What do you think of when you hear the word ‘junkie’ or ‘alchie?’ Do you think of ‘Methadone Mick’ from Still Game (interestingly a replacement for ‘Pete the Jakey’), or maybe Rab C. Nesbitt of the eponymous show? Characters coming from two of Scotland’s most popular sitcoms, and all fitting a stereotype – the downtrodden, unemployed, feckless individual – exemplifying what us Scots see when they think of addiction, and it isn’t particularly helpful.
In some respects, we all use substances to deal with life. For some of us, coffee in the morning gives us the energy to function throughout the day (ask our teachers!), for others its nicotine, for some of us its a glass of wine with dinner to relax. For some of us it’s a few drinks whilst partying, as it’s the only way we can put ourselves in a position to sing terrible karaoke or to actually talk to that person we secretly fancy. Maybe its a nice tub of ice cream and a movie? However for many, there is a need for stronger substances, for much more serious reasons, taken in a way that provides quick relief, which are more likely to be unregulated and contaminated, which inevitably leads to harm.
Addiction is very much in the public consciousness right now, exemplified by the tragic annual figures of Scottish drug deaths (1339 in 2020) and alcohol deaths (1190) – the latter likely to be a significant underestimate of alcohol-related deaths, given its effects on the body as a whole. The numbers of course only scratch the surface of what’s going on – individuals dying after years of torment, loved ones helplessly watching on, relationships and families broken. Scotland has some of the highest rates of drug and alcohol deaths in the world, and we are desperately looking for solutions to deal with this.
But why should we care? I mean, they put themselves in this position right? They made a choice to drink the way they do and use drugs? Why should we help when they did it to themselves? Well of course, life is not that simple, and we are all entitled to make poor choices in life without it condemning them to a life of pain and suffering and death. Many (if not most) medical conditions are a function of poor lifestyle choices or dubious decisions in general. Furthermore the pain suffered by a person with addiction is also suffered by those around them, and we could be condemning generations of people to suffering through no fault of their own. It can also become a significant public health issue, and Glasgow had had its outbreaks of infectious diseases amongst people who inject drugs, including an HIV outbreak in 2015 (leading to NHS Greater Glasgow & Clyde’s report – “Taking away the chaos” – recommending a number of public health and harm reduction initiatives).
So who are our “junkies” and “alchies”? The vast majority of people I’ve met did not choose to be in the position they are in now and have very valid reasons for being in the position they are now – many are individuals who have been brought up in a world where deprivation, inequalities, and lack of opportunities in life are prevalent, compounded by trauma, who have endeavoured to manage their distress by using one of the few options they have – self-medicating with a substance. Many are very high functioning and educated people who have struggled with various demons in their life but are so ashamed to deal with it openly, so they quietly self-medicate. Many are treating an underlying (and usually undiagnosed) mental or physical health condition. Many are “you and me” – and I can guarantee that there is a silent minority reading this who are struggling alone with addiction and too ashamed to deal with it, though public stigma, discrimination, and being labelled as an “addict” (and apparently deserving of their fate).
With the increases in drug and alcohol deaths, there’s a lot of talk about care and treatment of addiction, and a lot of attention has gone on to Medication Assisted Treatment (MAT) through the Drug Deaths Taskforce. MAT has a strong evidence base, over many years now. Methadone has its stigma (evidenced by “Methadone Mick”), but when prescribed at optimal doses it’s a very good treatment option for those who struggle with opiate addictions, as is buprenorphine (which now comes in a long acting injection, taking away much of the supervision associated with our treatments). There’s medication that help those who struggle with alcohol dependency stay away from drinking (disulfiram) or to manage cravings (acamprosate). There are other medical treatment options and supports for other forms of drug dependency. No treatment is a substitute for willpower, though, but they definitely help and thankfully I have many success stories from these type of treatments.
There has also been a lot of talk about residential rehabilitation of addiction (rehab). For many people, rehab seems the domain of the rich and famous, somewhere to hide and recover from their own mental health and addictions issues. However rehab has been available through various charitable and religious organisations for many years, though never enough to meet demand. However we need to be careful about our expectations for this type of treatment – at best it should be an evidenced based and holistic package of care that provides long term recovery for individuals long after exiting the unit, at worst it becomes a short-term detox where the individual is thrown back into the life they were trying to escape. Rehab (and detoxes in isolation) can potentially be risky for many – if someone has their only coping strategy for their distress taken away from them without a clear substitute (as MAT tries to do), then they are exposed to their distress on return to their home, and there’s a high risk of using substances again. If the body has lost some of its tolerance to an addictive substance though a period of sobriety, and there’s a relapse, there’s a higher risk of death. Nevertheless, rehab will be a viable option for many individuals, and we at least need the opportunity to develop and maintain robust residential services.
There is no value in treating the addiction if you don’t also address the underlying causes, and giving people the opportunity to live rather than to exist. I provide mental health oversight to those in my service, alongside psychologists and mental health nurses. General nurses, social workers, occupational therapists, peer support workers, housing and employment support, and more, do their best to improve peoples’ quality of life and functioning. But the true heroes in our service are undoubtedly our addictions workers, primarily social care trained, who do the day to day work with their clients, and work through all the ups and downs that addiction leads to.
Ultimately, the best treatment for people who struggle with drug or alcohol problems is compassion. The biggest challenge for many people struggling with addiction is the stigma associated with it, and the way we treat people with addiction on a day to day basis. I spend a lot of time discussing the importance of compassion with my medical students and junior doctors, and the importance of promoting trust in health and social care services. There is no value in reinforcing stereotypes and perpetuating trauma by our own actions, and it pushes people away from treatment rather than supporting people into treatment. In practice, we all need to remind ourselves of this, and think “people first”. People who use drugs, not “junkies”, people who use alcohol, not “alchies”. People, first and foremost. I’ve seen people completely turn their life around by a single encounter with someone who took them seriously and showed the compassion and care to them that they had been starved of for many years.
There is so much more to addiction than what I can write in a school column – the neurochemistry of reward, the importance of dealing with adverse childhood experiences (ACEs), behavioural addictions including gambling, relative risks of substances, brief psychosocial interventions, and more. However, should you or someone you know is struggling with addiction – please seek support, you’re most definitely not alone. If you have an interest in medicine, psychology, nursing, social work, occupational therapy, social care – please think about a career in addictions. And if you encounter someone with addiction, please be compassionate – you might save their life.
By Arun Menon, class of 1998, Lead Clinician and Consultant Addiction Psychiatrist, NHS Greater Glasgow & Clyde Alcohol and Drug Recovery Services, writing solely in a personal capacity