Responding to Drug Use - Dr. M. Marks, GP, Drug Dependency Advisory Group - Transcript - 30 July 2004

DR MICHAEL MARKS, GP AND MEMBER OF DRUG DEPENDENCY ADVISORY GROUP

Section of Drug Misuse and Dependence - Guidelines on Clinical Management quoted by Deputy M. Dubras-

In a substantial proportion of patients, drug misuse tends to improve with time and age, particularly when specific treatment and rehabilitation techniques are used. There is also increasing evidence that that treatment (medical and social) is effective in maintaining the health of the individual and promoting the process of recovery. Studies of self-recovery by drug users have shown that access to formal welfare supports, together with encouragement from friends, partners, children, parents and other significant individuals, is commonly involved in the pathway out of addiction.'

1 Is addiction an illness inherent in the individual or is addiction due to the nature of opiates?

1. Addiction should be consideredas a disease not a crime.Forsomepeople, a minority, thereis a predispositiontosubstancemisuse.
2. Addictswill tend toworkthroughaddiction,assumingtheysurvive, over a period of 10 - 15 years,unlessthere is some form of majorintervention.
3. Average life expectancy for an addictis35yearsofage.(Disputed)
4. Addiction is a revolvingdoordisease - peoplecomefortreatment,leaverelapseand return fortreatment.
5. Family lines of alcoholaddictioncanclearly be traced in numerouscases.Studies have not been undertaken in respect of opiates.However,opiates are muchmoreaddictiveand withdrawal is moresevere.
6. Pink List'(aconfidentialdocument listing drug addictstreated by GPs - which mustby law be reported toMedicalOfficerofHealthwithin 7 days).

• In 1998 there were 149 names; 9 have died; 14 are still in treatment.

• In 2004 there are currently 231 names, of which 102 have significant known criminal records - 30 are currently in prison with sentences amounting to a total of 100 years.

2. Harm ReductioninPrison

1. Medicationcurrentlywithdrawnfrom addicts on reception includingthoseonremand,not convicted - allowed togointowithdrawal,givendihydrocodeine(whichDrMarks is not allowed touse)treatmentprogrammecutoff - there is no medical justification for that happening.
2. DrMarks has raised this issue with MedicalOfficers at the Prison.Thepractice is justified by thePrisonforvariousadministrativereasons - but a questionable practice in terms of Human Rights.
3. Harm Reduction measures in Prison - We need to stop talking about a programme which is designed to get people off drugs. Harm reduction should be the policy at all levels, in and

out of prison. It isn't currently the case. My obligation is to get everyone I'm looking after off drugs

preferably sooner rather than later. There are budgetary constraints, protocols, designed to take people in off the street onto substitution medication, reduce the dose and off. There is harm reduction in place in the community, needle exchange, free condoms and so on.'

4. It makescommonsense to have harm reduction measures in place in thePrison.Since there is a number of addicts in thePrison(andthere is evidently a ready supplyofdrugs getting in and needlesharinghappening) they should have accesstosimilar harm reduction measuresavailabletothoseontheoutside,tominimisetheimpactof them beingthere, otherwise there is a risk of spreading infection within prison and to thecommunity.
5. Cost of keeping a prisoner at La Moye = £42,000 pa.Thecost of keepingthe 30 sickpeople (mentionedabove) in prisonamountsto £4.2 million.
6. 70 % of prisoners are addicts or mentallyill - often both.(UnitedKingdom f igures)

3. HIV andHepatitis C

1. In seeking out HIV in thedrug using communityDrMarks has yettofind a single new case. (NOTE:subsequentlydiscoveredonecase)
2. Hep B vaccinationsare available free at weeklyaddictionclinic.
3. Hep C iscommonamongdrug using population - but nowherenearasprevalent as in United Kingdom.50%negativity in drug using should be seen as an opportunity to stopthat group spreading the disease.
4. Cost of treatingHep C veryexpensive - weareonlybeginningtosee the impact in the community. It takes a longtimetofeedthrough into thecommunity - it's a monsterofgreat proportionswhichhopefullywill be addressed by immunisation in thefuture.

4. MethadoneSubutex and alternatives

1. Pleased to be usingsubutex - by choice,would only usemethadonein limited specific circumstances.
2. Unable to prescribe subutex to those using valium or benzodiazepines due to licence restrictions(theseareignored in Australia)
3. Subutexmuchsaferbecauseit's a blocker not just a replacement;easiertowithdraw from; no need forcommunitynurse visits
4. Cinderellaservice - lack adequateaftercare to keepaddictsoffdrugs - staff facilities resourcesalmost non existent by comparison with facilities andexpenditure on prisons.
5. Anotherwayofgoingbeyondmethadone - In Australia,naltrexone(opiateblocker)used effectively as implants - allowstime with aftercare tolookupon life in a different way - regarded with seriousdisquiet in publicsector in UnitedKingdom.

5. Heroin

1. Heroin confiscated by enforcementagenciescannot be recycledforlegaluse due to levels of purity.
2. Low price drug at sourceeg in Afghanistan.
3. Cost of heroin in Jersey is veryhigh(highestinworld) - £20,000 pa to feed drug habit.Drug useseldomshowsincrimestatistics.
4. Youngpeople mainly whocomeintocontact with the Law and are then pushed into prison ratherthantreatment.
5. Wrongimpression that we have a lot of hardcoreusers in Jersey.Manycomeintocontact with drugs at early age - under16.Wecouldhave a majorimpacton this group - weshould go at with every possible option - theyarenotyetdied-in-the-wooladdicts - weshould be tryingtosave them from a disease with results in shortlifeexpectancy,marginalisation, debilitation.Young are a veryvulnerablegrouptargeted by pushers.
6. Easyto distinguish professionaldealersfrom addicts -

The conviction of a confirmed addict for possession with intent to supply should be struck from the book'.

6. Windowofopportunity' - Whydoesthereappear to be a lack ofimmediate responsetopeople in crisis?

1. Limited numberofkeyworkers at ADS with a veryheavycaseload.There is a duty counsellor on callatADSbetween 9am and 5pmwhocanrespond to peoplewho call at GloucesterLodge.
2. Thereare various protocolsinplace,designed to identifythenatureoftheproblem, confirm the addiction,assesshowtheycanbehelpedmosteffectively.Itdoestaketime - but it shouldnotbemorethan a fewdays.
3. Thereare safety issuesinvolved - eg clients can't be startedon a methadoneprogramme over the weekend when there are nostaffavailabletomonitor.

If I start a patient on methadone on Thursday and he dies on Saturday, then I go to prison'.

4. Therearen'tusuallywaiting lists formethadone or subutexprogramme - at present, however,there is a waiting list becauseDrMarkshas been away in Tanzania,sothere have been no clinics.
5. Thereare two otherGPswhoprovideservicesforaddictsin their surgeriesupto a point, within theconstraintsappliedbytheirpractices.
6. DrMarksworks on a voluntarybasis for ADS,not on a contract basis. He is paid a fee by the States but theservicetotheclient at his addiction clinic is free.The clinic operates out of hours - at lunch time or in theevening.

7. Use of voluntaryagencies - is theresufficientimportanceattachedtothem?

1. Favours12stepapproachasthebasisoflife-longabstinence - nothingtobeat it.
2. Tremendoussuccessrateforplaces like thePriory in UnitedKingdombutvery expensive(£4,000 a week)and based on self-selectionsothesuccessrate is veryhigh.
3. Thereis a seriousproblempersuadingpeople between ages 16 and25 to adopt this approach.There is a placeforresidential facilities based on an alternativeapproach but it is probablybetterfor young people to beoff the island - it is too easy to walk out aftersome weeks and renewformerdrugcontacts.
4. Nointentionofrunningdownlocalresidential facilities - this ispart of a widerdebateon after care and psychologicalsupportandmeritslongerdiscussion.
5. He believes thatthe Island isworkingtowardsincreasing referrals to voluntaryagencies as thereisnow a budget,£70,000,for this purpose,butonly recently.

8 Opting out of treating addicts.

(a) New United Kingdom contracts for GPs, likely to be adopted as a model here in Jersey, allows GPs to opt out of treating addicts. This already happens at a high level here in Jersey

- very few GPs treat addicts.

(b) He sometimes reminds colleagues of this statement by the General Medical Council -

It is unethical for a doctor to withhold treatment for any patient on the basis of a moral judgement that the patient's activities or lifestyle might have contributed to the condition for which treatment was being sought. Unethical behaviour of this kind may raise the question of serious professional misconduct.

9. Centralised Community Service - how would it work?

1. DrMarksexplainedthat he enjoyedwhathewasdoing - an interesting area of medicine becauseyouachievegoodoutcomes(like an obstetrician!). Youchangepeople'sliveswith relatively smallinterventions - but hewon't be aroundforever.
2. Hewould love tosee a good generalpractice based communityservice, with younggroup of professionalsdoingthejob he is currently doing but in a recognisedcontractualway.He wouldgive priority to this overbuilding a newwingfor the prison.
3. An example is SpittalStreetcentre in Edinburgh,one of mostfamous in theworld,whereall addicts referred by GPs.Theopposite of divideandrule.
4. The moreyou allow addicts to be treated in thecommunity, with 100 GPseachdoing what theylike,thelesscontrolyouhave over what is going on.
5. The Island could do a greatdealmoretoprovidecommunitydetoxandaftercare through a centralisedservice - we are dealing withthefuture of youngpeople,the future of our society.
6. Addiction is a problemforthecommunityto deal with.There is no problem with operating

a subutex programme in the community.

7. Residentialdetoxshouldnot be part of thepsychiatricservice.It is usedcurrently becauseanadequatecommunityservicedoesn'texist.Ingeneralpsychiatricwardsarenot designed or equippedfordetox.
8. Thereisanargumentforshootinggalleries', ie safeenvironment,where addicts canuse safely in a supervisedenvironment.Itwould be betterforeveryone - eg reduce the risk of findingneedles on beaches.
9. Gold standardprescribers'shouldbe allowed toprescribediamorphinetoaddictsbut in very rare circumstances

10 Dealing with addiction - should we deal with the whole person, the root personality

causes or just focus on physical effects of using opiates?

1. If psychologicalissues are not dealt with, clients will comebackrequiringfurthertreatment.
2. A highproportion of addicts have dual pathology.DrMarks is alwayson the look out for psychiatric problems - As muchpractisingpsychiatry as conducting an opiatesubstitution programme.
3. He has verygoodsupportfromthe psychiatric service - he canaccess a consultant on the phone and get a consultation within a week.Thismeans he isabletosee a number of quite seriouslyillpeoplewithin the communitydealing with drug andpsychiatricproblems.
4. Hecomes into conflict withpsychiatristsoverissue of depression.Hetendstoreactearly in treating depressionotherwise it willleadtofailure with other programmes.There are particularmedications - such as mirtazipine - which are effective in reducingthe side effects of opiatewithdrawal.Up to halfhispatients are on this medication.Mostinstances of depression in thecommunity are seen byGPsrather than psychiatristswhotreatonlythe mostseverecases.
5. It is vital to follow upopiate substitution programmes but thisprovesto be very difficult. Patients,whohavereceived free treatment in his clinic foraddiction, are then expected to pay forfollow up treatment.

11. Other issues

(a) Reference was made to other issues outside the remit of the Panel, including decriminalisation of drugs and cannabis-induced pyschosis.