Archive for December, 2012

Aw you guys…

Monday, December 31st, 2012

I hope everyone had a lovely Christmas and you are all now dusting off your raving shoes for a big one tonight. I am staying in, as although some time off work has made me despise the human race slightly less, I’d still prefer not to squash myself against sweaty drunk people, and besides I am a complete nutter magnet. Plus I always find myself feeling grotty as I have to play ‘Spot the Substance’ (can’t help it, occupational hazard). So in summary I’d rather be sitting here with a Stella talking to you lot.

Below is a very professional-looking report sent to me by WordPress, who host my blog. (If anyone is thinking of starting writing a blog, use them, I can’t recommend them enough.) This report has forced me to reflect on a couple of things, and it seems timely to share them:

– I have only been writing this blog for 8 weeks! I seems bizarre because it now feels like a part of me, integral to my life, but it is really still very much in its infancy.

– in those 8 weeks, my blog has been viewed over 1200 times, by people from 14 different countries, and that doesn’t include the emails that go out to the 64 people who have signed up to receive updates. If I include the email views, the total number of views is closer to 2000.

Now this might not sound impressive to people who are pros at this game, but let me tell you this – it blows my mind. The idea of having an audience at all, never mind one so vast and so diverse – well, it makes me feel proud, and positive about what 2013 may hold.

And so, although it may seem somewhat lame and premature to be making something equivalent to an Oscars acceptance speech, I would just like to say THANK YOU to everyone who has read my blog, everyone who has contributed with comments and feedback, everyone who has told their friends and colleagues about it, everyone who has put links from their own sites and Facebook and Twitter accounts, and everyone who has got in touch with words of support. As some of you know, it has been a funny few months for me, and having this focus, this outlet, and this beacon of hope that maybe things can be different – well, it has been a joy and a privilege. So genuinely, thank you, may 2013 bring new beginnings for us all, and HAPPY NEW YEAR!

And for those who need it, I am available for substance-related support tomorrow.. 😉

Here’s an excerpt:

The new Boeing 787 Dreamliner can carry about 250 passengers. This blog was viewed about 1,200 times in 2012. If it were a Dreamliner, it would take about 5 trips to carry that many people.

Click here to see the complete report.

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From drugs work to the grave

Tuesday, December 18th, 2012

It’s a funny thing, contemplating a career change. We all spend years expressing internal groans at the sound of the morning alarm, hiding underneath the duvet, begging and praying that some natural disaster has occurred overnight that will suffice as an excuse not to go in today (death for a few people is surely a justifiable pay-off, no?), only to discover from a quick scan of available media that today is a day like any other. Shitbags. But the brief glimmer of hope that you might not have to deal with X,Y and Z today has meant, unavoidably, that you have now carved a brain-path directly to X, Y and Z – and so work starts straight away.

The simple joy of the morning shower is spent internally arguing with the nob-end that sits near you in the office, who you would never come into contact with socially and would subtly shuffle away from if you had the misfortune of a chance encounter in a public arena, but have to not only tolerate but attempt to be civil with, every miserable working day, leaving you resenting your pay-packet because it represents you whoring your soul to the devil. Then breakfast, surely intended as a pleasant and civil part of the day, is made somewhat less so as your bran flakes remind you of the dead, flakey skin around yesterday’s necrotic wound, and you find yourself wondering whether this would have the texture of a freshly-served crisp flake or a milk-soaked chewy one. And despite your attempts to gee yourself up with one of your favourite albums on the way to work, the sense of impending doom induced by the knowledge that today is going to entail battling the Safeguarding referral system (“Sorry, run that by me again – this is supposed to be a high-threshold, fast-response referral process, created to protect children from the most severe types of immediate harm, but you won’t take verbal information and no longer offer the facility for me to discuss the case with a social worker first – so I have to spend an hour completing paperwork, then face the traumatic, potentially damaging and counter-productive scenario of informing the family I have serious concerns about their parenting and so are breaching their confidentiality, in the knowledge that you will probably knock it back or do nothing about it anyway?”) means that you may as well be listening to someone shouting “You are mortal and one day, possibly soon, your time on earth will be over, more than likely following a period of extreme pain” in a broad South African accent, for all the relaxation the music provides. And that’s before you get to work to discover what shit has hit the fan overnight – who has been arrested, who has been admitted to hospital and, unfortunately, on occasions, who has died – and start getting paid.

But – for all its pains and strains and drains – not only does it pay the bills, it has seen you through some hard times. There is no better distraction from a failing relationship than a critical deep vein thrombosis with severe cellulitis; no quicker way to forget about personal tragedy than premature labour induced by persistent crack use.

However, without this job, would the relationship fail? And for everyone one case worthy of your emotional input at a time of personal heartache, how many needless metaphorical arse wipes must you perform? How many faces do you imagine smashing into desks with screams of “If you rip the copper out of your own boiler your landlord has every right to evict you, that doesn’t make you a victim – my own tragedies far surpass yours so I frankly couldn’t give a shit about the hole you have just dug yourself into!”? Imagine getting home each evening with something left to give other than anger and irritation at the world…

It’s a strange pay-off, and one which I am currently making attempts to unpick – is the emotional investment (or drain) offset by the distraction from one’s own problems? To what degree are these intense investments and distractions responsible for the lack of progress in one’s own life? And, fair enough, I might not want to be a drugs worker any more – but if not a drugs worker, then what? Do I have an identity at all? Or if I jack it all in, will I slip into a deep depression, brought on by a sudden lack of purpose, and find myself opening cans of baked beans with a screwdriver underneath a motorway bridge?

The only way I can resolve this internal dialogue is to remind myself that – if I stay in this job, I am likely to become ill(er) in the head, have very little or no chance of maintaining a healthy and drama-free relationship, and will probably, at some point, slip into a deep depression and find myself opening cans of baked beans with a screwdriver underneath a motorway bridge. I think I can make a fair, educated guess that, in this case, it is not better the devil I know. And so, career or no career, there is no healthy future for me as a drugs worker – and whatever the months and years ahead may hold, at least for now I have you lot to rant at, and have a sense of purpose in my attempts to inform and entertain. Thanks guys, you are keeping me (relatively / debatably) sane. And anyway, I like bar work.

Decriminalisation: And the point is….?

Wednesday, December 12th, 2012

In response to my post on MCat (Maurice the Feline), and following the media coverage this week, someone got in touch to ask me my opinions on the decriminalisation of drugs. It’s a tricky one.

If you’re wanting a short, sharp answer to be able to fire off in the office or at dinner parties to make you look intelligent; firstly, you’re in the wrong place, and secondly, sorry but I have more questions than answers on this one.

The first thing that irritates me is the term ‘drugs’ (which I admit may seem odd given my job title). My dispute with the word began whilst working at a ‘Drug and Alcohol Project’ (I have an issue with this use of the word ‘project’ too, but let’s stick to one pedantic rant for now). So I was a drug and alcohol worker. How anyone working in the field could have missed that alcohol is, in fact, a drug was beyond me. I’m no closer to finding the reason for using this terminology so regularly within the field of substance misuse (another stupid coined phrase – who defines what is use and what is misuse??? Probably the same people who pretend that alcohol isn’t a drug. Idiots). The reason it tits me off so significantly is that alcohol is, clearly, so much more damaging than any other substance I have encountered, both in terms of the poisoning effect it has on the body (compared to, for example, heroin, which in its pure form causes NO damage to internal organs), and the fact that every single regrettable incident in my life occurred whilst under its influence. Therefore, the only reason I can see for separating it from other, less sociably acceptable drugs is for the purpose of corporate sale, and to enable the piss-head policy-makers to put some hazy distance between themselves and the demon drug users.

The second issue I see relates again to categorisation. To use the word ‘drugs’ to represent a homogenous group (apart from alcohol… and prescription medications… and things we drink to wake us up a bit at work…) is over-simplistic and nonsensical. And so to discuss decriminalising ‘drugs’ – well, I don’t really know what that means.

Let’s imagine, for example, that on one hand we have a 40-year-old professional who smokes cannabis at weekends, and on the other hand, we have an 17-year-old NEET (not in employment, education or training) who injects crack cocaine eight times a day. These two people have different relationships with their drugs of choice – one is likely to consider himself a recreational user, the other is likely to consider himself as dependent – and so their interaction with the substance will vary unrecognisably. Cannabis Man (wouldn’t that be world’s most boring superhero) may consider his drug as an old, reliable friend with whom he can relax and enjoy a chuckle after a busy week. Crack man (he sounds like a crap porn star) may see his drug as a possessive and abusive partner, a stalker, following him everywhere, getting into his thoughts, forcing him to do things he doesn’t want to, ruining his life. Now the relationship between the drugs and their users are poles apart; so how can they be lumped together as if we were discussing broccoli and cauliflower?

Consider again Cannabis Man, and compare his cannabis use with that of Cannabis Girl, a 13-year-old who has been brought up between her grandmother and local authority care because her schizophrenic mother is unable to parent her consistently. They are taking the same drug, but their reasons for smoking it, how they get the money to smoke it, where they smoke it, who they smoke it with, the effect it gives them, and the likely outcomes of smoking it, are very different. They may both feel that smoking cannabis enhances their lives – but it doesn’t take a psychiatrist to see that Cannabis Girl is pretty much heading for the nut-house and will most likely spend her adult life receiving transmissions from extraterrestrials and ducking the invisible bats of death.

Now let’s play a little game – I’ll call it ‘Theresa May.. Or May Not Know What She’s On About’. The home secretary was quoted in The Guardian as saying “People can die as a result of taking drugs, and significant mental health problems can arise as a result of taking drugs.” Take this phrase and remove the words ‘taking drugs’, see what other phrases we can put in their place to make the sentence less pointless. (Sensible choices might be ‘base-jumping’, ‘war’, or ‘Big Macs with cheese’, but you can in fact entertain yourself for some time thinking how death-by-…. might occur – and I will guarantee it will be more interesting and less blandly stereotyped than death-by-drugs. Suggestions welcome.)

I think there are few people who believe that Cannabis Man is a criminal, or would see be any real benefit to the public spending their money labelling and punishing him, and most would see that in charging him with possession of an illegal substance we would probably be doing the country a disservice by adding him to the queue at the Jobcentre. But then wouldn’t we say the same if Cannabis Man also had the odd line of coke at a party? Or even if he had a penchant for the occasional smoke of heroin, as a reminder of his time travelling in Thailand, if he did it in the privacy of his own home and still got up for work on Monday morning?

So my point is – it’s not ‘drugs’, or even any specific drug, that causes problems, it is the context in which the drugs are used. You only need to look at the range of experiences available from the current use of alcohol to see that. Or, to drill down the point, to look at khat use amongst Somali refugees – this plant, chewed as a social custom for thousands of years in parts of Africa, and still widely so, has had devastating effects within some Somali communities in the UK. The substance is the same, the people are the same – but the environment is different, the life experiences are different, and the circumstances within society are different. It is these factors, not the drug itself, that has increased susceptibility to abuse.

So I suppose, in terms of decriminalisation, these points would lean towards the ‘yes’ argument, as the drugs that are classed as ‘bad’ are really not all that different to those that are considered fine and even normal.

I have to say though, when we look at the incredibly damaging spread of the ‘legal high’ where, as I’ve said before, ‘legal’ is often wrongly considered synonymous with ‘safe’ – and then consider a group of teenagers explaining to each other the difference between ‘legal’ and ‘decriminalised’ – I am having visions of the off-side rule. (Come on, most people can’t even define a unit of alcohol..)

One last point, which is somewhat extraneous as it is about legalisation instead of decriminalisation – bearing in mind the number of people who already buy drugs illegally, does anyone actually think that the majority this group would buy taxed goods legally? Legal, decriminalised, illegal – there will always be a black market, and it will always be cheaper than the squeaky-clean one.

To treat or not to treat (Part 2)

Wednesday, December 5th, 2012

Sorry I went off on one a bit yesterday. I was in a vile mood. And sorry to mental health nurses in Community Drug Teams, I do recognise there are some of you out there who are very committed to working with drug users and aren’t just in it for the supervised urine tests.

The point I actually intended to make before I got side-tracked by my own negativity and social bitterness was – who should receive drug treatment, and who shouldn’t? The political back-drop I outlined yesterday does have an impact on this, as there are trends, depending on who is in power, how they feel about drug users, and how much money is available. However what I want to briefly consider here is a more clinical perspective.

When I first started as a treatment worker many years ago, prescribing methadone was perceived as an additional risk factor. The logic was that if someone was taking central nervous system (CNS) depressants, such as heroin, alcohol, benzodiazepines such as Valium, (all of which, may I add, are widely sought-after by engrained heroin users, and a combination of which is almost always present in cases of fatal overdose), and now the new wave of nerve painkillers such as pregablin and gabapentin, then adding another CNS depressant such as methadone would increase the risk of overdose.

Buprenorphine (Subutex) therefore became a popular choice – another opioid but which only works on two of the four opiate receptors in the brain, and so stops withdrawals without sedating. Subutex also blocks opiate receptors, making it difficult to get any effect at all from heroin when taking a regular, reasonably small dose of Subutex. It is brilliant stuff. However, in order for it to work, no heroin can be used for 12 hours before taking the first dose, and of course little effect can be gained from further heroin use – so needless to say, it is not a popular choice amongst the old hardcore. (Now in prisons, where it is crushed and snorted to get a buzz… that is a different matter.)

So, imagine that you are assessing someone for treatment – they come in and tell you that they are using heroin every 6 hours and their mental health isn’t great. Subutex might not be appropriate as they want the sedation provided by heroin to manage their mental state, so you decide together to opt for methadone. But this person has no intention of stopping heroin use at present because it is the only way they can block out the trauma they experienced as a child, which they do not feel ready to address until they have somewhere stable to live.

So the question is – do you offer them treatment?

In the olden days, the answer would have been “No”. People had to say they had no intention to continue using heroin once receiving a prescription, and this was monitored through regular drug tests. Any heroin-positive urine samples sent heads spinning, and would probably result in being given an ultimatum, and possibly no prescription (ouch). The logic behind this was that dual use would increase overdose risk.

The harm reduction movement changed that – once people had dared to continue to prescribing to those still using heroin, research showed that high doses of methadone not only ‘drowned’ opiate receptors and so also had a blocking effect, making it more difficult to experience the euphoric effects from taking heroin – but the surprise conclusion was that people were actually LESS likely to overdose when taking heroin on top of methadone. This was because people’s tolerance to opiates was so high that risk of overdose was greatly reduced, as long as they took their prescribed dosage daily to maintain their tolerance at this level. (If you imagine an alcoholic, who is used to supping a bottle of whisky a day, drinking half a Carling… if you want to try this experiment at home, get yourselves down Wetherspoon’s with a £1.40 in your pocket and talk to anyone sitting alone at the bar.) Plus, taking a decent dose of methadone meant no withdrawal symptoms; and so less frequent injecting, less dodgy, desperate injecting, and so less hepatitis C, HIV, deep vein thromboses and cellulitis. And so the answer back then would have been, “Yes, treat, and keep treating until they get bored with paying for something they aren’t getting an effect from”.

So how would the question be answered today? Well although methadone in itself is pretty cheap, and Subutex not unreasonable, the cost of these medications often lies in the level of monitoring that is required, because they are ‘controlled medications’. This often means paying the pharmacist to dispense it in single doses and supervising its ingestion each day. It also means more frequent monitoring by doctors and drug workers to ensure that prescribing is safe and to reduce extraneous risk factors such as mental health problems and homelessness.

The truth is, as the money dries up, doctors and mental health trusts are going to be significantly less interested in working with heroin users. Half of those still walking around have got bits dropping off them – open abscesses you could fit your fist in at the top of each thigh and swollen, purple legs, from injecting into the femoral vein and irreparably damaging the blood supply to the legs; terrible general health from years of poor diet and jabbing bacteria-laden substances directly into their blood vessels; and quite probably hepatitis C. To treat, they are expensive and time-consuming. And so, I fear, the answer to the question will increasingly be, again, “No”. And doctors can be extremely eloquent and creative when it comes to finding justifications for why someone is ‘not appropriate for treatment’.

Oh god, I’m having a go at doctors now, what is my problem?! I’d better go before I piss off the whole medical profession and start making wild claims like “All radiologists are gay”…

To treat or not to treat, that is the question

Monday, December 3rd, 2012

A recent paradigm shift within the drugs field has further complicated an already difficult and lively debate around what constitutes drug treatment and who should qualify for it. This movement has, weirdly, sprung from a combination of both grass-roots support groups and the Coalition’s austerity measures.

In years gone by (and still in some regions today), Community Drug Teams were primarily made up of mental health nurses who, from what I could see, had got fed up with shift work on acute wards (having to work nights with full-blown nut jobs) and decided that community work was probably a cushy number (9-5 weekdays and 44p a mile). On the whole, these services met very nicely the needs of the nurses – and the prescribing psychiatrists – who admittedly had to endure sitting in grubby rooms in run-down buildings (god forbid drug users be seen in health centres and mix with the public), escorting their patients to the toilet for weekly supervised drug tests in return for a methadone prescription. Services were there to treat, almost exclusively, heroin users; a social group who, at the time, were massively excluded and disempowered, and who were very much at the services’ mercy. The power dynamic was engrained and aggressively maintained – CDT consultation rooms were reminiscent of Dickensian orphanages, and for those of us new to the field and not (at that point) full of cynicism, it was uncomfortable to witness. The approach was not holistic, nor did it address the psychological or social needs of the individual, and only those prepared to dip their caps, express their subordinate gratitude, reduce their drug use as instructed, attend regular appointments, and grovel for several weeks, if not months, ever made it past the waiting list for a prescription.

For those who did make it as far as an appointment with the prescriber, the only treatment available was low-dose, short-term methadone. The standard treatment plan was: enter treatment, stop using all drugs immediately, then reduce methadone dosage rapidly until opiate-free. Unsurprisingly, this method was rarely successful, as not only did it leave service users in a state of opiate withdrawal from treatment start until several weeks after treatment end, it also failed to take into account the person’s reasons for starting to take heroin in the first place – so as the opioids reduced, past trauma resurfaced, mental health problems were unmasked and exacerbated, and the reality of life hit right between the eyes. And should Mr Druguser share his concerns with Mrs Nurse, possibly disclosing self-prescribed codeine or Valium use to manage the symptoms produced by fast detoxification from methadone, he ran the risk of being labelled ‘not ready for treatment’ and being plonked back onto the waiting list. People could sit on these for up to a year in some areas, and the nurses seemed to miss the fact that heroin – well, it’s quite moreish. Needless to say, what became known as ‘The Revolving Door of Treatment’ only helped anyone whose motivation was extremely high, support networks were excellent, and mental health was completely stable. Everyone else spent their time trying to get onto a script, only to be either kicked off mid-treatment, or detoxed so fast that relapse onto heroin to manage withdrawal symptoms from methadone became almost unavoidable.

Then people started dying. Or at least, the public started to notice people dying. Bodies were being dumped in wheelie bins and skips because the Police automatically attended overdoses with ambulances. Families of the dead started to campaign, drug services came under fire, and at the same time, the links between Class A drug use and acquisitive crime were being formally logged, making these problems not just for those at the bottom of the social strata, but for the whole community.

And so came the 10-Year Drug Strategy, the new Labour Government’s attempt to tackle the problem. Money came flooding in to fund new services, and the focus of treatment shifted from purely medical to consider social and psychological aspects, meaning that there were opportunities for non-medical staff within the field (sometimes even within the mystical and superior world of prescribing). Services even started to employ ex-service users who had furthered themselves in education and experience. The power dynamic between service provider and service user started to dissolve, drug users were listened to – and, in many cases, preferred and pampered, with complementary therapies, immediate access to specialist education provision, and vulnerability tags when applying for housing.

The philosophy became – treat everybody. The research providing the evidence-base told us that a heroin user is less likely to die in treatment than when not in treatment; lessons from the 80s told us that legal and public denial of injecting practices led to steep increases in HIV and hepatitis C infection as a result of needle-sharing; the costs of treating health problems associated with long-term IV use and policing drug-fuelled acquisitive crime became clearer; and so thresholds for access to treatment were reduced. Harm Reduction was the phrase of the era, and this was extended to the harm caused to communities as well as to drug users themselves. Year by year, the money kept on coming and, to be honest, drug users and drug workers alike became a bit spoilt.

And so we move into a recession and a right-wing government. New presentations into opiate treatment are few and far between because heroin is so passé, and those with the will have made use of the plethora of services and reintegrated into mainstream society. The group that are left are not happy – no more free gym passes or massages, no more sick pay for providing sick notes stating ‘substance misuse issues’, but instead an expectation to attend medicals and Jobcentre courses.

At the same time, the Recovery Movement becomes popular. Now the phrase, ‘Recovery’, does not sit comfortably with me. It is a phrase that comes from the mental health domain and conjures in my mind images of the sick – all very 12-Step Model, where substance use is not a choice but a disease for which there is no cure, where the victim must struggle through and put faith in a ‘higher power’ to help them manage this terrible affliction. Dodgy. I personally find it disempowering, patronising and lacking in the notion of personal responsibility – it’s not a disease, it’s a lifestyle choice, you haven’t got cancer for christ’s sake – but I appreciate that it is a phrase that was chosen and adopted by a group of service users, and so who am I to criticise. If it works and people relate to it, that’s fine by me.

The Recovery Model also promotes working towards abstinence. Now abstinence became somewhat of a taboo phrase during the Harm Reduction Years, as the focus was on engagement and retainment in treatment, to reduce the damage drug use did to individuals’ health and the overall damage done to communities (admittedly for financial reasons, not the sympathetic reasons Tony might have had us believe). And so what the Coalition has done, somewhat cleverly it has to be said, it to take a service user-led movement which focuses on moving people away from substance use by moving them towards ‘recovery’, and twisted this into “You know that expensive drug treatment you’ve all been getting for years? Well, much like your benefits, you’re not going to be getting it for much longer. Get your head round it. Oh and – it’s for your own good you know”. Handy – and cheap.

Now I’m not one for enabling drug users to remain unquestioningly stationary – and anyone who has read my other posts will know that I am also sick to death of the ‘dependency culture’ that has developed in this country. But taking a group of people who have been socially vilified then pitied, who have been consistently encouraged to get in treatment, stay in treatment, and routinely drink the green nectar as their contribution to society for the last ten years – and then giving them six months to fully detox from methadone and get a job – that is just too much to ask and too great a challenge to the belief system of someone who thinks that going to the chemist every day is a vocation.

Some services, fearing decommissioning, have done exactly that – employed a ‘six months and you’re out’ policy. Others have decided that if someone drops out of treatment, that ‘probably means’ they don’t need treatment any more and so must be classed statistically as a ‘successful discharge’. This lack of any real health-focused philosophy within drug services is driven by the Government’s new system of Payment By Results – and the results they want are drug users out of treatment and into work (hence the targets around successful discharges). As well as the questionable morality of removing what has been sold for many years as a medical intervention (without a change in the research-base about its effectiveness, may I add), it chooses to turn a blind eye to the lack of skill, experience or motivation of most of the people left within this (pretty hopeless) group. Most importantly, it fails to acknowledge the level of psychological dependence on the medication that has enabled the opiate-dependent to function as normal human beings, given that methadone and buprenorphine (Subutex) both have long half-lives where heroin’s is very short, and so users take their medication once a day and then can go about their business (probably watching Jeremy Kyle, training their Staffies to fight, and seeing who picks up benzodiazepines at the chemist today if I’m honest – but many also work, parent successfully, and lead more stable lives than I). The fear of opiate withdrawals is significantly worse and longer-lasting than the physical withdrawals themselves, and politicians encouraging, promoting and feeding that dependency for TEN YEARS, then withdrawing it, is, in my mind, nothing short of abusive.

And where will it take us, I wonder, when in a few months’ time this group are poorer, more desperate and without the crutch that for so long has reduced their risk of dying? Is that a revolving door I see…?

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