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Rapid Responses: Rapid Responses published:
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A misleading impression
- Don C Aston (2 May 2008)
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Opium production in Afghanistan: Is the US or the Taliban responsible?
- Simon J Spedding (5 May 2008)
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Opium production and Afghanistan
- Robert G Twycross (6 May 2008)
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Empty Rhetoric?
- Anthony P Joseph (7 May 2008)
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Afghan opium economy
- GEORGE Y CALDWELL, Singapore 259858. (8 May 2008)
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Plants and Animals
- Hugh Mann (12 May 2008)
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Poppies and Pain Relief
- Ilora G Finlay, Lord Mancroft, Frank Field MP (3 June 2008)
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Don C Aston, retired Solihull B90 2BG
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Mr Malloch-Brown surely gives a very misleading impression when he writes that global demand for opiates for medical purposes ` is fully satisfied `. The International Narcotics Control Board has also reported that there is little or no reported medical use of any opioid ( not just heroin/diamorphine ) in some two-thirds of the world`s countries. People who live there have just the same need for the the relief of pain and suffering especially in palliative care and particularly because of the ravages of AIDs epidemics. But they either have no access to doctors or other prescribers or nobody is willing to prescribe them or they are not allowed to. This often results from their indiscriminate demonisation/prohibition in the context of anti-drugs campaigns. As it happens in the UK also we are now in the fourth year of a major diamorphine injection shortage so that street heroin - said to be increasingly pure because of abundant supply - is now much cheaper than the price paid by the NHS for diamorphine ampoules, the only form licensed for non-oral administration. But at least in the UK this is not due to lack of wholesale diamorphine ( we are the world`s largest producer ) but to a sudden lack of freeze-drying capacity at the end of 2004 which has never been satisfactorily explained and remains unresolved. Competing interests: None declared |
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Simon J Spedding, Medical Advisor, Department of Veterans Affairs Department of Veterans Affairs, 199 Grenfell Street Adelaide SA5000 Australia
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Working for a year in the Kabul children’s hospital, back in the 70’s, gave me a certain perspective on Afghanistan. It conflicts with the Foreign Office view in ‘Opium production in Afghanistan’ (BMJ Editorial) that “the Talban is promoting opium production to finance terrorism”. The simple facts are that opium production was high under the US influenced government of Afghanistan of the 1970’s, then decreased 10 fold by 2001 under the Taliban and then increased 30+ fold under the US. History shows us how empires function; be they British or US. The East India Company organised the opium trade through “Free Traders” - men with fast ships and guns to fend off the pirates. One of the most famous Free Traders was Francis Light, founder of the British province of Penang. These are facts, whereas the idea that the CIA runs opium from Afghanistan would be a conspiracy theory....unless, you thought about the United Nations statistics or happened to have been to Afghanistan. We read about the increased opium production under the US administration and see pictures of the US Army driving happily through fields of poppies. Is it a coincidence that when the Talban were in control of Afghanistan, opium production was at its lowest in 30 years. Under US influence after 2001, opium production increased by 640% pa1 to the same level as in the 1970’s a time when Afghanistan was also under US influence. The Foreign Office view, that the current level of opium production is due to the Taliban, is not supported by the available evidence. I wondered if ’Clive of the East India Company’, whose statue is outside the Foreign Office front door, has influenced their interpretation of world events. Simon Spedding MBChB FACSP MAEpid REFERENCE 1. United Nations Office on Drugs and Crime (Vienna Office), accessed 05 May 08. http://www.unodc.org/pdf/afg/afghanistan_opium_survey_2004.pdf, Competing interests: None declared |
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Robert G Twycross, Director, palliativedrugs.com Ltd: Former Head, WHO Collaborating Centre for Palliative Care, Oxford Tewsfield, Oxford, OX3 8HF
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Dear Editor I fully support the position taken by the UK government in relation to opium production in Afghanistan, namely that legalizing its production there and redirecting it into legitimate medical channels is neither feasible nor desirable (Editorial, May 3, p.972). However, by repeating the claim by the International Narcotics Control Board that ‘global demands for opiates for medical purposes is fully satisfied’, the editorial could be misleading, despite the subsequent caveat that the market for medical morphine could well be underdeveloped. Harking back to just last year in the BMJ(Logie, D. et al. BMJ 2007;335:685), I would suggest that the worldwide need for medicinal morphine is far from satisfied. It is difficult to know how to calculate actual global needs, but they are probably at least 10–20 fold more than present consumption. Yours faithfully Competing interests: None declared |
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Anthony P Joseph, GP London N1
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Cyberspace is my least favourite communication medium but reading Mark Malloch-Brown's Editorial (p. 972 BMJ 3 May 2008) motivated me to comment. In his last paragraph, second and third sentences thereof, he states that "The Home Office drugs strategy 2008-18 aims to restrict the supply of illegal drugs to the UK and reduce demand. It will do so through tackling drug supply and drug related crime, .... " I would have liked Malloch-Brown to have been much more prescriptive as to just HOW this goal is to be achieved. I retired from mainstream fulltime General Practice in 1999 and I have worked in a variety of clinical settings ever since. Perhaps the most consistent of these working bases has been a two day per week committment to a central London practice offering care to homeless individuals. Illegal substance consumption and all the complications that can flow from it (frequently including premature death of the consumer) is one the predominant clinical problems that this service handles. If anything the numbers of victims that we see is increasing rather than the reverse. Occasionally the media report a successful surveillance operation that has resulted in a major supply network being disrupted, a massive haul of heroin etc. being recovered, and some Police character tells the nation how much safer the streets are now that that load cannot be distributed by the pushers. We are never told how many operations fail to achieve such good results. Then the fate of the apprehended criminals appears to be at the whim almost of a legal lottery and where the (well paid) employment of the Legal Profession seems a higher priority than keeping drug supplying perpetrators out of business. I have yet to detect any robust policy in action to discourage using "Human-Rights legislation" for the benefit of criminal drug suppliers (who can frequently afford from their profits to employ experienced lawyers on their behalf). Only this week was reported the irony of how freezing the assets of convicted drug suppliers is a poisoned chalice: because the legal work involved in enforcing this situation is met out of Legal Aid and because the rates paid by this service are too low to attract lawyers to take on this work, it has been ruled that a convicted supplier cannot get a fair hearing. In such circumstances the case for freezing the assets is dismissed leaving the convict free to spend his ill-gotten gains when he has served whatever sentence may have been imposed. There seems to be a very formidable entrenched culture protecting (possibly unintentionally) the liberal availabilityof illegal substances in the community. Unless Malloch-Brown knows of a robust way of removing this culture, and implementing such robust method, I fear the editorial is simply empty rhetoric and wishful thinking. I do not plan to give up my work for homeless people on the basis that a major cause of their clinical needs will disappear in the near future. Anthony Joseph Competing interests: Reduction in workload if Malloch-Brown is successful! |
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GEORGE Y CALDWELL, GENERAL PRACTITIONER 31 Balmoral Park, #18-33,, Singapore 259858.
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With the great assistance of the NATO forces the Afghan administration could harvest the Opium and pay just above market price for it. Opium is the only economy of Afghanistan. Control it. Process it locally under supervision. Store it. Then market it to the world. Not yet, but in the fullness of time other crops may be induced to grow in this inhospitable country, with the help of new irrigation projects. That infertile land must not be destroyed with "defoliation techniques" beloved by the Americans, as in Vietnam. The overall cost will be minimal compared with the cost of the war there and the price that Opium and Heroin brings on the world market. The unadulterated Heroin can then be supplied to designated Coffee Shops ("Kandahar Cafes") throughout the world at a cheap price, or even free at first to addicts. Clean needles and syringes supplied, at a small charge. There the social workers can get to know those who would like to stop their addiction. There is also a need for cheap pain-killers in many parts of the world, the Americas, South and Central, and in benighted African countries. There should be no excuse for anyone there dying in pain. Make the effort. Try. Do not sit back in comfort and say "it can't be done." Competing interests: None declared |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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We underestimate the plant kingdom. Plants are so ubiquitous and stationary
that we ignore them and take them for granted. We assume that plants are
passive and dumb. We call lazy people "couch potatoes" and dull people
"vegetables." It is natural for us to have these negative feelings about plants
- after all, we are animals. Competing interests: None declared |
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Ilora G Finlay, Professor of Palliative Medicine Velindre Cancer Centre, CF14 2TL, Lord Mancroft, Frank Field MP
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Dear Sir, In his article about Afghan opium (BMJ 03.05.08), Lord Malloch-Brown contends that there is no need to increase supplies of legal medicinal opium, citing in support the International Narcotics Control Board (INCB), which has the task of controlling the world market. INCB estimates global demand on the basis of last year’s consumption, rather than medical need. Unfortunately, in poorer countries a long history of restrictive regulation and medical under-prescription perpetuates a system where the richest 20% of countries consume 95% of the world’s morphine in obtaining pain-relief. (1) Thus the whole of Latin America, with growing rates of pain from AIDS and cancer, only receives 1% of the global supply of analgesic opioids. The WHO recognises that millions of patients in poorer countries are facing illness with unnecessary pain and suffering. (2) The UK’s approach is to decrease illicit opium production believing it fuels instability and insurgency. Yet this policy is failing as Afghan poppy production has increased year on year since the Allied invasion, to an all time high in 2006. Malloch-Brown claims that HMG has repeatedly examined the idea of legal poppy cultivation, such as in the 2001 report by David Mansfield. (3) But he ignores Mansfield’s 2007 report which states, “Evidence from the field shows that the growth in the opium poppy economy is the outcome – not the cause – of state and development failure in Afghanistan.” (4) At present there are two strategies being followed to deal with illegal opium. The first is eradication, and the second reconstruction. However, it is difficult to reconstruct a country on the one hand, while at the same time failing to establish secure contracts to buy up the largest sector (poppy production) of that country’s most important industry, which is agriculture. And, as returning soldiers have repeatedly pointed out, the battle to win hearts and minds is not helped by the eradication of livelihoods. Where Malloch-Brown is right, is in emphasising the importance of reducing demand for illegal drugs at home, by increasing and improving prevention and treatment services. The demand from addicts is fundamentally a social and health problem in our society. We recognise that some provinces are now poppy-free and producing alternative crops, but we want the third policy - of buying up what is left - to be re-examined. If the Afghan poppy production could provide the raw product for quality controlled analgesic production, then for many millions of people around the globe pain relief may become feasible. The current policy does nothing in humanitarian terms to tackle the enormous suffering through untreated pain worldwide. The main beneficiaries at present remain the dealers and traffickers in illegal opium. Yours faithfully, Baroness Finlay, House of Lords and Professor of Palliative Medicine, Cardiff University. Lord Mancroft, House of Lords and Vice Chairman, Parliamentary All Party Drug Misuse Group Frank Field MP, House of Commons and founder of Poppy Relief Monday 3rd June 2008 (1) Senlis Council Report, Poppy for Medicine, London June 2007, p. 91. Available at http://www.senliscouncil.net/documents/poppy_medicine_technical_dossier (2) World Health Organisation Briefing Note: Access to Controlled Medication. Geneva March 2007. (3) Mansfield D. The displacement of opium poppy cultivation: a shift in the regional threat? 2001. www.davidmansfield.org/data/Policy_Advice/UK/Disp_Report.doc. (4) Mansfield D & Pain A. Evidence from the Field: Understanding Changing Levels of Opium Poppy Cultivation in Afghanistan, November 2007. Available at www.areu.org.af/index.php?option=com_docman&Itemid=&task=doc_download&gid=545 - Competing interests: None declared |
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