspection suggests that these statistics are about as reliable as the police's inflated estimates of the street value of their latest seizure. Claims for the effectiveness of drug prevention and treatment programmes, when they are not simply asserted, rely on similarly spurious figures.
Now over the 20 years or so I have been in practice, I have been conducting my own research into the drug problem. My (statistically rigorous) conclusions are as follows: 1) There are quite a lot of drugs about and all sorts of people take them, mostly recreationally without much harm, while some pursue a self-destructive course. 2) Though there have been significant shifts in the patterns of drug use (the rise of crack and Ecstasy, the decline of solvents, barbiturates and amphetamines) and there are marked local variations and passing fashions, I doubt that overall there has been a major increase in consumption. 3) Prevention and treatment programmes are worse than useless.
As the first point is self-evident and the second highly subjective (just like the official assessments), I'll concentrate here on the third.
In its editorial welcoming the drugs White Paper, the British Medical Journal particularly endorsed the government's commitment to pursuing an 'evidence-based' policy (9 May). It then proceeded to admit that evidence for the effectiveness of the preventive measures proposed - including drugs education in primary schools - 'is unfortunately weak'. In fact, much evidence suggests that such activities are ineffective, if not counterproductive.
In an account of the launch of the 'Heroin screws you up' publicity campaign in the 1980s, Robert Power has detailed the 'apprehension and misgivings on the part of professionals in the drugs field' who feared that it might provoke imitative behaviour and 'increase the prevalence of drug misuse' ('Drugs and the media' in Drugs and British Society: Responses to a Social Problem in the 1980s, ed Susanne MacGregor). The fact that the campaign poster subsequently became a popular feature of druggy bedsits suggests that these fears were amply realised.
As Power indicates, this problem has long been recognised in the USA, where 'decades of prevention campaigns have been seen to result in "boomerang" effects': 'The anti-chewing tobacco drive of the 1900s contributed to an increase in smoking; the anti-barbiturate campaign of the 1940s led to more widespread use; and the anti-amphetamine programmes of the 1960s alerted a new generation not only to the perils but also to the pleas-ures of the drug. More recently, anti-cannabis, LSD and glue campaigns were all followed by an increase in use.'
The drive to impose anti-drugs propaganda on schools is based on some elem-entary misconceptions. Young people do not take drugs because they are ignorant of the dangers, but to get high, irrespect-ive of, perhaps even because of, the dangers. Telling them scare stories will not put them off; on the contrary, it will encourage them, partly because they don't believe them, partly because they want to defy authority and partly because they relish taking risks.
The other arm of the government strategy is to encourage GPs to prescribe substitute medications such as meth-adone for heroin users. The aim of this policy is what is known as 'harm reduction', reducing the harm to the individual from injecting drugs of unknown quality and reducing the harm to society caused by the (sometimes criminal) activities required to raise the necessary cash.
My experience of prescribing methadone - and that of most of my colleagues - is close to 100 per cent failure. I think this is because of two fundamental problems with the substitute medication policy, one relating to motivation, the other to addiction.
When somebody asks to go on a methadone programme, it is customary to judge their suitability for medication by assessing their 'motivation'. In fact this is superfluous, because the very fact that they have presented the problem in this way confirms that their motivation is to continue taking drugs rather than to stop taking them; they simply want to continue in a different way, getting less of a high perhaps, but also getting less hassle. The high level of conflict in relations between GPs and junkies often arises from this basic confusion: while the GP thinks they want to stop, the junkie just wants to continue.
The second problem follows from the endorsement of the concept of addiction. Whereas heroin is generally considered to be highly addictive, methadone is not. Yet people who consider themselves addicted to heroin are quite capable of becoming addicted to methadone, or even relatively minor analgesics like dihydrocodeine or coproxamol, which are not regarded as addictive and have only slight narcotic effects. This suggests that the pattern of behaviour associated with drug addiction is socially conditioned rather than being bio- logically or pharmacologically determined.
When I come across people who have taken drugs like heroin in the past, sometimes for quite long periods, I often ask them what made them stop. It turns out that this is rarely the result of drug treatment programmes, 'detoxification' or 'rehabilitation', but usually follows some wider change of lifestyle prompted by a new partner or a new job, a spell in prison or by simply getting bored with the drug scene. This confirms that when people really decide to stop, they just stop and often report relatively little difficulty with the familiar problems of physical and psychological dependency.
My conclusion is that the way forward lies through both decriminalising and demedicalising drugs. If teachers taught children something interesting, doctors treated people who were sick and polit-icians got on with running the country, instead of all interfering in matters about which they know little, maybe fewer people would seek escape and solace in drugs.
Reproduced from LM issue 111, June 1998