It’s time to rethink drug addiction treatment

Health news has, unsurprisingly, been dominated by Covid and its terrible consequences over the last couple of years, but so many other health conditions have been forgotten or overlooked. As waiting lists pile high, no one is further down the agenda than those who many believe have brought their problems upon themselves: drug addicts.  

Dying alone

Whilst many were shocked and saddened by the idea of Covid patients dying alone at home during lockdown, with no one checking in on them, the truth is that this has been happening to many heroin addicts for several years now. Others are found dead on the streets, the forgotten homeless. Our prisons are full of drug addicts, with heroin proving an attractive way to get your hit since it has a far shorter period of detectability within the body than, say cannabis, making it easier to appear “clean” when drug testing day comes around.  The Random Mandatory Drug Testing programme (RMDT) randomly tests 5-10% of prisoners every month to monitor the problem. 

News broke this morning of an investigation by LBC into the issue of drugs within prisons.

“LBC discovered that dealers have been profiting from the exploitation of the prison remand system. They’ve been paying convicts released on license as much as £1,000 a pop to commit a crime and get sent back to jail, so they can smuggle drugs, weapons and miniature mobile phones back inside with them.

Figures obtained by LBC show at least 12,500 ambulances and paramedic cars were sent to prisons in England in 2019 and 2020. More than 200 of those were because of an overdose or a stabbing.”

https://www.lbc.co.uk/news/criminal-gangs-profit-prisons-hmp-lincoln/

Drugs and crime

Whilst it’s easy to write drug addicts off as having self-inflicted woes, it’s harder to wave away the effects of drugs on our society and the associated crime. Most people solely think about the level of crime committed by a single, addicted person in terms of shoplifting or burglary to fund their habit, but a striking amount of other crime is involved and connected with the sale and use of illegal drugs. A large amount of violence is committed between rival drug dealing gangs and against users who owe them money as well as further violence committed whilst under the influence of drugs. Whilst the legal drug, alcohol, is most commonly associated with domestic abuse, manslaughter, murder and serious injuries, drugs are often involved, too. In 2019/20, the police recorded 175,000 drug offences, which was an increase of 13% on the previous year 2018/19.

In October 2020, a briefing paper was published by the House of Commons detailing the effects of drug crime in England and Wales.

The data within it shows that deaths related to drug poisoning are increasing ye=,.ar on year. A 66% increase has been seen from 2011 (2,652) to 2019 (4,393) but 2017-2018 was the biggest increase in deaths – a 16% rise. 

A public health issue

As per the House of Commons report, “drug misuse is often accompanied by mental and physical ill-health, making it a public health concern.” This was a sentiment echoed by Laura, 38, from Peterborough*, who noted that the majority of addicts she has known since she first started taking drugs, in the 1990s, were already struggling with some kind of mental illness. Laura, who happily describes herself as a former junkie, (“a term we used as a bonding word, it was affectionate camaraderie”), said she was a typical moody teenager who felt lonely and isolated after a relationship breakdown. She was at university, one of the few women on her course and quickly made friends with a male neighbour who was doing the masters version of her course. Before long, he was posting prozac through her door, having already been through detox but failing to stay clean since he simply left rehab to return to the same life, friends and surroundings he had occupied whilst using.

Laura “had a car and money”, which meant she had the means to source the drugs that fuelled their friendship. What, I asked Laura, did she make of the warnings that abounded around heroin use? Was she not worried about what might happen; that she would become addicted? The problem was, she said, that the warnings initially felt like nonsense. So many of us have bought the idea that heroin addiction is literally instant – that you spend every time after your first “chasing the dragon”, trying to replicate the first time you ever took the drug. When that absolutely instant addiction never really materialised, Laura assumed it was just scaremongering bullshit, that she could safely ignore. “It was the 90s”, she laughs, “heroin was cool in the 1990s”.

For the first six months, she explained, everything seemed fine and she could use it when she liked with seemingly no ill effects. Until, one day, things change. “One day you notice you feel shit, you have cold symptoms and then you use a day later and feel better. Before long, you realise that the the drug makes you feel better. If you’re stressed, busy, on a deadline, etc, you can’t take a few days off to recover, so you feed that physical addiction once again and before you know it you’ve postponed for another six month and boom, you have a full-blown addiction.” 

Which treatments work… and which are available?

When you’re taking a range of different drugs – Laura explains – like crack cocaine for example – you soon learn what other drugs help to counteract the worst side effects. So you end up with a total dependency on two or more. 

Our current policy on drug treatment for those who are dependent on drugs to function just isn’t working – the statistics on drug-related crimes and the deaths associated with drug misuse and drug poisoning demonstrate this. Laura, who has been clean for just under 10 years, has seen a lot of change in drug treatment policy since she first sought help for her addiction. Back then, there were “much greater modalities of prescriptions available”. So she was able to be offered injectable forms of replacement drug therapy as well as tablets or if you could not stick with the methadone offered, you could be prescribed morphine, which she says is more suitable for some addicts. Now addicts are solely offered methadone or buprenorphine tablets. 

How do the treatments work?

Many drug treatments for heroin addiction are based on still giving the brain the opiates that it has become dependent on, but without the accompanying euphoria that heroin gives. The treatments therefore stop the withdrawal symptoms that make addicts feel so unwell and stops the cravings. 

Other treatments, with combined drugs, are based on blocking the euphoric sensations that taking opiates produces, as well as stopping withdrawal and cravings. One of the drugs willl “sit” in the brain’s neuronal receptors and therefore block chemicals from entering the brain, should other opiates be taken afterwards. They are similar to the stomach implants (Antabuse) that are given to alcoholics that stop them drinking in that the pleasurable aspects of drinking are prevented (usually as the implants cause the drink to be expelled via vomiting or that the side effects of alcohol are intolerable).

Barriers to getting clean

However, Laura explains, drug treatment is not easy to get into these days. A month or two waiting list can be the difference between wanting and being able to enter treatment or things sliding even further into despair. Having detoxed 10 times, Laura has a rounded understanding of what makes for successful treatment and today’s methods are seriously wanting. When you first start drug treatment, she says, you must do so in the presence of a pharmacist – on a daily basis. It’s called supervised pick up and not only is it humiliating – but for some it’s a major barrier to completing treatment. One of her friends lives almost 3 miles from his local pharmacist and with no transport of his own, he’s failing more often than he’s succeeding in staying away from the drugs he’s compelled by his body to take. Were he able to wake up in the morning and take his medication with his breakfast in his own home, she argues, rather than traipsing to the pharmacy for opening time in all weathers, he’d likely to be far more successful. What’s more, this regime really impacts on the ability of someone who might currently be a “functioning addict”, requiring help, to remain so. After all, not all heroin addicts are homeless shoplifters – many of them are hiding in plain sights within offices and working in our shops. Daily pick up regimes and the waiting lists are just two major barriers for someone with a modest addiction to recovering instead of spiralling into someone with crippling debt, tempted into crime and at risk of losing all they have. 

A woman contemplates her syringe

Doomed to fail?

Whilst methadone is the preferred treatment for medics to prescribe, it’s far from popular with addicts, who complain it makes them fat, constipated, dull and sleepy; more symptoms that are hard to live with when you’re also battling with your will, cravings, withdrawal and the mental health issues that led you down the pathway to addiction in the first place. Laura’s argument is that drug treatment programmes are also doomed to fail due to their aim to get people off any drugs as fast as possible, without treating the underlying causes and the social difficulties that are also involved in the problem. Sorting the withdrawal symptoms and cravings is just working on the last symptoms of the underlying issue. Drug users who relapse are often doomed to do so by circumstance, location and opportunity, something that isn’t changed by turning up at their local Boots pharmacy on a daily basis to take their meds in front of a pharmacist that Laura says “usually hates drug addicts”. What helped Laura finally succeed in drug treatment was hauling herself out of the hole when she was stable on treatment – time that often current addicts aren’t given the luxury of affording. Daily, supervised pick up destroys any possibility of being a “functioning” addict and the prospect of working life. Before you take the stabilisers off the bike, she says, let the addicts learn to cruise a little.

According to one Independent article, other countries have looked to our past to help treat their addicts. From 1926, to 1967, drug addiction to heroin and cocaine was not a massive problem as those who were struggling with addiction could seek treatment from their GP. Prescribed diamorphine, medical-grade heroin, these addicts could remain stable and their addiction was treated as a medical issue rather than a criminal problem. By 1960, drug addict numbers were under 500, between 1936 and 1953, it fell from 616 to 290. 

“Aging cohort of drug users”

In August, the BBC reported that “drug deaths in England and Wales highest since 1993”. ONS figures were used and the ONS suggested “the increase could possibly be down to an ageing cohort of drug users suffering from the effects of long-term use, as well as new trends in taking certain drugs – including gabapentinoids and benzodiazepines – at the same time as heroin or morphine.” https://www.bbc.co.uk/news/uk-58070848 

This original system does remain but very few addicts can access it – less than 300 people are estimated (based on 2017 FOI request) to currently use legally provided diamorphine.

“While more intensive than methadone, the drug is more successful at keeping people in treatment and away from street drugs, and can be a lifesaving tool for a small percentage of entrenched heroin users.”

Pyramid scheme of addiction

Where drugs are prescribed to users by the state, there is no reason for drug users to introduce others to their drug of choice in order to pay for their own habit. There’s literally no requirement to add anyone to your warped “pyramid scheme” of drug addiction; you can get what you need and continue living your life, raising your prospects of finally reaching a place where you can get clean.

Indeed, it is even rumoured that the reason rates were low during this period between the 1920s and 1960s, was that organised drug gangs just could see there was no market for their wares. When you get your prescription from your friendly local GP, there’s no need to visit the murky world of drug gangs, build up a debt you can’t pay or commit crime to fund your addiction. What’s not to like? What compounds the difficulty today is the fact that waiting lists for substitute opiate prescriptions are so long, but, commit a minor crime and sometimes your prescription from the drugs workers in jail will come almost instantly. So crime really does pay.

Stigma kills

In Denmark, Laura says, they have “shooting galleries”, places where you can go to get clean paraphernalia to help you smoke or “shoot up” your drugs in injectable form. They have nurses to check your injection sites and provide healthcare like vaccinations and vitamins as well as a friendly face. The stigma just isn’t there and it’s treated just like any other health issue. Stigma is one of the biggest barriers to treatment, too, she says and it almost meant death for her, too. It’s not just the difficulty of admitting the problem, it’s what having your addiction on your medical file might mean. Suspicion if you come into hospital needing treatment, what you’re given when you’re genuinely in pain – what treatment you receive for a litany of medical issues will all be coloured with addiction-coloured glasses. 

As a moderate amount of heroin is now more affordable than a pack of 20 cigarettes, deaths attributable to drug poisoning and drug misuse are rising year on year and the fact of the hundreds of associated crimes, it’s time to think seriously about revisiting our history. 

*interviewee’s details changed for reasons of privacy

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