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Heroin assisted treatment is coming, but will it reduce drug harms? asks Terry Maguire

Increasingly it seems, politicians, columnists and other opinion leaders support, sometimes actively promote, further liberalisation of recreational drug-use. The Utopia they seek is to rid society of the drug-pushers and the cartels while supporting the addict who they see as a victim. The damage recreational drug- use creates in any society is unpleasant to say the least and when things are at their worst it is then, in moral panic, society moves; creatively, innovatively, frictionlessly, towards other ways of addressing the problem.

The ‘War on Drugs’ was lost years ago shortly after its inception in the early 1970s. Peter Hitchens in his 2012 book The War We Never Fought, makes the case that there never was much appetite by, what he calls, the British Establishment, to take on the social liberals hell-bent on liberalising drug- use as a human right. How we view drug- use in contemporary society is politicise with the Left supporting a more liberal, health and social care approach, while the Right support a Draconian, criminal justice approach. The problem is that today, as a result of liberal activists, recreational drugs are more available, and after experimental use, those predisposed end up dependent and in need of significant help and support in the long-term. Here again the Right and the Left differ; the Right see the addict as weak and selfish, the Left as a victim.

How this plays out in policy is very interesting. As the sides cannot agree and ideological views are entrenched things need reframed before they can move on.

A key reframing was the promotion of the medical-model of addiction now dominant and which defines addiction as a disease and directs treatment policy. Another reframing has been harm-reduction; if the addict does not wish to, or cannot stop, then drug use must be made as safe as possible.

Harm reduction makes obvious sense. Coming late to this option it is only in the past 20 years that Northern Ireland introduced substitution prescribing (methadone and buprenorphine), needle exchange services, and naloxone services. Before that a dominant paramilitary grouping brutally kept the problem at bay (in republican areas at least), but that’s going off message.

Harm reduction policies have saved lives and improved other outcomes; less criminality, less HIV and hepatitis, and more in recovery, but the number of addicts has grown and this must be seen as a problem. Few of those dependent on opiates get clean within a year of entering services and most working in addiction services appreciate that their patients using methadone or buprenorphine are unlikely to get cured of their dependency. Studies suggest only 2-to-5 per cent get clean within a year. Substitutes do not provide the rewards heroin brings, but reduces withdrawal (and blocks heroin when combined with naloxone) meaning those taking substitutes can live reasonably productive lives and that in itself is an important outcome. But too many relapse.

A few years ago I attended Addiction Northern Ireland’s 40th Anniversary event and I was impressed by the strength of the advocacy on behalf of addicts. Families, advocates, agitators, and service-users (they prefer not to be called addicts) had lots of criticisms of formal addition services. An emotional presentation from the CEO of the charity ‘Anyone’s Child’ told the personal and tragic story of her son who died of an “unnecessary overdose”. Her son did not want to use methadone and was trying “heroin assisted recovery”, but the system did not accommodate him and so he was left to use heroin of unknown strength supplied by dealers and he had to do so unsupervised. He died of a batch of heroin that was “too strong”.

What she was referring to is now called Heroin Assisted Therapy (HAT) and is the next step in the harm-reduction reframing of our opiate epidemic. Scotland has introduced HAT in a limited way in Glasgow and the Scottish government has long opposed the insistence of the UK government to retain the legislation that technically makes HAT illegal across the UK. We in Northern Ireland are moving this way too and I would predict a HAT service in Belfast in the coming months as our drug problem has, with recent deaths in the city centre, reached that level of moral panic necessary to support the next step.

I read Theodore Dalrymple’s book Romancing Opiates when it was first published back in 2008. A retired GP with prison work experience, Dr Dalrymple offered, back then, an interesting if simplistic view on drugs and their abuse in modern society. Drugs are not bad he claimed; its people’s behaviour that’s bad. Whereas there might be evidence that people in methadone services commit less crime the evidence he presented indicates that they are still prone to commit crime. Crime does not necessarily stop it just lessens.

In short, his thesis is that people, particularly men, do not commit crime because of a drug habit; their propensity to criminality existed before their drug habit began; indeed, a propensity to criminality leads to drug experimentation and abuse in the first place. Those who are drug dependent, he suggests, are people who abuse the social system to their own gain; they find it easier to be victims of social injustice than finding ways to help themselves.

They complain of horrific withdrawal symptoms if they do not get a fix when in fact symptoms of heroin withdrawal are similar to the symptoms from a bout of flu. In a healthy individual this is unpleasant, but hardly life- threatening, he asserts. You could safely say Dr Dalrymple is politically on the Right.

Addiction, according to Dr Dalrymple, is a social construct that drug-users create to ensure continued drug supply and social workers use to keep their jobs and social status. No, he declares, we need to keep the criminal focus on heroin abuse and not support prescribing in “shooting galleries”. His extreme view is that all harm reduction service should be closed down and investment made to support GPs dealing with the emerging clinical needs of dependent patients.

Dr Dalrymple’s views are too extreme for most tastes, but I do remain to be convinced of the merits of HAT and perhaps time will tell. How well HAT worked in Portugal and the other European countries now providing this service depends on who you ask. Portugal is having a rethink on its decriminalisation policy as the shine comes off that policy and reality sinks in; more drugs mean more addiction. We are not yet near a decriminalisation policy in the UK, but we have moved far into the harm- reduction reframing of opiate use and I wonder if we will reach a point where harm reduction becomes public endorsement for, and normalisation of, the very problem it is trying to address. Advocates will always, of course, say that HAT is only for the medical treatment of those who are dependent and not free heroin on prescription.