Prohibition-era logic not the answer to drug abuse

The issue of drug abuse has received particular attention in the media recently, with personal and family testimonies highlighting the impact of heroin addiction.

As someone with more than 20 years’ experience of treating drug users both in the UK and Ireland, I get anxious when I hear people suggesting simple solutions to this complex problem; that abstinence is the one and only path to redemption for those who are addicted to drugs.

Experience shows that abstinence, while desirable, is often not achievable. Our main health priority should be to keep a drug user alive and safe from the significant health harms associated with drug abuse. Numerous research studies in many jurisdictions confirm that replacing heroin with methadone has been shown to do just that.

Underlying issues
Drug users come from all walks of life and all types of families. Some are born suffering withdrawals from drugs or alcohol their mothers have abused. That is a tough start in life. Other users have complex problems that stem from underlying mental health issues, childhood experiences of sexual or physical abuse, social deprivation, or a family history of addiction.

Criminality is another important aspect of the problem, with drug-related crimes accounting for a large proportion of custodial sentences in Irish prisons. To suggest that there is one simple solution to solve the challenges of drug abuse is at best naive. At worst it is potentially dangerous.

A comprehensive assessment by experienced professionals will help to establish which treatment option should work best for an individual drug user. I see a lot of patients who have multiple addictions and it can be challenging to help them to stabilise safely.

Patient safety is a key issue, as detoxing can be a dangerous time. While most drug users aspire to eventually being drug-free, many will have unsuccessfully tried going “cold turkey” before presenting for treatment. For these people, methadone is a safe, well-documented treatment option which gives a drug user an opportunity to stay alive and regain their health.

By stabilising their lifestyle, parents can regain the opportunity to enhance their parental role. Some drug users no longer need to steal and so can stay out of prison. Others may gain access to further education or employment. Having achieved some stability, there is a good opportunity for services to offer other effective support to the person. For many drug users that’s not a bad deal.

Recently it has been suggested that providing heroin as a substitute treatment is beneficial for some patients. Current international evidence supports this strategy; however, it is recommended only when other treatment options have been unsuccessful and the patient continues to inject heroin. In these cases, safe heroin-injecting rooms have been shown to have a value.

Moderation in language is also important in this debate on drugs. No pharmacological intervention can offer a cure for addiction – addiction is more complex than that. However, substitution treatments can offer a patient an opportunity to become stable enough to have some of their other problems addressed.

Drug-free
One patient who had struggled with heroin and other addictions for many years has recently graduated from college. Although clearly a bright girl, she had been expelled from school. An underlying mental health problem was eventually diagnosed and treated once she became stable with the help of the methadone programme. For the first time she stopped using illicit drugs to self-medicate her mental health symptoms. She remains drug-free and has also successfully detoxed off methadone.

Stigmatising drug users because they have chosen the methadone option rather than abstinence is counter-productive. Demanding abstinence from all drug users is Prohibition-era logic and does not help today either. Finding the most appropriate treatment option for each individual is a challenge; it can take a while to get it right.

In Ireland, the heroin problem has been stabilising in recent years, with a reduction in new presentations to treatment services. Of course, the problem of substance misuse and addiction has not gone away. Our nation’s battle with addiction to legal substances such as alcohol, prescription drugs and over-the-counter codeine is well-documented. Perhaps we need to look deeper into the causes of addiction in our society, rather than stigmatising those who fall victim to it.

Dr Íde Delargy is director of the substance misuse programme at the Irish College of General Practitioners and national GP co-ordinator for the HSE addiction services. This article represents her personal opinion. idedelargy@eircom.net