Wednesday, September 16, 2009

Drugs 'r bad, M'kay!*

Except when they're good. Some can be both. I've recently been asked by a friend for a response to the suggestion that we import Swiss style "Shooting Galleries" to the U.K. for injecting heroin users. I have to start by admitting absolutely no expertise in this area, but some experience in caring for drug users working towards withdrawal trough the substitution of methadone or subutex for their heroin. I'm also a big fan of it personally** for its proven role in pain control.

So, all that said, what about these shooting galleries then?

The answer I'm afraid, is complicated. Taking it one step back for a moment what about injecting users then? What do we know, and what have we been taught to believe?

We know it's bad. It must be, after all it's against the law and has been like forever hasn't it? Well not quite, only really from about 1920, and only a "Controlled Drug" in Blighty from around 1971.

Well O.K. it must be really bad for your mental helath yes? Well perhaps, though probably a lot less so than amphetamines and later "mood enhancers". All the punters I've seen with drug induced psychoses have been using amphetamines.

But it kills people! Well yes, no arguing with that, but because of prohibition we have only the sketchiest guesstimates of how many heroin users there are, so we can't say how many as a percentage, though instinct suggests its likely fewer than either alcohol or nicotine do. Overdoses are dangerous, but speak more to the despair and lack of hope that many users experience, of which their drug use if but one symptom. Inadvertent overdoses have happened when uncut drugs have been supplied, so that instead of a 90% talc (or worse) 10% heroin dose users have ended up taking 100% pure junk. Every avoidable death is a tragedy so arguments over relative risk seem specious in that context, but it probably remains the case that of all the drugs we chose for "recreation" heroin is a long way off being the most harmful.

The reality is that prohibition has created a lot of the problems we face right now. Heroin is addicting. To feed a habit costs money, but to have a lifestyle acomodating heroin is likely to imply a level of chaos that precludes a high or regular income. Hence to feed the habit users either deal or steal. Then we catch them and lock them up with dozens (or hundreds) of other dealers and stealers, so they learn how to do it "better". To keep them sweet we turn a blind eye to their continued use in stir-- after all at least they're off the streets, and heroin won't make you violent...

Then there's the "once a user always a user" myth. We have a number of users who have successfully quit not just injecting, but all illicit drug use. The trick is to "normalize" their care so they can be seen in the surgery without all and sundry knowing what they are here for. With a good rapport, a clear prescribing policy, and a willingness to accept change we can make opiate use so boring that clients will glady turn their backs on it, sometimes just for a time, but sometimes for good. Attending our surgery and not a "drug service" is a door back into the mainstream for some and it's this as much as the methadone substitution that gives them the push to move on with their lives and break out of the loop.

So, shooting galeries then?

Well on the plus side we get controlled dosing, reliable and affordable supply, sterile technique to avoid the harm of unsafe injecting and even perhaps a way in to accessing services for may users who are at present excluded precisely because they are "choosing" to continue to inject which will rule them out of admission to the vast majority of rehab systems.

On the minus side we get state sponsored addiction, less pressure to end a demonstrably harmful habit and a system likely to be too rigid to allow the chaos that is the lot of many current injecting users.

Were it to be made to work it could do a lot of good. The U.K is not the C.H. any more than it is the U.S.A. and any attempt to import techniques from another culture needs a lot of thought, but it appears on balance to be an import worthy of consideration.

* time to revive the tradition of the Virtual Chocolate Hob Nob for the first correct attribution.

** but not "personally" obviously.


hypotemuse said...

Thank you for responding in such detail and thank you for sharing your knowledge and insight. I've certainly learned a few things I wasn't aware of.

The Swiss policy on drugs is based on prevention, harm reduction, therapy and repression (in that order). It was put in motion as a pragmatic rather than ideological response to the open drugs scene in Zurich, Bern and other Swiss cities in the 1990s. Z├╝rich's "needle park", e.g., in plain view of the railway station, was notorious. (A stain on oh so staid oh so clean oh so perfect CH.) The police strategy at the time was control and damage limitation.

We voted a couple of years ago to continue the prescription strategy, which was initially introduced as a ten-year trial. It had widespread political support across the spectrum. All but the very small ultra-right-wing/religious parties were in favour. Fact is: it *has* reduced the number of drug-related deaths and allows addicts who have failed methadone-based therapies behind them lead relatively normal lives and hold down jobs. Not every heroin addict is suitable for the prescription scheme - as far as I'm aware, it's reserved for a minority of "hopeless" cases with one or several failed withdrawal attempts.

So I agree, state sponsoring of addiction can never be something to strive for, but it's reality for a few and a huge improvement on the system we had before.

Earl Grey is my poison, by the way. Tried to snort it once... what a bloody mess!


ageing student said...

South Park?

alhi said...

Mr Mackey in South Park.

Doctor Jest said...

Hypotemuse-- happy to be of service. Harm reduction is supposed to be our aim here too, with needle exchanges long established and extensive Methadone programmes, just not supervised injecting or prsription injectables. AS for the idea of a TEN YEAR trial we can only dream of such things. Here if an initiative doesn't deliver in 12-18 months the DoH can't resist fiddling, and all mentions of the D word sends the entire political class into a monumental blue funk.

A.S-- EVHN to you sir and well done.

alhi-- Also proud winner of an EVHN for supplying Mr Mackie in person. Well played.

Nostrumdammit said...

May I just say that I have no axe to grind here at all, but I agree with Dr J. I'd like to go several stages further and legitimise all recreational drug use. I feel certain that if supply of substances at the right dose, in the right formulation, could be made safely and in a regulated fashion from appropriate premises under careful supervision and reglation with a suitable tax levied to provide said supply and support services. That way we would de-mystify the black art. There would be no stigma and greater openness to treatment. Access could be more controlled for the vulnerable & stupid. Theoretically crimes to support the habit would be reduced.
If we are indeed living in liberal times, we need to move to protect the libertines from themselves by letting play their dangerous games in as safe a manner as possible and reducing potential harm to our liberal communities.
Having worked closely with methadone patients at the sharp end of service delivery, I have seen all aspects of the user spectrum. It's very heartening when a chaotic life is rendered stable by daily or weekly support and a wee chat with old codger down the chemists. It is equally infuriating when slovenly ne'er do wells in their Burberry Chavgear continue selfishly and oafishly disturbing the lives of those around them. But it's all worth it when one sees success. If shooting galleries set users on the road to success - then I vote for 'em!
Things are going to get considerably worse as police and customs resources are cut to pay for civil service and govt pensions in the coming years. So we might as well start dealing directly with the cartels and tidy the whole place up somewhat whilst dragging in some revenue.
If people continue to make silly decisions outwith the system of control and care then Darwinian natural selection should be left to run it's course. Not that I'm suggesting a cull...or am I?

ageing student said...

I guess gender can only be guessed at when using noms de plume, but I have to advise you that A.S. is not a sir. However, I am pleased to accept the EVHN in the spirit in which it was offered and would like to thank everyone involved in its production.

Doctor Jest said...

Nostrum'-- thought provoking (and slightly scary) stuff there, but I do agree taking a small part in turning a life around can be worth all the strife that attends. We may have to agree to differ on the cull proposal though :-0

A.S. A thousand apologies. I'm suitably mortified, but in my defence it was late and dark and you were backlit.... I'll try not to do it again. Sorry :-(

Nostrumdammit said...

Dr J...sorry about the cull comment. It was just the port talking. I would never countenance the indiscriminate taking of lives just because certain tranches of the population had become inconvenient. That's why I served in the last conflict. Unless of course there's some other way to deal with NHS middle management?
Glad that you found some of it scary. Unless there's a challenge - we do nothing and good people get harmed. Both in war and peace. Philosophically speaking we are in a state of tension between the two with so many of society cheated of the option for peace due to various reasons. Sad, when one considers that we have the resources for all to enjoy life in some measure or other.
Sorry Dr J - I think I might actually be sober!

Doctor Jest said...

Nostrum'-- "I think I might actually be sober!" Which Heaven forefend! Srsly tho' don't worry I took your comment in the spirit it was intended, and our present entrenched and failing approaches need challenge. Keep up the good work!