Addiction is unfortunately part of the human condition. It is due to the reward system hard wired into our brains, giving us the feeling of pleasure, which is essential to keep us functioning. Emotions, reproductive drive and the instinct to eat and survive are all part of this. And it can easily be hi-jacked by substances like nicotine, drugs, alcohol, and certain foods, and it is extremely difficult for humans to fight against it. If you develop something to stop people experience pleasure, they may well not want to live. A drug to combat overeating which did just that by blocking cannabis receptors was found to increase depression and suicide rates and therefore its licence was withdrawn. However, addiction causes much misery, increases crime rates, and damages health, both mental and physical.

This is well known. Over the time that I practiced medicine, drug addiction in particular mushroomed into a major problem for society. But when I started practicing as a GP, the culture of management of addiction was very different from how it is today.

In the 60’s, while I was training to be a doctor in London, nearly all addicts were treated medically, in the same way, as they would be for any other illness. Any doctor could prescribe maintenance therapy, usually heroin and later methadone, and so patients had the benefit of one-to-one care by a sympathetic doctor. (Usually doctors who weren’t sympathetic didn’t do it, as they didn’t have to, and the patients just went to someone else). It was known as “the British system” and was almost unknown in other countries. Addiction here was thought of a medical problem with social effects, and there wasn’t a stigma attached to it nor were patients expected to stop the drug. There were punishments for illegal use and supply but these were separate from treatment. Patients had to register for treatment, and would then get their drug needs free. At the time most of the supply came from prescribed drugs, with some coming in from abroad, and drug trafficking and dealing was not a big problem. For over 40 years this system had resulted in a stable number of patients who did not have to steal or commit crimes to get their drugs. I treated a middle-aged man with oral methadone for years. He had become addicted to heroin while living abroad, but managed to get a job when he returned and held it for years until his health deteriorated with problems unrelated to his addiction.

Things changed though. We all knew in the 70’s and 80’s that there were some doctors who prescribed heroin and methadone privately in large amounts, and everyone was worried that these drugs would then get out for recreational use. In America there was a growing problem with drug dealing and severe addiction, and it was treated as a sign of weakness, so a punitive system had quickly grown up. Criminal gangs made huge amounts of money by importing drugs from countries like Afghanistan and Mexico, which were sold to Americans. This boosted the crime rate as addicts had nowhere to go for their drugs but the black market when they were desperate for the their fix. The resulting social problems meant that pressure was put on all countries to change laws to try to reduce the availability of drugs. In 1961 a convention set up to try to control global drug trading had recommended that countries should not treat addicts by prescribing illegal substances, and should allow only scientific and medical uses of drugs. It was not itself binding on countries, which had to pass their own legislation. Britain didn’t do this for quite some time, but in 1964 it did introduce penalties for possession and supplying drugs and in 1971 it classified drugs into various categories depending on how dangerous they were perceived to be – class A B or C. By the 1980’s most clinics were restricted by a lack of staff and support services. Patients were treated as “problem drug users” rather than people with a medical need. From 1991 there was more separation of medical treatment versus punitive responses by the authorities. Most treatment now went on in clinics (drug treatment centres) which were available both privately and under the NHS, but the concept of addiction, as an illness had waned, and the aim of treatment now became to get people off the drugs quickly.  Policing for possession and dealing in drugs became more aggressive with “stop and search” becoming very common, so the concept of the “British method” finally died.

Increasing availability of recreational addictive drugs made the problem very difficult to manage. Then central government became more involved with more and more laws (the Misuse of Drugs Acts) were passed for the criminal justice system. In America they have had their “War on Drugs” with some extreme penalties, but the problems only got worse.

New dangerous drugs flooded the market, and the death rate rose. However the drug scene is constantly changing and over time In America, heroin became a problem mainly for middle-aged and elderly and addiction fell slightly in poor communities. But a new problem arose there from the late 1990’s on and currently the groups who are now suffering most are middle class people who have been prescribed synthetic substances such as OxyContin, an opiate.

From 2000 on we GP’s in the UK noticed that we were being encouraged to use opiates and other really strong painkillers, not for terminal cancer or really severe neuropathic pain as before, but for non-life threatening chronic illnesses such as arthritis, and after operations, when it was often self-administered. It was about the same time as evidence showed that many painkillers we doled out weren’t really working very well, so it appealed to our compassionate side. But there were quite of few of us, me included, who were very worried about the possibility of addiction. And indeed, opiate drugs such as fentanyl and OxyContin have been very aggressively marketed and their propensity to cause addiction downplayed. This has resulted in huge sales and enormous profits for some companies, so much so that now there are many lawsuits on-going against them. Excess prescription drugs were sold on and more people became addicted, with people getting them on-line without prescriptions. The increase in deaths from opioid overdose has been dramatic, and opioids were responsible for 47,600 of the 70,200 deaths from overdose in the US in 2017. Whole communities of white middleclass Americans, such as in Appalachia, are being decimated. There is now a backlash against the pharmaceutical companies that have misled people about the addictive properties of the drugs, and the huge profits they have made. And the problem, as ever, is crossing the Atlantic. It is more difficult for patients to get hold of a large supply here than in America as prescription drugs are more tightly controlled, but patients can get them on the black market. And they are just as heavily addicted. I treated a man who was addicted to a drug which had been prescribed for intermittent abdominal pain in hospital, and he was highly dependent on it. Everyone in the practice treated him because he was highly manipulative. He was a very successful businessman with plenty of money, but he wasn’t content with paying privately in London for his supply. He wanted it on the NHS as well, so we had to register him with the Home Office in order to do this. He would never stick to the dose which was prescribed and used to tell the most brazen lies in order to get his fix. Once he phoned reception saying that he was on a business trip to Paris and that he had to stay an extra 2 days to finish a deal. He wanted his next weeks supply to be ready for him when he returned the next day even though it wasn’t yet due. The receptionist was about to instruct the dispenser to do this when our nurse told us that she had seen him in town that day. It was a real try on. But he was very difficult to resist. He caused a lot of trouble in the practice, and on several occasions had to be sent on to other practices in the area. It was a shame really because a lot of people in his business knew about his problem and he didn’t get the respect he deserved. However he did continue to work at a high level for many years despite his addiction. But of course in Britain he did have recourse to a free, safe supply.

Most workers in the field have known for a long time that criminalizing drugs and harsh penalties do not work and result in more drug addiction, more drug deaths, trafficking and a huge increase in crime. Right wing groups especially in America are very opposed to liberalising drug laws because of their mind-set of free trade and because the usual victims do not vote for them. But now their own voter base in rural white communities is suffering, republicans might care to readdress the situation.

The cannabis situation has also changed. Its use is widespread at all levels of society in all countries, and the market, worth at least £1bn per year in the UK, is dominated by criminal gangs. It results in huge levels of violent crime on our streets. So some countries are experimenting with de-criminalising cannabis and taxing it, just as we do with tobacco, which immediately reduces the power of the criminal gangs. In Canada for instance cannabis is grown locally and sold in licensed stores. The levels of two main cannabinoids, THC and CHB (THC is the one which gives the highs) are marked on labels like the alcohol content on beer. People are therefore legally able to choose to buy cannabis. However the black market still exists as it can undercut the price in the stores, so it isn’t as yet a complete solution. But another difficulty you have when cannabis is illegal is that it can then be unavailable for treating patients who might benefit from it. Cannabis has been legally supplied for many years in the UK; I used Sativex, which contains both THC and CBD, several times to painful spasms in MS, although it wasn’t very effective. Clinical trials showed a very valuabe 30% reduction in pain levels for some sorts of chronic pain. Dronabinol, another cannabinoid, can also be used for nausea and vomiting during chemotherapy. Recently after a lot of publicity the law was changed to allow patients to be treated with a cannabinoid for treatment resistant epilepsy after a family campaigned hard for it to be available for their son. Sadly, due to the paucity of clinical trials showing benefit, and the fact that it seems only a very few people would actually benefit from the drug; it hasn’t made getting treatment any easier for patients. So would it not be better to remove restrictions altogether?
Several countries and states in the US have done this, with generally beneficial results. Usually, such countries find that the amount of violent crime goes down; there are savings due to sale of drugs, and less money is spent on enforcement of the law and prisons. There are downsides though; more people use cannabis, with a risk of psychosis in susceptible people, often the young; and hospitals have to treat more cases of intoxication.

The main problem though is that legalization does not tackle the social inequity that surrounds drug use and drug markets in many countries, and drugs are still produced by poor farmers all over the world who depend on the trade to survive. Powerful drug cartels do not go away.
But actually it may not be de-criminalizing cannabis that helps. It is how you treat patients that makes the difference. Portugal seems to be taking over the “British system” with some success. After the overthrow of the dictatorship of Antonio Salazar in 1973, the country was wide open to drugs especially heroin. Under the dictatorship even coca cola and cigarette lighters were banned, and as the gates were lifted, heroin and cannabis flooded in. It became a big problem, affecting all families, rich and poor. Like parts of America today every family had had a death from drugs. But in 1973 doctors in the north of the country treated addicts with methadone in clinics similar to those in Britain at the time. Needle exchange programmes were established and gradually the ethos changed – probably because it wasn’t only a radicalized minority that was affected. Rather than being arrested, those caught with a personal supply might be given a warning, a small fine, or told to appear before a local commission – a doctor, a lawyer and a social worker – about treatment, harm reduction, and the support services that were available to them.
Social attitudes changed and clinics continued to operate and expanded, and full decriminalization of drug use was enacted in 2001. Portugal’s policy rests on three pillars: one, that there’s no such thing as a soft or hard drug, only healthy and unhealthy relationships with drugs; two, that an individual’s unhealthy relationship with drugs often conceals frayed relationships with loved ones, with the world around them, and with themselves; and three, that the eradication of all drugs is an impossible goal.
We will never get rid of drugs. There is a world wide industry which makes billions in making sure some people will get addicted, But treating addicts in a harm reduction environment offers the best way of dealing with the worst of the dreadful effects. To go back to what I said in the beginning of this blog, addiction is a biochemical pathway causing a compulsion that to get whatever it was that had triggered the biochemical process in the first place, whether the stimulus was a drug, or what we consume such as nicotine, alcohol or food. If any other biochemical pathway in the body goes wrong or is overloaded, we in medicine will try to put it right. There is absolutely no benefit to be had by punishing people or criminalizing people. That way lays disaster for the sufferer and terrible effects on the whole world. I hope public opinion is going in this direction and lawmakers will see sense. But in the meantime, it would help the whole of society if we tried to help addicts, not punish them. After all, it might be our son or daughter, or our friends who are affected.

References
The psychiatric side effects of rimonabant
NCBIhttps://www.ncbi.nlm.nih.gov/pubmed/19578688
Fat Chance – the hidden truth, Dr. Robert Lustig
Drug Legalisation
BMJ 2014;349:g5233 doi: 10.1136
British Drug Policies in the 1980s
British Journal of Addiction (1987) 82, 477-488

Opioid epidemic in the United States – Wikipedia

Portugal’s radical drugs policy is working. Why hasn’t the world copied it?
Susana Ferreira
Guardian long read, 5th December 2017