EU updates its plan to reduce drug misuse
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1762 (Published 25 September 2008) Cite this as: BMJ 2008;337:a1762
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Whilst I’m not sure of the relevance of Niall Scott’s comments in
reducing drug use, I agree with him, the term addiction is not used in
either ICD10 DSM-1V. However dependence is. Interestingly enough that term
has almost identical criteria to what was referred to as ‘addiction’ in
DSM 3. The decision to use ‘dependence’ in DSM-1V was in fact decided by
just one vote on the grounds that it was less pejorative than addiction;
(1&2) it did not however, materially affect the criteria, nor sadly has it
helped to reduce the total harms caused by addictive psycho active drugs,
nor has it reduced drug use., or drug related deaths.
Niall’s opinion that the use of ‘addiction’ may deter people seeking
treatment is a social learning hypothesis which has no evidence to support
it. On the contrary the politically correct, or other inspired agenda, to
use non defined terms, completely void of criteria, has not in any way
reduced drug use in the UK, whilst the number in treatment, as opposed to
recovery, is in itself, a simplistic way of measuring success,
The documented facts referenced in my response to Rory Watson’s
article are inescapable, both drug related diseases and drug deaths are
increasing and will continue to increase until such times as we face up to
the facts of addiction and drastically increase the availability of
abstinence focused treatment for the addicted.
If Niall was to take the time to visit a number of ‘open’ meetings of
either Narcotics or Alcoholics Anonymous and listen to the voices in
substance free recovery, he would discover that neither the terms addict
or alcoholic, has prevented the members from re-building their life and
accepting the reality of the fact that they do have an irreversible
condition to which science has yet to find an answer. Indeed it is the
acceptance of that reality, rather than seeking to mask their condition
with meaningless euphemisms, which has made a major contribution to their
recovery, which in turn is totally different from ‘treatment’ in much the
same way that abstinence, is different from sobriety. Whilst both
contribute positively to reducing drug use, the latter as Niall would
discover for himself, is much more enjoyable.
References:
1.What’s in a Word? Addiction versus Dependency: O’Brien, Charles P;
Volkow, Nora: American Journal of Psychiatry 163:764-765, May 2006.
2.What’s in a Word? Addiction versus Dependency: Fainsinger, R. L.
Thai, V. Frank, G. and Fergusson, J. American Journal of Psychiatry
163:2014-a, November 2006 doi: 10.1176/appi.ajp.163.11.2014-a.
Competing interests:
Alocohl and Other Drug Addiction Recovery.
Competing interests: No competing interests
Without wishing to address each of Peter’s points, we have responded
to those relating to the main thrust of his argument below:
We are unclear why Peter seems to question the consensus panel’s view
that ‘voluntary sustained control over substance use’ can include both
abstinence and maintenance approaches to recovery. However, by making the
point that addiction is related to the inability to control use (and
referencing DSM-1V and ICD-10), he supports rather than undermines the
idea that ‘control over substance use’ is part of recovery.
To say that the UKDPC ‘disregards’ the fact that those on methadone
do not always achieve recovery is simply wrong. It is clear from all of
our outputs relating to this project that the consensus panel did not say
methadone alone constitutes recovery (just as abstinence alone doesn’t).
Peter accepts that recovery is an ongoing process but does not seem
to accept that for some people methadone (or similar prescribed medicines)
rather than abstinence will help to maximise their health and wellbeing.
Becoming ‘drug-free’ simply isn’t an option for some people and relapse
following a period of ‘white-knuckle abstinence’ can be traumatic and
result in overdose and death. The consensus statement supports the view
that if, at any point in time, prescribed medication is impeding rather
than assisting recovery then it should cease to be prescribed.
However, to deny that a maintenance approach to recovery is possible
simply does not reflect reality and ignores the wealth of evidence that
has led to NICE guidance which supports the use of methadone and
buprenorphine.
Any definition of recovery must accept this and be inclusive. Indeed,
the Betty Ford consensus (which Peter seems to prefer) is also inclusive
of those using naltrexonone, buprenorphine or methadone as prescribed.
Competing interests:
None declared
Competing interests: No competing interests
Peter's letter is littered with the word 'addiction'. May I point out
that the word does not feature in either DSMiv or ICD10. Many people
engage in substance use that could be perceived as problematic yet change
this behaviour with or without the help of services. This often involves
engaging in lower levels of substance which most would see as positive.
The desire to label people with the term 'addict' may reduce the
likelihood people will enter treatment. The fact that people who abstain
experience fewer further problems is logically irrelevant as these are a
self-selected sample. The people who develop substance use problems and
seek treatment are a tiny portion of those who use drugs (see British
Crime Survey). A pragmatic approach to substance use (which has and will
always occur) and substance use problems would benefit us all.
Competing interests:
None declared
Competing interests: No competing interests
Rory Watson’s’ article on EU updates to reduce drug use by reducing
demand and supply of addictive psycho active illicit substances,
coincides with what appears to be a determined effort by the charitably
funded, and highly influential United Kingdom Drug Policy Commission,
(UKDPC) to reach national agreement to condone the ongoing use of those
substances, by redefining ‘recovery’.
Whilst there is no universal definition of ‘Recovery, it has
traditionally, for those who meet the clinical criteria for addiction,
been regarded as an ongoing process which, with the exception of medically
prescribed medication for co-occurring disorders, is either abstinence
based or focused. The UKDPC in its publication, ‘Recovery Consensus
Statement’, (1) is seeking to change that to:
‘The process of recovery from problematic substance use is
characterised by voluntarily-sustained control over substance use which
maximises health and wellbeing and participation in the rights, roles and
responsibilities of society.’
Apart from the fact that there is no universal definition of
‘problematic substance use’ and the fact that the UKDPC has declined to
define what it means by that phrase (2) the UKDPC claims that as a
starting point to arrive at the above definition, it took a recent report
of the Betty Ford Institute Consensus Panel in America, which involved key
individuals in the field of Addictions and Recovery in the US, including
William White and Thomas McLellan. However that document defines recovery
as:
‘A voluntarily maintained lifestyle characterised by sobriety,
personal health, and citizenship’. (3)
The same document defines sobriety as’ abstinence from alcohol and
all other non prescribed drugs , together with the rider, ‘This criterion
is considered to be primary and necessary for a recovery lifestyle.
Evidence indicates that for formerly dependent individuals, sobriety is
most reliably achieved through the practice of abstinence from alcohol and
all other drugs of abuse.’
Leaving aside the glaring differences of what constitutes recovery,
this writer suggests that should the UKDPC definition be adopted by the
National Health Service, (NHS) and subsequently implemented by the
National Treatment Agency, (NTA) it would amount to legitimising the
ongoing use of drugs and therefore make no contribution to preventing use.
Indeed it could be argued that the opposite is likely to occur with such
drugs available on prescription, it would also lead to more widespread
illegal marketing as is the present case with methadone and other
prescription drugs, many of which are available on the net. Nevertheless
the UKDPC insists ‘voluntary sustained control over substance use’ is not
the same as ‘controlled use’ and further claims “control over substance
use” is deliberately inclusive of both abstinence and maintenance
approaches to recovery.”
Quite how the UKDPC conclusion is arrived at is unexplained, however
such reasoning also seeks to ignore that an essential criterion of
addiction as stipulated in both the Diagnostic and Statistical Manual of
mental Disorders,(DSM-1V) of and the International Classification of
Mental and Behaviour Disorders, (ICD-10) is the inability to control use.
The reasoning of the UKDPC also disregards a number of other facts,
not the least of which is that those on maintenance programmes are
classified as being ‘in treatment’; sadly addiction, as with most, if not
all intractable conditions, does not always lead to recovery. On the
contrary, methadone deaths in England and Wales are increasing. (4) It is
also a fact that of those in treatment during 2006 just three per cent
emerged abstinent. (5)
It is also true that those on methadone maintenance (MMT) perceive
their health negatively and experience high levels of health related
concerns, but continue to engage in behaviours, including poly drug
misuse, are likely to have negative health outcomes. (6) Add that to the
common problems of sleep disorders among those on MMT (7) and one is
forced to conclude that the chances of those in substitute treatment and
ongoing use of other substances, of maximising their ‘health and
wellbeing’, appear to be slim, yet this is what the UKDPC, together with
ongoing drug use, is asking us to accept as ‘recovery’.
Seeking to define recovery to include ongoing use, is especially
worrying since neuroscience has shown us that the continued use by the
addicted, increases the severity of addiction, to the point where the free
of will of the addicted is eroded, (8) thereby eliminating any prospect of
recovery, whilst precluding any possibility of ‘voluntary-sustained
control over substance use’.
It would be tempting to dismiss the attempt of the UKDPC to redefine
recovery as the well intentioned, but misguided efforts of ideology were
it not for the fact that it formed the key feature of the recent tax payer
funded NTA conference, (9) where the eminent addiction specialist,
Professor John Strang presented and endorsed it, as did John Howard and
Colin Blakemore.
Leaving aside whether or not it is an appropriate use of public money
to advance the agenda of the UKDPC, it seems to this writer that whoever
in the government authorised it, is keen to adopt the idea that ongoing
substance use as acceptable. Quite how that will go down with the European
Commission objective of reducing demand and supply remains to be seen.
References:
1.www.ukdpc.org.uk/Recovery_Consesus_Statement.shtml July 2008
2.Exchange of emails between the writer and Nicola Singleton UKDPC,
August 2008
3.Betty Ford Institute Consensus Panel (2007) “What is recovery? A
working definition from the Betty Ford Institute” Journal of Substance
Abuse Treatment, 33, 221-228
4.Oliver Morgan, Office for National Statistics and Imperial College
London, Clare Griffiths, Barbara Toson and Cleo Rooney, Office for
National Statistics, Azeem Majeed, Imperial College London, Matthew
Hickman, University of Bristol. Office of National Statistics article;
April 2007.
5.The Daily Telegraph 31 October 2007.
6.Philip James, David Spiro, Noreen Geoghegan, Anita Connor, Gail
Hawthorne. Nursingtimes.net 28.Aug 2008
7.Peter D. Friedmann, citing Peles E, Hetzroni T, Bar-Hamburger R, et
al. Melatonin for perceived sleep disturbances associated with
benzodiazepine withdrawal among patients in methadone maintenance
treatment: a double-blind randomized clinical trial.
Addiction::2007;102(12):
8.Mark Moran, citing Volkow, N. Psychiatric News July 6, 2007 Volume
42, Number 13, page 16.
9.http://www.nta.nhs.uk/publications/documents/conference_2008_highlights.pdf
.
Competing interests:
Alcohol and Other Drug Addiction Recovery.
Competing interests: No competing interests
Re: Reducing Drug Use
I thank Ben Lynam of the UKDPC for his response to my letter.
Having studied the contents I do hope that I have not misinterpreted
his response as an attempt to diverge from the key issue of reducing drug
use.
The reason why I question the fact that ‘voluntary sustained control
over drug use’ does not include abstinence is self evident; unlike the
Betty Ford definition of recovery there is no mention of it, nor for that
matter is there any mention of the more important quality of sobriety,
both of which are guaranteed to reduce drug use, whereas the phrase chosen
by the UKDPC condones, if not actually encourages continued use; either or
both the latter seeks intentionally, or otherwise, to legitimise ongoing
use and therefore for the reasons I outlined in my earlier letter are
more likely to increase , rather than reduce drug use.
Ben, appears to have misunderstood my comments on methadone, in the
context of the UKDPC views, therefore I would ask him to read again what I
actually wrote.
It is true that both the increasing deaths attributed to methadone,
which I referenced, together with the abysmal outcome of that treatment on
abstinence, as a precursor to recovery, also referenced, combined with the
documented and once again referenced, negative health outcomes, associated
with ongoing methadone treatment is obviously counter productive to
‘maximising’ the mental physical and spiritual health and wellbeing of
those who have become dependent on it. Add to that the common and commonly
acknowledged, continuing use of other addictive psycho active substances
by those on methadone treatment, it is paradoxical to suggest that they
are in recovery. What is true is that although methadone maintenance helps
to keep people ‘in treatment’ its value to recovery and ongoing use is
currently being investigated by the Canadian Government. (1) I would also
refer Ben to the document ‘Methadone Diversion. Abuse and misuse: Deaths
increasing at an alarming rate’. (2)
In conclusion the old chestnut raised by Ben on ‘white knuckle
abstinence’ as we both know has little or no empirical evidence to support
his views, nor does he attempt to offer any. What is true is that
withdrawal is always difficult, as is maintaining abstinence, especially
during the first year or two. It is also true that initially relapses are
more common that not, however that does not preclude recovery in the vast
majority of cases. The one thing Ben and I can agree on is that the latter
is a process which cannot be judged by anecdotal evidence or the passage
of time. It follows that if we want to reduce drug use then we should be
focusing on increasing the availability of abstinent focused recovery
facilities, together with ongoing after care, rather than seeking to re-
invent the wheel by redefining recovery,
References:
1.U.S Department of Justice: National Drug Intelligence Centre; 2007-
Q0317-001 November 2007.
2.‘Task force to probe methadone care’: Donovan, K. Leeder J.
www.TheStar.com 27 April 2006.
Competing interests:
Alcohol and other Drug addiction recovery
Competing interests: No competing interests