Just Say No to this ‘radical rethink’ on drugs

After a two-year review of the drugs problem in the UK, a prestigious commission established by the UK Royal Society for the Arts (RSA) has come up with a ‘radical rethink’ aiming to influence the impending major government review of the National Drugs Strategy (1). Another current campaign against addiction – the ‘Get Unhooked’ TV and cinema adverts featuring smokers impaled on fish-hooks – reveals the prevailing contempt for those regarded as being in the grip of a chemical dependency that also pervades the RSA report (2).

The common theme is that the user of drugs (whether nicotine, heroin or alcohol) is an automaton, a being without intentions and unable to make choices, a physiological system that requires pharmacological correction. To pursue the official metaphor, the drug user is on a par with a fish, a level of vertebrate life so low that only the most fundamentalist of animal rights activists can be bothered to protest against fishing.

The ‘Get Unhooked’ adverts offer a powerful endorsement of the myths underlying both current drugs policy and the RSA’s radical rethink. These myths are exposed by Theodore Dalrymple, whose devastating critique of ‘pharmacological lies and the addiction bureaucracy’ is informed by the experience of working as a psychiatrist at a British prison (3).

The first myth is the notion that addiction is the result of an unfortunate accident: one minute the hapless victim is swimming happily in the pond of life and the next is impaled by the hook of the malign substance. The apparently random victim is instantly at the mercy of whoever holds the rod and line – and in the advert is agonisingly dragged along the floor. But, as Dalrymple shows, becoming addicted to heroin requires effort and discipline, determination and time. Though the notions that the drug is the active agent and the addict the passive victim are popular among users and drug workers alike, they deny both the responsibility of the individual for adopting this lifestyle and the possibility of rejecting it. The image of the pathetic addict squirming on the hook is also contradicted by the reality of the busy and purposeful life required to sustain a drug habit.

The second great myth is that withdrawal from drugs is a deeply traumatic process – like removing a barbed hook from your mouth. This myth has reached a high pitch of histrionic exaggeration in relation to heroin, in the familiar ‘cold turkey’ horrors dramatised in novels and films. Reporting both extensive professional experience and the medical literature, Dalrymple confirms that heroin withdrawal is an uncomfortable, but not a serious condition, with a much lower rate of complications than withdrawal from alcohol, barbiturates or benzodiazepines.

A third myth is that once the victim is ensnared on the hook, addiction immediately becomes a chronic disease requiring medical treatment – in the forms of diverse regimes of detoxification and rehabilitation. This is contradicted by the familiar experience that many users of drugs abandon the habit spontaneously – if supply is interrupted (by imprisonment) or by some change in circumstances (a new relationship, having a baby). As Dalrymple observes, ‘a motive is both a necessary and a sufficient condition for them to give up’. This does not work for chronic diseases such as tuberculosis or rheumatoid arthritis. The ‘treatment’ of opiate dependency with methadone – the mainstay of medical management of heroin addicts for decades – has had such a low success rate (in terms of achieving abstinence) that the goal of treatment has largely shifted to achieving ‘maintenance’ on an indefinite supply of this stupefying drug.

Methadone has been associated with a steady expansion of heroin use (and a large number of deaths from methadone overdoses). The RSA’s answer is more, but ‘better and more consistent’ methadone prescribing, and – the ultimate badge of radicalism in drugs policy – ‘heroin prescribing wherever appropriate’. This is popular with the police who believe that it may reduce crime, but not with GPs who will be expected to do the prescribing. It is difficult to think of measures more likely to encourage both the scale of heroin abuse and the mortality and morbidity associated with it (apart, perhaps, from the provision of ‘shooting galleries’ for intravenous drug use and rewarding addicts with residential rehab programmes of the sort promoted by celebrities – both measures approved in the RSA report).

The RSA report proclaims as the essence of its innovative approach its emphasis on ‘harm minimisation’ as the central theme of drugs policy. Of course, ‘harm minimisation’, the mainstay of official drugs ‘guidelines’ since at least 1991, has been another spectacular failure (4). Depriving self-indulgent actions of their worst consequences is likely to encourage them to spread. Dalrymple is alert to the wider implications: ‘[I]f consequences are removed from enough actions, then the very concept of human agency evaporates, life itself becomes meaningless, and is thenceforth a vacuum in which people oscillate between boredom and oblivion.’ The concept of harm minimisation assumes that the authorities take over responsibility for the consequences of individuals’ behaviour. It is ‘inherently infantilising’.

The dogma promoted by the RSA report, that drug addiction is a chronic disease, is both absurd and irresponsible. Drug addiction, as Dalrymple insists, is ‘a moral or spiritual condition that will never yield to medical treatment’. The medicalisation of drug abuse is a combination of ‘moral cowardice, displacement activity and employment opportunity’.

I would heartily endorse Dalrymple’s radical first step towards tackling the drugs problem: close down all clinics claiming to treat drug addicts (on the basis of my experience as an inner-city GP, I would also recommend closing down drug treatment programmes in primary care). Addicts would then have to face the truth: ‘They are as responsible for their actions as anyone else.’ This measure might help to set them free – and it might also help to release doctors from the corrosive deceptions underlying current drug policies. It is striking that while the RSA report is piously non-judgmental towards drug users and eschews coercive policies, it seethes with righteous indignation at GPs who might refuse to follow its dogmatic approach and insists twice in the five pages of its executive summary that GPs should not be allowed ‘to opt out of providing drugs treatment’. The notion that doctors should be coerced into providing dangerous treatments for their patients in the hope that this might reduce the crime rate reflects the damaging effect of drug policy on the ethics of medical practice.

Dalrymple concludes with a discussion of the case for the legalisation of drugs, which he concedes is ‘not a straightforward matter’. After considering both philosophical and prudential arguments, ‘on balance’ he does not favour legalisation – the only point on which he is in accord with the RSA. While recognising the enormous cost to individuals and to society of our relationship with our most familiar intoxicant, alcohol, I believe that we have to learn to live with other ‘substances’, too, without resorting to criminal legislation. However, I strongly agree with Dalrymple’s emphasis that ‘far more important in the long run than the question of legalisation…is our attitude towards addiction’.

The radicalism of the RSA’s rethink of drugs policy is symbolised by its bold insistence on the repeal of the 1971 Misuse of Drugs Act – and its replacement with a Misuse of Substances Act. But changing the labels – while perpetuating the myths about drug use – will do nothing to tackle the damaging effects of drugs on individuals and society. The RSA report concedes that ‘drugs education’ – a concept scarcely less mind-numbing than heroin addiction – has failed. The answer? Never mind that ‘there has been too little evaluation for anyone to be certain what works’, we need more of the same, with the heart-sinking rider that it ‘should be focused more on primary schools’.

Why not teach children something interesting and inspiring, that might give them the truly radical idea that culture and society have more to offer than drug-induced oblivion?

Dr Michael Fitzpatrick is author of The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA).

(1) Royal Society for the Encouragement of Arts, Manufactures and Commerce (RSA), Drugs – Facing Facts: Report of the RSA Commission on Illegal Drugs, Communities and Public Policy, March 2007

(2) See the Get Unhooked website

(3) Theodore Dalrymple, Romancing Opiates: Pharmacological Lies and the Addiction Bureaucracy, Encounter, New York, 2006

(4) ‘Methadone: an ethical imperative?’ in Michael Fitzpatrick, The Tyranny of Health, Routledge 2001, pp 103-105