Clinical & Policy Updates:
SMMGP Policy Update November-December 2011
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"The Beckley Foundation - Global Initiative for Drug Policy Reform" was launched at the House of Lords during November to bring together countries interested in reform, with countries who have successfully implemented alternative drug control strategies together with the Global Commission on Drug Policy; in order to discuss new evidence and reports commissioned by the Foundation, with the goal of reforming global drug policy.
The public letter which was released to coincide with the launch, and widely reported in the Press, makes the following cogent points:
- Use of controlled drugs has risen and supply is cheaper, purer and more readily available than ever before. The UN estimate is that there are now 250 million drug users world wide.
- Illicit drugs are now the third most valuable industry in the world - after food and oil - and an estimated worth of $450 billion annually from this industry is in control of criminals.
- The drug-free world, that those who supported it were so certain of when the plans were formulated for the war on drugs, has not materialised and is further than ever from being attained.
The letter calls for the 1961 UN Single Convention on Narcotic Drugs to be re-examined and a document Rewriting the UN Drug Conventions has been produced which suggests, inter alia, that individual countries should be allowed the freedom to explore drug policies best suited to their domestic needs, rather than seeking to impose a "one size fits all" solution.
It says that the "policies of prohibition" create more damage than anything they prevent. It asks that resources be shifted away from criminalising tens of millions of people - towards health, harm reduction and respect for human rights.
The EU drugs agency EMCDDA's 2011 report shows that drug use is relatively stable in Europe, with some signs that cocaine use has peaked and cannabis use continues to decline. These signs of stability however are starkly contrasted by the threat posed by the widespread use of new (synthetic) drugs and polydrug use. The report sends out a warning that drug policies and responses must now be configured to face the challenges of this decade posed by this rapidly emerging threat.
Cocaine - recent surveys of cocaine use in the countries most affected, including Denmark, Spain, Italy and the UK, report some decline in use amongst young adults (echoing trends observed in Canada and the US). The report states that "the financial burden associated with regular cocaine use may make it a less attractive option..."
Cannabis is still Europe's most commonly consumed illicit drug but the latest European data confirm the generally stable or downwards trend in cannabis use among young adults. The report suggests that decreases in tobacco smoking may be exerting some influence on cannabis trends in Europe. However, regular cannabis use remains a concern with an estimated 9 million users aged 15-34 years in the last month.
The market for synthetic drugs (including ecstasy and amphetamines) is becoming increasingly complex, with new pre-cursor chemicals being developed and sophisticated techniques employed to bypass regulations intended to prevent the diversion of these.
Rapid emergence of new drugs and the growing inter-relation of "legal highs" and illicit drug markets: the new non-controlled psychoactive substances ("legal highs") represent a huge and growing challenge - the most recent EMCDDA snapshot of online retailers of these substances identified "a record" 600 online shops which are purportedly selling psychoactive products.
The report finds that there is a growing interplay between "legal highs" and illicit drug markets, for example mixtures of cathinones, piperazines or phenethylamines (non-controlled psychoactive substances) found in tablets sold as ecstasy on the illicit market.
Dr Rosali Pacula, co-director of RAND Drug Policy Research Centre in California, recently gave a lecture, the second in the Alison Chesney and Eddie Killoran memorial lecture series, on her research around the impacts of economics on drug and alcohol use. Her research work has included in-depth policy analyses of parity legislation, medical marijuana policies, and decriminalisation policies in the US and internationally.
Dr Pacula argues that empirical evidence shows that heavy drinking - and the health problems associated with it - decline during economic downturns in high income countries, although overall prevalence rates of general drinking may rise. The study compared national household survey data with national health data e.g. hospital admissions; and data from crime trends.
She postulates that economic factors (such as lower income, need for austerity) could dominate over psychological processes (drinking to relieve stress). There is a difference with illegal drug markets in that prices in the illegal markets may be more responsive to changes in economic conditions e.g. if illicit drug prices fall during a recession, then these price effects may result in a rise in illicit drug use, despite lowered incomes (unlike as observed for alcohol). There were some caveats: this recession is unprecedented in the history of the West and is not yet over; the study did not take into account individual and cultural factors; and marginalised populations (although often unduly affected by economic recession) are often under-represented in household surveys such as those used for the study.
Key findings from her research include:
- Alcohol consumption falls in the general population during a recession, which in turn impacts on levels of alcohol related deaths and liver disease (health); and murder, violence (crime) in that they reduce too;
- Overall, populations drink more sensibly during a time of economic recession (brought about by psychological and economic factors);
- There is no clear link between illicit drug prices and recession;
- The evidence suggests that during recession in developed countries young people's drug use rises (e.g. cannabis and cocaine).
To eradicate the production, demand or use of drugs in the world has proved to be an impossible task based on the thinking of 50 years ago, and a new approach from the current fall-back position is clearly needed. Or as Terry Pratchett says "Going back to where you started is not the same as never leaving" (Terry Pratchett "A Hat Full of Sky").
With the failure of drug policies to contain the issue of drugs, and the rapid - and dare we say - alarming rate of spread of new drugs, the task feels really immense. Some things are changing; and others must change. Refresh your opinions by taking part in the International Drug Survey which aims to find out what people think are the harms and benefits associated with recreational drugs, including alcohol and tobacco. It is hoped that the findings will inform the growing movement which calls for a major rethink of existing drug laws.
Keep your feet on the ground here in the UK with Drugscope's invaluable Street Drugs Trends Survey, which this year showed that more people are coming to drug services for help with problems arising from the use of ketamine. The annual survey compiles and analyses feedback from 80 drug services, police forces, drug action teams and service user groups in 20 towns and cities across the UK. The survey provides an overview of patterns in the use and supply of drugs to give a snapshot of current UK street drug trends and prices.
Key messages from the Health Protection Agency's annual report this year on infections amongst people who inject drugs include:
- Infections are common among people who inject drugs, with about a third reporting having a symptom of a bacterial infection at an injecting site in the past year.
- Staphylococcus aureus and Group A Streptococcal infections continue to cause severe illness to people who inject drugs.
- Since 2000 the vast majority of reported cases of wound botulism (163 cases), C. Novyi (93), anthrax (52 confirmed) and tetanus (35) in Europe among people who inject drugs have been from the UK.
- Approximately 50% of people who inject drugs have been infected with Hepatitis C; and 1in 6 with Hepatitis B.
- HIV prevalence remains comparatively low at 1 in 100 of people who inject.
- Needle and syringe sharing, whilst lower than a decade ago, still takes place amongst 1 in 5 injecting drug users.
Despite having a large population of people who use opiates and crack, England has one of the lowest rates of blood borne viruses. However, the figures show that large numbers of people still report injecting practice that put them at risk of infection, including bacterial infections. The HPA continue to support the role of needle and syringe programmes, in line with NICE guidelines.
It is encouraging that the HIV prevalence remains low among people who inject, though with 1 in 100 of people who inject drugs being infected we cannot be complacent when it comes to harm reduction advice. The hepatitis C figures at 50% of IDUs is too high. The HPA has funded the RCGP Certificate to meet the need for Detection, Diagnosis and Management of Hepatitis B & C in Primary Care, and its immediate success indicates that there is a willingness amongst primary care practitioners to address this "silent epidemic". Coupled with the advances in treatment to eradicate Hep C, tremendous advances have been made, but more can be done. For more information about the training, see the RCGP Training page.
This research report and campaign which accompanies it, focuses on babies aged less than 1 year, as this is a critical time in a child's development and a large proportion of serious case reviews concern this age group, with three risk factors commonly identified for vulnerable families and children - namely domestic violence, mental health problems and substance misuse.
Statistics show that, of babies under the age of 1 in the UK:
- 19,500 are living with a parent who has used a Class A drug in the past year;
- 39,000 live in households affected by domestic violence;
- 93,500 are living with a parent who is a problem drinking;
- 144,000 live with a parent with a mental health problem.
For illicit drugs, the report finds that "it would be misleading to suggest that all parents who are drug users present a danger to their children" but it is a factor in a large proportion of reviews, whilst it is clear that the relationship between alcohol and parenting is complex and often influenced by other factors. The study contains information on programmes currently operating or being evaluated in the UK including Parents under Pressure, the parenting programme aimed at helping parents in substance misuse treatment to develop positive and secure relationships with their children, and which upholds the relationship between being in treatment for substance misuse and parental hopes and expectations.
The programme uses a strength-based approach, is highly individualised to family needs and will be rolled out over a period of 3 years, where it is hoped to reach 650 families across the UK.
It would be remiss to ignore the fact that drug or alcohol use in families has a wider impact than just on the person at the centre. Whilst this report caused some upset by the use of the term "toxic trio" to describe the problems of parental substance use (together with mental health problems and domestic violence), it is welcomed by organisations who work with families of people who use drugs and alcohol (such as Adfam).
Overall it supports the notion of improved practitioner response to parental drug and alcohol use. Hand in hand with this is the need to reduce the stigma felt by all family members affected by drug and alcohol use, including parents who use these substances. If practitioners are trained to a level of confidence in assessing and supporting parents who use drugs and alcohol which prevents the automatic stigmatisation of them as "bad parents", children - and families - are more likely to benefit.
Primary care, based in communities, often working with all family members and with links to a range of professions, including health visitors, is tailor made to work with parents and their children, if we are offered the right support.
For this reason, we welcome the debate engendered by the report and the chance it provides to discuss the importance of engaging with parents who use drugs and alcohol in an entirely constructive manner, and the practical nature of the programme will resonate - with all parents.
IDHDP was launched in Bangkok in 2009 with the aim of improving the participation of doctors in drug policy reform, and it has gone from strength to strength with now over 145 members in more than 40 countries - headed up by Dr Chris Ford as clinical lead.
It also aims to close the gap between evidence based practice and drug policy which exists in many countries and to lobby internationally to influence changes in drug policy where this is needed.
IDHDP offers support to doctors in their home countries or regions by having core objectives or position statements, which promote harm reduction and sound drug policies. The website has a public discussion forum, as well as one for doctor members. Have a look at their website today!