Pubdate: Saturday 9 August 1997 Source: British Medical Journal, No 7104 Volume 315 Contact: The Editor, BMJ, BMA House, Tavistock Square, London WC1H 9JR fax: +44 (0)171 383 6418/6299 tel: +44 (0)171 387 4499 email: Editorial Why Britain's drug czar mustn't wage war on drugs Aim for pragmatism, not dogma The British government has advertised the first ever post of drug supremo, or 'drug czar' to borrow the term used in the United States. It is good news that the new Labour government is evidently serious about the growing national and international drug problem and intends to strengthen further the pandepartmental approach taken by the central drugs coordinating unit and its strategic document for England, Tackling Drugs Together.(1) But there is a grave danger that the increased political attention could backfire, producing a more politicised approach to the problem and causing the new czar's dominant orientation to be one of control. Crime dominated posturing would lead to a damaging dissociation between the public appeal of the policy and actual evidence of effectiveness. It could lead to a mistaken bias to funding more panda cars, prisons, and pop propaganda instead of evidencebased treatment, rehabilitation, and preventive strategies. In contrast, diverting limited resources from enforcement to treatment and rehabilitation would result in more costeffective crime prevention and community safety. Prisons are already bursting with new inmates on remand or sentence for addiction fuelled crime; it would be criminal negligence to spend yet more on control whilst demand for treatment still far outstrips capacity. The 'war' rhetoric is particularly dangerous. It is therefore disappointing that the new post draws its 'czar' title from the United States a strange role model to select considering its vastly greater prevalence of drug misuse(2) and is charged with leading the 'battle against drugs.' The macho nature of the post is further signalled by its title no czarina need apply. If this imagery is not to misfire, the new supremo must understand UK drug policy. In the UK, pragma has trumped dogma. This has allowed, for example, antiHIV approaches such as needle and syringe exchange(3) nearly a decade earlier than the US, thus preventing the apparently inevitable epidemic of HIV infection among drug injectors.(4) Other examples of pragmatism include the tolerance of at least some prescribing of injectable heroin and methadone.(5) Britain should be proud of its capacity to put rhetoric aside and pursue strategies which best benefit the health of the nation. The nature of the war on drugs needs to be understood. War it is, but not in the sense conveyed by the government's job advertisement. For it is a war that will never be won, and yet against which we must continue to battle, just as with the war on cancer and the war on poverty. In this war, it is public health physicians and town planners who should be our generals; and doctors, drug workers, and community policemen should be our foot soldiers. As we have previously argued,(6) for each of these unwinnable wars it is imperative to direct our available resources to fight on the right fronts those on which we have good reason to believe that advances will be made as a result of our activities. The new czar will need to follow the lead of evidence based medicine: redirecting funds into those treatments with demonstrable effectiveness, which may not be the same as the most popular; applying an evidence based strategy to areas such as drug control and education; and altering the balance of funding between control, treatment, and education on the basis of these findings. A stronger treatment arm to the drug strategy is vital. The previous UK drug strategy in 1995(1) represented a clear swing to a crime dominated perspective and was in sharp contrast to the dominant public health perspective on AIDS and drug misuse in the late 1980s.(7) However, the picture is now different. Not only is the new government intent on being tough on the causes of the drug problem as well as tough on the problem itself, but we also now have good evidence of multiple benefits from some treatments. For example, we have international evidence of reduced levels of drug use, injecting, and criminal behaviour with methadone maintenance in patients addicted to opiates.(8, 9) Three messages should be pinned above the new czar's desk. Firstly, be clear about the objectives of a new drug strategy, with the reduction of damage to individuals and society as the guiding principle. Secondly, look beyond the many examples of failing drug strategies to the growing evidence base for alcohol and tobacco policies:(10,11) this would allow the drug strategy to be developed appropriately alongside emerging strategies for alcohol and smoking. And finally, be determined in pursuit of evidence based strategy, incorporating elements not for political or professional popularity but according to the quality of evidence of benefit to individuals and the public. If the evidence does not currently exist, the czar should set aside perhaps 1% of the budget to establish centres charged with correcting the poverty of research output in this field in Britain.(12) Science would then properly serve the policy making process, and the appointment of a UK drug czar would be a true step forward. John Strang Director National Addiction Centre, 4 Windsor Walk, London SE5 8AF William B Clee Chair Welsh Advisory Committee on Drug and Alcohol Misuse, ParcCaonl Practice, Church Village, RhonddaCynonTaff, South Wales Lawrence Gruer Consultant in public health medicine HIV and Addictions Resource Centre, Ruchill Hospital, Glasgow G20 9NE Duncan Raistrick Director Leeds Addiction Unit, 19 Springfield Mount, Leeds LS2 9NG References 1 HM Government. Tackling drugs together: a strategy for England, 19951998. London: HMSO, 1995. 2 Kleber H. The US antidrug prevention strategy: science and policy connections. In: Edwards G, Strang J, Jaffe JH, (Eds). Drugs, alcohol and tobacco: making the science and policy connections. Oxford: Oxford University Press, 1993:10920. 3 Stimson G V, Alldritt L, Dolan K, Donoghoe M, Lart R. Syringe exchange schemes for drug users in England and Scotland. BMJ 1988;296:17179. 4 Stimson G V. AIDS and injecting drug use in the United Kingdom, 19871993: the policy response and prevention of the epidemic. Soc Sci Med 1995;41:699716. 5 Strang J, Ruben S, Farrell M, Gossop M. Prescribing heroin and other injectable drugs. In: Strang J, Gossop M, eds. Heroin addiction and drug policy: the British system. Oxford: Oxford University Press, 1994:192206. 6 Strang J. Injecting drug misuse: response to Health of the Nation. BMJ 1991;303:10436. 7 Advisory Council on the Misuse of Drugs. AIDS and drug misuse: update report. London: HMSO, 1993. 8 Ball J C, Ross A. The effectiveness of methadone maintenance treatment: patients, programs, services and outcome. New York: Springer, 1991. 9 Farrell M, Ward J, Des Jarlais D C, Gossop M, Stimson G V, Hall W, et al. Methadone maintenance programmes: review of new data with special reference to impact on HIV transmission. BMJ 1994; 309:9911001. 10 Edwards G, Anderson P, Babor T, Casswell S, Ferrence R, Giesbrecht N, et al. Alcohol policy and the public good. Oxford: Oxford University Press, 1994. 11 Raw M, McNeill A. The prevention of tobaccorelated disease. Addiction 1994;89:15059. 12 Department of Health Task Force. The Task Force to review services for drugs misusers: report of an independent survey of drug treatment services in England. London: Department of Health, 1996.