Select Committee on Home Affairs Memoranda


Submitted by the Royal College of Psychiatrists


  The Faculty of Substance Misuse, Royal College of Psychiatrists, represents Addiction Psychiatry throughout the British Isles. Addiction psychiatrists are qualified psychiatrists who undergo additional training in substance misuse. Addiction psychiatrists play a lead role in specialist treatment centres and have contributed substantially to developing the evidence base on which modern practice is based. There is a growing consensus among specialists as the optimum approach in the treatment of drug misuse. We are committed to driving forward this agenda.

  We have not dealt with the issue of decriminalisation in depth. Evidence to date indicates that substance misuse will increase if there is decriminalisation, as will health problems and demands on health and social care services. It is a socio-political decision as to whether there are compensating social and personal advantages, and we consider that decision lies outside our area of expertise.

  We have focused on current drug policy. We believe the Government's ten-year plan was well conceived and has already brought considerable benefits. It is now in danger of being undermined by three major problems, which need to be addressed urgently.

  The treatment element of the ten-year plan has been distorted and rendered less effective by criminal justice priorities.

  Training, recruitment and retention are grossly inadequate. A new human resource strategy is required.

  Research at all levels is massively underfunded. This includes evaluation of current practice.

  We welcome the establishment of the National Treatment Agency. It is vital that its policy is based on advice from addiction specialists in all professions, rather than opting for politically attractive quick-fix solutions.


  We are alarmed at the expansion of Criminal Justice priorities over drug addiction treatment. This should be a key issue for the newly formed National Treatment Agency.

  The National Treatment Agency aims to establish standards for treatment services. It is of the utmost importance that specialists in the treatment of addiction (doctors, nurses and psychologists) play a key role in the development of this new initiative.

  We believe that Criminal Justice initiatives are in conflict with health priorities.

  Recent initiatives include Treatment and Testing Orders which are expensive and of uncertain benefit. Funding would have been better spent on reducing waiting lists generally and reducing caseloads.

  We do not believe that evidence supports the efficacy of coercive treatments. In the final analysis, successful treatment requires co-operation. Behavioural modification based on compulsion engenders resistance rather than lasting positive change.

  In some districts, the quickest way to access treatment is to commit a serious crime. Criminals overtake patients with more serious health needs eg. AIDS, hepatitis or pregnant users. The current Hepatitis C epidemic is a major public health problem, as it will lead to a large increase in cirrhosis and cancer. The drive to soften its impact may be undermined by misguided prioritisation of patients and fear of coercion if they are identified as drug users.

  The Home Office focus on illicit drugs ignores the more important contribution of tobacco and alcohol to the burden of sickness. Alcohol is also a major cause of crime. As a result we still await a National Alcohol Plan, and tobacco treatment remains absurdly underfunded.

  We recommend that the National Treatment Agency make health issues its top priority, and scrutinise Criminal Justice initiatives to ensure that there is no conflict with this objective.


  It is estimated that addictions account for over a third of the health problems treated by the NHS Treatment of addiction is cost-effective.Smoking cessation interventions costs between £212 to £873 per life year gained, compared with £17,000 median cost for 310 other common medical interventions. The treatment of both opiate and alcohol misuse saves about three times as much as it costs.

  In spite of this compelling data, training in addiction is grossly inadequate. On average medical students receive less than six hours of relevant education. Over the last 10 years this minimal input has diminished, despite the increase in addiction problems. Most GPs and hospital doctors receive no further training. The situation is no better for nurses, psychologists and social workers.

  Due to the neglect of addiction training, there is an alarming lack of trained professionals to deliver the Government drug strategy.

  Most clinical areas demand increased training to improve clinical practice, service delivery, organisational standards and commissioning.

  We recommend that addiction training throughout health education from undergraduate to postgraduate level be dramatically increased.

  We recommend that the Specialist Training Authority recognise Addiction Psychiatry as a Specialty, as is already the case in the United States and many European countries. This will increase the status of this field of medicine, aiding recruitment and retention, and extending the quality and quantity of specialist multidisciplinary service provision.

  We recommend that recruitment and retention be enhanced by adding a "specialty lead uplift" to the salaries of suitably qualified professionals in the field (eg nurses, psychologists).This strategy has already reaped dividends in the field of forensic psychiatry.


  Policy development should follow evidence. This remains inadequate, particularly that derived from national research. The UK relies almost entirely on research from the United States and Australia, even though their drug problems and policies differ substantially from the UK. Both countries spend much more than the UK on drug research. Recent figures indicate that the US Government spends 4 per cent of its total drugs expenditure on drugs compared to 0.02 per cent in the UK. Until we have a systematic national strategic research programme, policy makers must base their recommendations on impressions, anecdotes and prejudice rather than on facts.

  As a starting point, we recommend that 1 per cent of the annual drugs budget would inject £14 million a year into addiction research.

  Multidisciplinary research groups with consistent core funding should be established. These should include basic and theoretical research eg in neurosciences, genetics and psychology, as well as applied research which is multidisciplinary and multicentred.

  Evaluation of current practice is also essential. Too many new initiatives are introduced without adequate evaluation.

Examples of necessary research that will impact on practice:

    —  Criminal justice initiatives there is scant evidence about the cost effectiveness or efficacy of enforced treatment.

    —  Innovative medications: what is the best way to combine pharmacological and psychosocial interventions?

    —  Best models of service delivery eg impatient versus outpatient treatment.

    —  Reducing the impact of the current Hepatitis C epidemic.

    —  Understanding drug use in the very young.

    —  Reducing drug-related deaths.

    —  Harms associated with cannabis compared with other substances.

September 2001


  Parrot S, Godfrey C, Raw M, West R & McNeill A (1998) Guidance for commissioners on the cost effectiveness of smoking cessation interventions Thorax 53 Supplement 5 S1-S36.

  Gossop M (1999) NTORS: two year outcomes. The National Treatment Outcome Research Study.

  Changes in substance use, health and crime. Department of Health, London.

  Society for the Study of Addictions (2000) Tackling alcohol together Free Association Books, London.

  Crome IB. (1999) The trouble with training: substance misuse education in British medical schools revisited. What are the issues? Drugs: Education, Prevention and Policy 6: 111-123.

  Working Party of the Royal College of Psychiatrists and the Royal of Physicians (2000) Drugs.

  Dilemmas and Choices London: Gaskell 224-226.

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Prepared 20 December 2001