pH7 Magazine - From Prison to Prescription

Hans with leather jacket and laid back manner is as stereotypical a drugs expert as the Netherlands could ever produce. With 30 years in the field he is also one of the most experienced. “Ah, the British system’’, he mused about the UK ways of treating drug abuse, “we tried that once.”
Lena, a Swedish GP, looked puzzled as we sat in her austere surgery. “We have had nobody drop out of drugs treatment after the first few days.”

Mike, a police and health drugs link, in New South Wales was adamant. “Heroin treatment is relatively easy, it is amphetamines that are harder to treat.”
Marc, a practitioner and also a research professor from Bordeaux, was precise. “Treating heroin has the same medical success definition and rates as any other chronic relapsing disease.”

Different systems, different political ideologies, different social attitudes to drugs, but one common denominator: Treating heroin is relatively straightforward. Yet the British debate on lessons to be learned from abroad concentrates on the fringe activities.
Parliament has heard politicians wax lyrical about residential rehabilitation in Sweden. Yet two-thirds of these services have been closed in the last year because of their failings. The Sydney heroin injection room is hailed by some as the way forward, yet it is a single experiment expressly established for use by prostitutes and their clients. The Dutch cannabis cafés have a near mythical status in UK debate, yet a third have closed because of lack of demand and their main customer base is tourists. Injectable prescribed heroin is seen as a magical palliative by some, yet its use is targeted at elderly addicts with a 20 to 30-year history of injection.

All these debates are of interest and do inform, but none are about the core of the problem. The British system was developed dramatically in the mid-1960s when drug treatment was taken out of the hands of GPs and given to psychiatrists.
Two years ago I held a three-day public inquiry into heroin in my Bassetlaw constituency. During this the inherent weaknesses of the British system were exposed.
Newly graduated students, probation officers, police officers and others were making decisions on drug treatment. A revolving door of detox after detox had become the norm, with addicts and their families contemptuous of the waiting lists, missed appointments and an underlying assumption that they had to prove themselves ready for treatment.
In other words, heroin addiction was primarily seen as a psychological problem.

Bassetlaw has therefore rejected the British system. We no longer tolerate decisions on medical intervention led by non-medical professionals. A year ago, the average dosage of methadone given out in the UK was 25mg. Every expert I asked across the world said that for most patients this would not work.
We now use mainstream primary care trust funding for GP-led treatment. Addicts are treated by their own doctor, in their local surgery. Methadone and subutex are used as maintenance treatment, with no presumption on people having to exit either treatment.
GPs take responsibility for the individual care needs of their patients. If a GP practice wishes not to serve their patients, they can expect a visit and more from their local MP. GPs draw down the services of specialist support workers, exactly as they do in all forms of primary care.

Mainstream treatment,in mainstream practices with mainstream funding. We have a word for this: rehabilitation. Our redefinition of rehabilitation is into the community. Stage one of rehabilitation is to be able to use your own GP. Stage two is to re-engage with family and neighbours, who can live free of the fear of theft and the heroin cycle of behaviour. For stage three, rehabilitation into work, we are creating an intermediate labour market to provide an employer with a risk-free return to work programme. We are engaging the trade unions in developing workplace agreements that will accommodate and support this.
It sounds expensive, but it is already a proving to be a saving to the Exchequer.

GP time involved is predictable and manageable, with practice nurses playing an important role. There is a significant time-saving. Every addict in this area has a family, whose use of GP services is falling as the stress of dealing with a heroin-addicted son or daughter comes to an end. For many parents and grandparents their physical health improvements and life expectations match those of their offspring.

Accident and emergency overdose admissions are falling very significantly, with consequential in-patient bed use reduction.
We currently have 170 addicts in GP treatment, and the number is rising rapidly. Over 95 per cent were involved in crime. As an indicator: there were 80 burglaries in May 2002, in May 2004 there were 18. Less crime to feed addiction frees up police resources. In Bassetlaw this has allowed for the targeting of drug suppliers, with 35 arrests over a six week period.

Previously, defence barristers could argue about a lack of drugs treatment. Now they cannot. Consequently, sentences are becoming appropriately long. The police are able to offer drug addicts a choice of prison or treatment in advance of new offences being committed and many are delighted to choose treatment. Re-offending of those who do is minimal.

The police estimate for theft per addict is between £60,000 and £80,000 per annum. The savings are already at over £4 million annually. Many previously unemployable people are back in work, giving the biggest saving of all. A conservative estimate is that we are already saving the exchequer £25 million a year.

There is also a saving to the community that cannot be measured. Two years ago Bassetlaw had 12 overdose deaths, this year we have had none. One set of parents showed me a photo recently, with the words: “our son, the taxpayer”.
For 40 years we have allowed drug treatment to be the Cinderella service. We are proving that for heroin, it saves us money to send Cinderella to the ball.

As Hans said, “I do not understand why Britain has such a big problem?” Two years on from my enquiry, neither do I.