Thinking sensibly

We have been given to believe that the health components of our drug and alcohol strategies are based on what the consensus of the clinical literature has to tell us. So it is somewhat suprising that the government has just announced that the advice to pregnant women is not to drink any alcohol at all. To date the advice has been that a couple of glasses of wine a week was fine. So what has changed? Nothing. According to the deputy Chief Medical Officer, this new advice was meant to send a 'strong signal' that women who drank more than the recommended limit were putting their babies at risk. But hang on, the new advice does not reiterate the current advice on sticking to the recommended limit, but urges women to abstain completely. So the government advice is confusing from the get-go. On top of which, the Royal College of Obstetricians and Gynaecologists intend to stick to their advice that in moderation, alcohol poses little or no threat for the unborn child. And presumably they should know. So if women weren't confused, chances are they are now.

But of course, they probably never were. Governments tend to assume that unless health messages are written in block captials using red crayon, the nation falls into an abyss of hand-wringing anxiety. Women (even when they are pregnant!) are perfectly capable of making sensible decisions about any lifestyle changes they feel are necessary.

Which is just as well because the clinical evidence of long-term damage to children related to maternal alcohol and drug use is highly contested. The media love to be able to trumpet the latest scare to put the fear of God into prospective parents. But those children in most danger are probably subject to a battery of maternal factors - diet, social status, housing as well as chronic drug and alcohol use. Clinical trials to isolate risk would be unethical so as The Times pointed out (25th May) taking the cautious approach on health advice is 'as much a matter of philosophy as science'.

Prescription for better care

The cover story for the next issue of Druglink (May/June) out this week, concerns heroin prescribing with an exclusive inside look at the workings of the current UK heroin trial. But we also feature an article that looks back to a time when the only treatment for drug problems was a visit to the local GP.

Up until 1968, any GP could prescribe drugs to a user in support of their addiction. No other country allowed this and so it became known as the 'British System'. Of course, the user population was very smaller than today, just about into four figures - and located primarily in London and the south East. And there were some villains among the hero doctors, who were just in it for the money. But the principle was sound - you could see a local doctor who would assess your problem and prescribe if necessary. In fact, the head of the Home Office Drugs Branch at the time, Bing Spear, later called the decision to ban doctors from prescribing as one of the biggest mistakes of British drug policy. He strongly believed that doctors could be trusted in this respect and that the use of the Home Office Tribunal System (never properly implemented) could have dealt with any rogues.

Instead, community doctors were taken out of the treatment mix and it has taken decades to make any inroads into bringing GPs round to the idea that they can treat people with drug problems. Much of the credit for this goes to the SMMGP (Substance Misuse Management in General Practice), who recently held their 12th Annual Conference. The first conference was very sparsely attended: now 600 delegates are turning up with many more turned away. But much work remains: still only around 25% of GPs have any caseload of drug users and the rudimentary nature of GP training in this area doesn't help.

But it could well be the future: the idea that drug treatment becomes more of a mainstream responsibility for health and social care. If drug users are to be brought in from the margins, then GPs should be brought along as well.

http://www.smmgp.org.uk