The Pharmaceutical Journal
Vol 279 No 7472 p380
6 October 2007

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Why heroin needs a criminal focus and “shooting galleries” are not a good idea

By Terry Maguire

I felt important but that was only until the Community Restorative Justice (CRJ) chap, with whom I shared a surname and half a podium seat, was asked to introduce himself and to say a few words about his organisation. With his buttock firmly pressed against mine, he launched into a tirade of abuse about pharmacists. There were too many pharmacies; there were, as far as he knew, no impoverished pharmacists and anyway none of these people lived in the local areas where they worked.

This discussion session, organised by the local drugs and alcohol strategy group, was only six minutes into the meeting when closing down pharmacies seemed the preferred solution to the local drugs and alcohol problem. I did not rise to the bait; I calmly explained why pharmacy was needed to regulate medicine supply, so then they rounded on the GPs.

Yet in all the discussion the only individuals who avoided criticism were those who snort cocaine, inject heroin or destroy property when drunk. These individuals were, it was concluded, the victims and for them things needed to be done.

There is no such thing as right or wrong. There are only opinions: opinions that create policy that in turn create solutions. Right and wrong depends on where you are, what your view of the world is and how much you truly understand the problem. Societies are good at coming up with ideas but less good in achieving excellent solutions.

I worried when I read that the top 10 per cent of successful managers in British industry only get 45 per cent of their decisions right. These are the most intelligent and creative business leaders in our society and yet they are less than half right at any point in time. What does that say for the rest of us as we muddle through?

Decision making is organic and creative and sometimes we do get it right — for a while. Sometimes we get it wrong, badly wrong. We try one solution and if this does not work we try another and so one. Overall, in theory anyway, solutions progress forward to create a society where things are better for most. I fear that this forward trajectory is not working for drug policy across the UK.

Increasingly, bright and intelligent media columnists and other opinion leaders, certainly those at my drug strategy meeting, support further liberalisation of illicit drug abuse and more specifically the development of support services, even prescribing heroin to addicts and the setting up “shooting galleries”. They see this as an innovative tactic, a new front in the War On Drugs.

Johann Hari, from The Independent, waxes lyrically on the social benefits of supplying addicts with heroin. He is convinced, and seems to make a convincing case, that prohibition is the core problem with heroin on our streets. Making the heroin market less profitable will rob it of its violence. In his world view the violence is the problem.

An expert report from the Royal Society for the Encouragement of Arts, Manufactures and Commerce (RSA) has jumped onto the bandwagon claiming that UK drug policy has failed. This committee of social workers, politicians and academics suggest that drug policy is driven by “moral panic”.

Central to the report's recommendations is that since alcohol and tobacco are legal and since they are also dangerous, logically other drugs of abuse need to be decriminalised. It suggests rather than criminalising addicts, society should offer them housing and jobs. Illicit drug abuse is a health and social problem not a legal problem, they argue. Seems hugely simplistic.

But sadly Mr Hari, the RSA and my local drugs strategy group have all fallen into the trap that most social commentators on drug and alcohol problems fall into and this is that these problems cannot be explained by a simple cause-and-effect system or even by a complex (expert) system. Drugs and alcohol problems can only be explained in terms of a chaotic system. Understanding the problem as a chaotic system will allow society to address and manage it and then truly help the individuals affected.

Robert West, a clinical psychologist at University College London, gives this insight in his excellent book “A theory of drug addiction’. West has come as close as anyone to a theory explaining drug addiction as a dysfunction of the motivational system, that part of us that gets us out of bed in the morning.

Furthermore drug addiction is active at a societal level where drug availability and environmental living conditions greatly impact on the problem. Solutions can only come from an understanding of the operation and impact of myriad factors in this chaotic system.

Yet few seem to want to do this preferring to define the problem as a simple cause and effect system and proceeding with a single action approach. Many have a vested interest in viewing the current drugs and alcohol problem in this way and, through censure of being politically incorrect, stop others voicing opinions that may be equally valid.

Theodore Darlrymple’s book ‘Romancing opiates’ is a good case in point. A retired GP with prison work experience, Dr Darlrymple has an alternative view on the role of drugs and their abuse in modern society. Drugs are not bad; it is people’s behaviour that is bad, he argues. Whereas there might be evidence that people in methadone schemes commit less crime, the detail suggests that they are still prone to commit crime.

Crime does not necessarily stop; it just lessens. People, particularly men, do not commit crime because of a drug habit: their propensity to criminality exists before their drug habit begins. Indeed a propensity to criminality leads to drug experimentation and abuse in the first place. Robert West uses the scientific literature to support this point.

Drug addicts in general are people who abuse the social system to their own gain; they find it easy to be victims of social injustice yet unwilling to help themselves. They complain of horrific withdrawal symptoms if they do not get a fix when, in fact, symptoms of heroin withdrawal are similar to symptoms from a bout of influenza in a healthy individual: unpleasant but hardly life-threatening.

Addiction, according to both Dalrymple and West, is a social construct. Dalrymple is rather more blunt in his views suggesting that users have created the current system to supply themselves with drugs and social workers use the system to keep their jobs and social status. I do not share this view but I do think we need to keep a strong criminal justice focus on heroin abuse and never support prescribing in “shooting galleries”.