Tubby or not tubby: that is the question

The Patients’ Association was up in arms this week because the National Institute of Health and Clinical Excellence (NICE) gave the green light to offering material reward for compliance with drug addiction treatment - known as contingency management. NICE have come under fire from patient groups, including the Patients' Association, over decisions not to recommend the prescribing of certain drugs for breast cancer and Alzheimer’s. However, the Patients' Association expressed its dismay by attacking those with drug problems as having brought it on themselves, a product of their own lifestyle choices.

But imagine how much more angry they would be if NICE announced that there would be no more free treatment on the NHS for those whose health problems were brought about by alcohol, smoking and in particular obesity. A recent report by the Foods Standards Agency discovered that obesity was as likely to be found in middle-class families as those on low incomes. And a government-commissioned report leaked to the Observer (29th July) revealed government’s three-year target to reduce unhealthy eating was pie in the sky and that the NHS “will have to spend billions more pounds every year on treating patients with obesity-related illnesses”. Let he or she who is without sin cast the first doughnut.

DoH!

Question 34 in the government drug strategy consultation document asks, how can we improve the effectiveness of specialist drug treatment services…? Well, for starters how about not cutting £50m over three years from the pooled treatment budget as revealed in the Sunday Telegraph? (29th July).

Harry Shapiro

Cannabis: unanswered questions

In keeping with most commentators and DrugScope, Mary Riddell in Sunday's Observer (22nd July) criticised the decision to review yet again the classification of cannabis as an unnecessary distraction from the real problems surrounding drug use in the UK. The only rationale for the decision appears to be the continuing belief that cannabis is stronger than it used to be and so hence poses a greater threat to mental health. Mary Riddell acknowledges DrugScope's view that there is no 'robust evidence' for this, but points out nonetheless that she knows of young people who have stopped smoking cannabis because they became frightened of the effects. So what might be happening?

It could be that across the board, cannabis being smoked in the UK, either home grown herbal cannabis or imported resin is much stronger than it used to be. But the only way to establish the general level of THC content is to actually spend some money finding out because the Forensic Science Service does not routinely test for cannabis potency - this is not required for the purposes of criminal prosecution. However if government policy (and public perception of risk) is being driven by the potency issue, then surely some simple testing of samples collected nationwide could be done? Obviously you cannot then match the results with samples from five or ten years ago, but you could then search the forensic literature for any indications of trends. This would not produce definitive answers, but at least it would add to the evidence base and help inform the debate.

What else might be happening? Many of those working in the field are familiar with the idea that how drugs might affect the individual is not simply the product of the drug itself. Effects can be influenced by what the user expects to happen (called 'set') and the situation in which the drug is being used (called 'setting'). The literature suggests that of all the drugs, what happens to somebody under the influence of cannabis is particularly susceptible to the drug-set-setting formula. In effect, users have to 'learn' how to react to cannabis and this explains why many first time users say they experienced no effects at all from smoking cannabis. It is not impossible that some young people report experiencing stronger effects from cannabis not because the drug is actually stronger but because they believe it is stronger through a combination of persistent media assertions that it is and the reinforcing beliefs of their friends and those selling cannabis who would want customers to believe that their product was 'the real deal'.

But even with some more flesh on the bones of these issues, we would still be left with unanswered questions about how cannabis toxicity relates to health problems and it may be beyond the scope of medical ethics to answer these points conclusively. Which ultimately brings us to the position that any sensible policy should consider what is most likely to happen to most people who choose to smoke cannabis based on the best possible evidence available and not be unduly influenced by unsubstantiated assertions of risk.

Harry Shapiro

'Radical' change on drugs policy?

Before entering Number 10 Downing Street for the first time as Prime Minister, Gordon Brown promised “a new government” with “new priorities” and repeated the word “change” six times. What some describe as the most extensive cabinet reshuffle in 60 years was completed within hours.

A honeymoon period (e.g., a becalmed media and/or Opposition) is to be expected, but the phrase “a week is a long time in politics” is no less true for being the cliche it has become. Policy will shape public opinion, as much as obsession with style and how the new PM responds to “events” (already being tested) - so perhaps it was no surprise that the long awaited consultation paper on the next drugs strategy has been delayed. Due on 15th June the Home Office halted publication because the soon to be PM was taking “a close personal interest.”

The consensus among officials is that the PM's interest is a good thing, but views differ as to whether any changes to the document – and the future direction of travel on drugs policy - will be minor or substantial. Either way, the consultation (which must last a minimum of 12 weeks) may not start much before the end of July. A new drugs strategy is unlikely to be published until early 2008.

Speaking at the annual conference of the Association of Chief Police Officers (ACPO) on 19th June, Gordon Brown promised a “radical review” of the drugs strategy. He said, for example: ”…a new strategy needs to reach addicts earlier to get them into treatment, and we need to find what works best in getting them to stay the course. And drugs education needs to reach children at an earlier age in primary, as well as secondary schools, and to help families and communities protect them from the dealers and the gangs.”

Not much detail so far, but Gordon Brown is unlikely to promise a “radical review” unless he means it. It does not necessarily mean that there will be (immediate) radical change following the formal consultation, but it would be naive to rule it out – and the PM knows a potential hostage to fortune when he creates one.

It is difficult to read the runes on future drugs policy by those appointed to new cabinet and ministerial positions. Vernon Coaker MP continues as Under-Secretary of State at the Home Office and may well continue to have responsibility for tackling drugs, but at the time of writing (1st July) the Home Office website does not list individual responsibilities for the new ministerial team. Otherwise, all is change: a new Home Secretary and Secretary of State of Health; Caroline Flint MP, previously at the Department of Health with responsibility for drugs and alcohol, has moved to the Department of Work and Pensions...

But one cabinet change already looks to be significant: the appointment of Ed Balls MP (long-term adviser to Gordon Brown) as Secretary of State for the newly created Department for Children Schools and Families. Bringing together for the first time policy affecting children and young people, the new department's responsibilities include not only "working with the Home Office and the Department of Health on tackling drug use and with the Department for Communities and Local Government on youth homelessness and supported housing", but it will also "lead a new emphasis across government on the prevention of youth offending" [emphasis added!].

Is it surprising that Gordon Brown has, so soon, flagged an interest in drugs policy? On the one hand it could be read in part as a precautionary tactical position, demonstrating 'tough on crime, tough on the causes of crime' credentials before the Conservative Party possibly attempts to seize the agenda when it publishes the report of its Addictions working group. On the other hand, a politician with a keen interest (indeed passion) in tackling poverty and social exclusion cannot but be concerned about the causes and impacts of drug and alcohol misuse, and the marginalisation and stigmatisation of people dependent on drugs and alcohol, and their families.

Although both the Prime Minister and the Leader of the Opposition have been prepared, at different times, to address the difficult issue of drugs policy, it may be naive to hope for less party political posturing and instead a growing consensus. But perhaps not: we live in potentially interesting times. There will be a lot to debate and discuss over the next few months.

There is at least one issue that new ministers with responsibility for drugs and alcohol should look at, and urgently, not least because it goes against the emphasis on improving the lives of young people and the importance of prevention – and that is the cut to the Young People’s Substance Misuse Grant. As we will be highlighting in the next edition of DrugLink magazine, the cut is hurting and is, basically, indefensible.