Pubdate: Mon, 05 Sep 2005
Source: Herald, The (UK)
Copyright: 2005 The Herald
Contact:  http://www.theherald.co.uk/
Details: http://www.mapinc.org/media/189
Author: Neil McKeganey
Bookmark: http://www.mapinc.org/hr.htm (Harm Reduction)
Bookmark: http://www.mapinc.org/find?143 (Hepatitis)
Bookmark: http://www.mapinc.org/heroin.htm (Heroin)
Bookmark: http://www.mapinc.org/find?136 (Methadone)
Bookmark: http://www.mapinc.org/rehab.htm (Treatment)

WE ARE TRYING TO CUT HARM TO ADDICTS. WHY ARE WE FAILING?

A drug-addict death virtually every day of the year. That is the picture 
revealed in recent statistics from the Scottish Executive. Multiply every 
one of those deaths by a mother, a father, a brother, a sister, a husband 
and a wife, aunts and uncles and sundry cousins and friends and you have 
somewhere near the size of the tragedy we are facing in Scotland.

What is even worse is the fact that around half of the drug addicts in 
Scotland may be Hepatitis C and yet the deaths related to Hepatitis C have 
not yet even begun to show up in the official statistics. Those deaths we 
will start to see in the years to come. When you look at our addict 
population what you see is death hovering on the shoulder of tens of 
thousands of our young people. In the eighties, in San Francisco and other 
US cities, you could tell the gay men with Aids because the disease gave 
everybody the same ravaged, skeletal look. Now in Scotland we have the same 
uniformity in our drug addicts. All skin and bones and imminent death.

The Scottish Executive's stated goal in relation to drug deaths in Scotland 
is to bring about a 25% reduction in the number of addicts dying. There is 
simply no way we are going to achieve a 25% reduction in drug deaths. When 
Hugh Henry the deputy justice minister with responsibility for drugs was 
asked last week about the latest drug-death figures he said that he wanted 
to set aside the debate over the statistics and focus instead on the 
tragedy behind every individual death. A laudable sentiment, but 
unfortunately numbers count and the numbers are going up.

What does this mean for drug policy in Scotland? Over the past 10 years 
harm reduction has become the watchword of drug policy in Scotland. The aim 
of this policy is not so much to get addicts off drugs as to work with them 
to reduce the risks associated with their continued drug use.

There is nothing wrong with the theory of harm reduction other than the 
awkward fact that the reality of addict lives seems to be undermining it. 
When you see more than 300 addict deaths a year, getting on for 50% of 
addicts being Hepatitis C-positive, many thousands who are malnourished and 
similar numbers homeless and unemployed and many with mental health 
problems, you have to wonder what conceivable harm that policy is actually 
reducing.

A cornerstone of the harm reduction policy in Scotland has been to sign 
addicts up on to long-term methadone programmes. It is repeatedly stated by 
the Scottish Executive that no one approach to treatment works for all 
addicts. But we were told earlier this month that almost a third of 
Scotland's addicts are now on methadone programmes. Since only a fraction 
of Scotland's addicts are actually in treatment at any one time, this must 
mean that the vast majority of those in treatment are receiving methadone.

The level of methadone prescribing for heroin addicts in Scotland looks 
less like individually tailored health care and more like social problems 
prescribing on a massive scale. The budget for methadone in Scotland is now 
running at more than AUKP11m a year with no evident sign of it decreasing. 
The picture in England is depressingly similar with almost half of the 
AUKP500m drug treatment budget now being spent on methadone alone. There is 
a lot of money being made out of the drug problem in the UK and much of it 
is going to the companies making methadone.

Methadone is heavily promoted in Scotland, and in England, by doctors 
stressing that it is a route to creating stability in the addict's life. As 
it happens, it is also the drug that is associated with almost a third of 
all addict deaths in Scotland. Recently there was a massive award made 
against the drug company Merck because one of its painkilling drugs was 
found to have increased the risk of death of those arthritis sufferers 
taking the drug. In Scotland we find that a third of addict deaths are in 
some way connected with a drug that is being prescribed to them and we 
accept that finding with staggering equanimity. Why is that?

The supporters of methadone will tell you that the drug is helping addicts 
to commit less crime and lead more stable lives. They will quote the 
research studies showing that addicts on methadone do better than addicts 
on other drugs or those experiencing cold turkey. But is methadone helping 
these addicts get off drugs or is it simply maintaining them on another 
drug. Important as that question is, it is not one to which we have an 
answer at present because we have never even bothered to find out how many 
addicts are able to overcome their drug addiction through the route of 
methadone prescribing.

What we have done instead is to provide a highly addictive drug to a group 
of people with a known capacity to become drug dependent and we have not 
even asked whether it is helping them to get off drugs or simply adding to 
their addiction. And we have done that confident in the belief that addicts 
on methadone commit fewer crimes than those who are not on methadone.

But if that belief was correct we should now be seeing a massive reduction 
in crime in Scotland, given that almost a third of our addicts are taking 
the drug and most of the crime is committed by addicts. The reason we are 
not seeing a massive reduction in crime in Scotland is because the capacity 
of methadone to reduce addict crime is nowhere near what it is claimed to be.

The other arm of the harm reduction policy in Scotland has been to develop 
needle and syringe exchange services across the country. Within these 
clinics, addicts can get sterile needles and syringes. These services have 
worked well in reducing addicts' chances of getting HIV infection but have 
had miserable success in protecting them from Hepatitis C. The policy of 
harm reduction has not helped these addicts to anywhere near the degree we 
had hoped and it is right now to ask whether the policy of discouraging 
addicts from sharing needles and syringes is good enough. As unpalatable as 
it may sound, it may well be that the only way of reducing the number of 
addict deaths is reducing the number of addicts in the first place.

Stopping sharing is not good enough, we need success in stopping injecting. 
In much of our thinking about the drug problem in Scotland we have set the 
bar of aspiration too low. We have aimed to create stability in the 
addict's life when what we need to be working towards is getting them off 
the drugs entirely.

It is time to look critically at the policy of harm reduction not because 
the idea of reducing harm is somehow misplaced, but because we are so 
plainly failing to reduce the harms our drug users are facing. Do we have 
the right drug policies in place in Scotland? Are our treatment and 
prevention services the best they can be? Are we helping addicts get out of 
the addict lifestyle or are we maintaining them in it through the process 
of methadone maintenance. These are increasingly urgent questions.

Last year, Cathy Jamieson, the justice minister, announced her intention of 
setting up an agency which will provide oversight of our drug treatment 
services in Scotland. We need that agency now more than at any time in the 
past for the simple reason that we need the very best drug treatment 
services in Scotland. It is anybody's guess how close or far we are from 
that goal.

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Neil McKeganey is professor of drug misuse research at Glasgow University.
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MAP posted-by: Elizabeth Wehrman