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Dorey Scrutiny Panel - Review of Drug Service in Jersey
Mr. John Sharkey, Consultant Psychiatrist - views provided by e-mail dated 14th May and 15th June 2004
The biggest drug problem for Jersey is alcohol by a long way. The amount of time at work needed to buy enough alcohol to get drunk is too low. The needs of the alcohol dependant in the island play second fiddle to the heroin addicts.
The Alcohol and Drug service is comparatively well resourced. Their time is taken up unduly playing cat and mouse with habitual long-standing drug users who want a supply of methadone and valium for free to make their addiction less oppressive. These individuals are given a restricted access to methadone and buprenorphine on the understanding that they will not use heroin. If they use heroin they incur penalties based on the yellow/red card system in football. This results in a substantial cohort of drug users who remain on methadone for a few months are off the programme for a few months due to their red card and are then back on to repeat the cycle.
A substantial number of these people show a complete disconnection between what they say and what they do, implying that they are purposefully misleading care staff.
This group which I refer to as the 'low yield' population take up a huge amount of the time of staff on wild goose chases.
I believe there is a lack of clarity about what is expected from the drug and alcohol service from the political level. On one side we are asked to avoid methadone maintenance and on the other we become targeted by excessive expectation for behavioural change. There are a group of people who will always absorb an almost infinite amount of resource for no or very modest gain. Were we prepared to allow the open recognition of the low yield group taking a pragmatic rather than salvationistic approach then the greater population at large would benefit. This would leave a small group of disadvantaged and vulnerable people (who often have genuinely sad stories to tell) to feel unhelped. These individuals need to be offered counselling and needle exchange and any or many other services other than substitution prescribing, once they have proven resistant to reasonable attempts with substitution prescribing. The methadone programme should be limited to those who demonstrate their commitment.
In my opinion these people graduate to this position by being unable or unwilling to accept reasonable interventions at an earlier stage. They appear to want to remain on opiates for ever. They absorb so much clinical time for small individual benefits but to the detriment of the overall group.
This would be morally unacceptable for some and politically unpalatable for others but in my opinion it offers the best chance of providing the greatest benefit to the greatest number of people by freeing up the staff to work with those that are amenable to behavioural change through treatment.
This is just one example of the fairest way to ration tax-payers money to public services. With limited resources it is our duty to make the greatest us of those resources with distribution on the basis of effect rather than emotion. The 'low yield' addicts use emotion and threat (generally through politicians or the press) to get what they want whenever their behaviour suggests their words are false.
Certainly a relaxation in the rules and expansion of the availability of methadone is inappropriate and even considering heroin or tablet form methadone would be an absolute disaster. Subutex has been excellent and expansion of its availability with fewer methadone slots would be better. It is more expensive and that of course is an issue.
There are issues of who prescribes and under what auspices that are worth discussing with Mr Gafoor. The current arrangement whereby Dr Marks gives free prescriptions out in free consultations (he gets a signature for payment from Social security) probably does not give good value for tax-payers money and very little discussion time with the addicts.
The real question in this is do you want people to be got off opiates or for society to feel it is doing something for a vulnerable group (which in this context tends to about rendering them an invisible chronic underclass)