Drugs - illicit use
August 2008
The BMA has worked on the issue of illicit drug use for many years, resulting in the publication of two reports 'The Misuse of Drugs' and 'The Therapeutic Uses of Cannabis' in 1997.
'The Misuse of Drugs' provided an authoritative overview of drug misuse in the UK as of 1997, and made 28 recommendations aimed at improving services for patients. It stated that central government needed to develop a co-ordinated strategy for the care of drug misusers which involves health and local authorities, the prison and probation services and the health education authority.
The recommendations included calls for:
- increased, protected resources
- an expansion of the AIDS prevention budget to become a ‘bloodborne virus budget’ with a new emphasis on the prevention of hepatitis C
- better training, support and remuneration for general practitioners, and the GP practice team so that drug misusers can be treated in general practice under shared care arrangements
- a full range of services, including residential detoxification facilities to be available where needed in all local areas
- harm reduction schemes, including access to sterile injecting equipment and safe disposal for users
- prisoners to have the same standards of care as other drug misusers and injecting users to have access to sterilising materials
- a national comprehensive, confidential information system to provide up-to-date prescribing information on individuals. This is to allow GPs and other prescribers to check whether a patient has already been prescribed a controlled drug by another doctor
- changes to prescribing practice and prescribing regulations to combat the misuse of and dependence on benzodiazepines
- information for GPs on over-the-counter drug misuse and warning labels for patients.
As is clear from the recommendations, the report supports the development of a variety of systems to offer holistic care to those who misuse drugs. There is a clear role within primary care, as well as a need for more resources within the specialist secondary care community.
In 2006 the BMA’s annual representative meeting (ARM) adopted a resolution requesting that the Board of Science investigates the implications of legalising drugs of misuse. The Board of Science has produced a web resource - Legalising illicit drugs: A signposting resource - which is intended to be a summary of the key arguments for and against legalising illicit drugs.
Cannabis
The BMA believes that the law should be changed to allow the therapeutic use of cannabis based medicines so that certain cannabinoids - cannabis derivatives – can be prescribed to patients with particular medical conditions that are not adequately controlled by existing treatments.
The BMA’s policy report on cannabis - concentrates almost exclusively on its use in the therapeutic context. 'The Therapeutic Uses of Cannabis' (1997) provides an outline of the pharmacology of cannabis and cannabinoids relevant to medicinal aspects, followed by short reviews of the main proposed therapeutic uses. The BMA’s consideration of the legalisation or decriminalisation of the drug is made only with regard to its therapeutic use by patients under medical supervision, for particular medical conditions. A separate briefing paper on the therapeutic use of cannabis is available.
Decriminalisation
The primary concern of doctors is to reduce harm to patients (in medical terms) which is why the BMA has been such a strong supporter of initiatives such as needle exchange schemes.
On the question of decriminalisation of drugs, the BMA believes there is no clear and compelling evidence either way on the impact this might have on levels of drug use and upon the medical consequences and harmful effect of such use. The social arguments for decriminalisation may be more persuasive than the evidence of medical harm reduction. The arguments about the numbers of people who would become users and possibly dependent if decriminalisation occurred are not persuasive in either direction.
In January 2004 cannabis was reclassified from a class B to a class C drug throughout the UK. This meant that most offences of cannabis possession would probably result in a warning and confiscation of the drug.
Following the Government’s announcement in July 2002 that it intended to reclassify cannabis, the BMA wrote to the Chief Medical Officer and the Director of the drugs strategy unit calling for more research to be conducted to determine whether attitudes change as a result.
Although the BMA is concerned that the public might think that reclassification of the drug equals 'safe', it will make it easier to obtain more accurate information about the habits and health of regular/heavy users, given that they will be less inclined to under-report usage. An improved evidence base will in turn allow more accurate determination of the chronic effects of cannabis and the pattern of resulting diseases.
In July 2007 the Government announced that there would be a review of its drugs strategy including consultation on whether cannabis should be reclassified from class C to class B. Although the Advisory Council on the Misuse of Drugs concluded (May 2008) that cannabis should remain class C, the Home Office announced that cannabis will be upgraded to class B again.
At present, the BMA does not have policy on the legalisation of illicit drugs for non-medical or recreational use, and it is unlikely that it would support the legalisation of all illicit drugs, but would consider each on a case by case basis. At the BMA's 2003 Annual Representative Meeting, motions were debated regarding the legalisation of recreational drugs, which were overwhelmingly rejected.
Education and research
The BMA would strongly support improved education on the effects of illicit drug use. This would help individuals make informed decisions about taking illicit drugs, ensure that they are fully aware of the dangers involved and know what to do should things go wrong. There also needs to be high quality provision of care to those who do take drugs, for example, needle exchange schemes and access to tests and treatment for blood-borne viruses such as HIV and hepatitis B and C, as well as rehabilitation programmes.
Further research is needed to:
- evaluate cannabis use following reclassification in order to assess the effects of change in legislation.
- evaluate the long-term effects of cannabis and other illegal drugs
- prove a relationship between cannabis and the subsequent use of other illicit drugs, and the reasons behind it.
The role of general practitioners
While family doctors routinely look after the general medical care of patients who are drug misusers, including those addicted to heroin, prescribing diamorphine and/or treating their drug dependency is not part of routine general practice. This service requires specialised training and knowledge and should attract the necessary additional resources required by those GPs who wish to provide it.
In the report 'The Misuse of Drugs' recommendations included a call for better training, support and remuneration for GPs and the GP practice team so that drug misusers could be treated in general practice under shared care arrangements. However, we do not believe it would be either practical or appropriate for every GP to become trained in the specialist treatment of drug misuse, particularly at a time of a severe GP shortage. Certainly there is a need for the back up of specialist services when offering diamorphine by prescription as envisaged, as well as the provision of vaccinations such as Hepatitis B and specific risk assesments and harm reduction advice.
Prescribing to drug misusers is complex and time consuming. They need regular health assessments as well as specialised assessments regarding the correct dosage and frequency. Many are also "difficult" and disruptive - associated with their drug use and the effect that has on their neurochemistry and personality - so there are issues about safety and about other patients.
Under the new GP contract, the treatment of drug addiction is categorised as a National Enhanced Service, not provided by the majority of GP practices but available in every area from some source. Those GP practices wishing to offer this specialised treatment would inform the local primary care organisation which would have the responsibility for arranging the provision of the service under nationally agreed terms.
Medical undergraduate curriculum
The coverage of drug dependency issues within the medical undergraduate curriculum is a matter for the GMC's education committee. The BMA welcomed their approach to medical undergraduate training, which is increasingly to concentrate on areas such as the skills needed to evaluate evidence and to communicate effectively with patients, rather than to be proscriptive about what must be included in the detailed curriculum. The latter approach too often leads to curricula which fail to encourage teaching and learning on areas not specifically mentioned, or which artificially divide the course into tiny time slots. The patient-centred, and often problem-based approach, requires teaching and learning to be holistic and based upon the problems of the patient. No medical school operates independent of the local population. All medical students will work with patients who have drug misuse as a factor in their presentation to the health care system.
Drugs and driving: a separate briefing paper on drugs and driving is available.
For further information, please contact the parliamentary unit:
E-mail: parliamentaryunit@bma.org.uk.