Volume 1, Issue 7, Paper 2
by Dr John Marks, MB,ChB, MRCPsych
That humanity at large will ever be able to dispense with Artificial Paradises seems very unlikely. Most men and women lead lives at the worst so painful, at the best so monotonous, poor and limited, that the urge to escape, the longing to transcend themselves if only for a few moments, is and always has been one of the principal appetites of the soul
The above quote from Aldous Huxley, writing in 1951, illustrates the futility of the zero tolerance for drug use unless a fanatical tyranny is determined to suppress all who seek solace from life's vicissitudes. There will always exist a significant demand for drugs.
Where there is an influx and an outflux of people no system, however secure, can prevent contraband entering the institution.
If drug use cannot be suppressed even in a totalitarian institution such as a prison, it certainly cannot be in an open society. There will always exist a supply of drugs.
This paradoxical effect arises because to control the consumption of any commodity the state must control the supply of that commodity and regulate it appropriately. If the regulation is too lax, as now with alcohol, consumption is promoted. If the regulation is too tight, as now with opiates and other drugs, consumption is increased through peddling. Figure 1 indicates this relationship between the control of supply and demand.
UK (n=62,000,000) Reg- US(n=240,000,000) Regu- ulation lation Alcohol 1800-1870 - 1920-1960 0 1920-1930 + 1960-1990 - Opium 1800-1870 - 1920-1990 + 1870-1960 0 1960-1990 + - = insufficient regulation and increasing consumption, 0 = optimum regulation and minimum consumption, + = excessive regulation and increasing consumption.
This yields eight 'experiments' with an average duration of 51 years. Given the sizes of the populations and the quadratic nature of the variation of demand with supply, the probability of a null hypothesis, viz that the demand is independent of supply, may be calculated at p<10 exp 18 This extraordinary degree of significance (for all practical purposes absolute certainty), should not be unexpected for the stochastic laws of supply and demand have been subjected to enormous variations on the independent variable, supply. To date Western societies have expended in excess of five hundred thousand million dollars enforcing the prohibition against drugs.
In the UK, psychiatrists licensed to do so have the right and duty to control consumption of drugs by providing an optimally regulated supply. This does not really require a medical degree, but since 1920 UK law has allocated this function, almost invariably to doctors, and latterly, to psychiatrists. The very least psychiatrists could do is to operate this role properly instead of their current flagrant dereliction of duty. They rightly argue that this is not a medical job, but until they can divest themselves of this role to a more appropriate source (eg pharmacists) they should continue to discharge this duty. Currently a majority of licensed psychiatrists are not doing this from misguided notions of 'good practice' mostly emanating from the London school of thought and from America. To abandon the bad practice promoted by london and America is the first and most important thing psychiatrists have 'to offer as a wider strategy for substance misuse prevention' (BJHM editorial, 1994)
Vaillant has shown that no external intervention alters the duration of addiction. If therefore addicts recover in spite of doctors and policemen and not because of them, the best intervention (Editorial , Lancet, 1987), is to ensure a healthy, legal, live patient. Current practice ensures that they are automatically criminalised, unhealthy from adulterated drugs and overdoses (because drug composition and strength is uncertain) and 10-20% of them die (Stimson & Oppenheimer, 1982), a mortality rate similar to smallpox. Such practice is at least grossly negligent and now it is known to be unnecessary, to continue it is almost criminal.
Bschor has found (Bschor et al, 1984) one exception to Vaillant's demponstration of the impervious quality of addiction to outside interference. From Stimson & Oppenheimer's findings there would appear to be a spontaneous remission rate from addiction of 3% per annum, provided the patient lives. In 1984 Bschor et al found that the provision of a ration of the patient's drug ('maintenance') increases the remission rate to 5% per annum. Thus maintenance on the drug of addiction is the best treatment even for those eventually wishing to give up. This accords with clinical experience. It allows the patient more reflection on his life and proper attention to counselling instead of always having half his mind on where the next fix is coming from.
Dr John Marks, FRCPsych
Chapel Street Clinic, Widnes, UK
Fax: (+44) 151 410 8351
British Journal of Hospital Medicine (Editorial, 13th July) (1994) Drug mis-use and social cost. BJHM, 52, 65-67.
Bschor F. et al. (1984) Risiken und perspektiven der Drogenabhangigkeit. Deutsche Med. Woch. 109, 1101-1105.
Huxley, A. (1951) The Doors of Perception, London, Penguin.
Lancet, (1987) Editorial, (9th May) Management of Drug Addicts: hostility, humanity and pragmatism. Lancet, i, 1068-9.
Newcombe, R. (1993) The Empire Nightclub, Morecambe. Liverpool, 3D Research.
Rathbone, T. (1993) Personal Communication, November.
Stimson G & Oppenheimer E. (1982) Heroin addiction. London, Tavistock.
Vaillant (in Schneider, W. (1988) Zur frage von ausstiegschanzen und selbstheilung bei opiatabhangigkeit. Suchtgefahren, 34, 472-490.