Source: British Medical Journal, No 7104 Volume 315
Contact: The Editor, BMJ, BMA House, Tavistock Square, London WC1H 9JR
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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
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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.