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When it comes to drug addiction, greater focus on the more difficult, less palatable and more expensive recovery approach is needed if we really want to save lives, says Terry Maguire…

He gave his initials sometimes as LV, other times LB and his date of birth varied between July 1986 and July 1988.

He visited the pharmacy frequently after his release from prison, normally falling through the door, advancing up the shop with a gyrating gait as if arresting a fall down a steep embankment.

He swept towards our consultation area, indicating with a pointed finger to whoever was around that he wanted access to our needle and syringe exchange service.    

There was a serious intensity on his face. He could not stand still, moving backwards and forwards from foot to foot. I asked what he wanted and when, following a number of attempts, his wishes remained unclear, I handed him a 0.5ml pack (syringe/needles with associated paraphernalia), as acute and excessive cocaine use was the only explanation for these mental and physical manifestations.

Accepting the pack, he ripped it open, removing only items of interest. Did I have a bag? he would ask. I did but I insisted he took the cin-bin, knowing it would end up in a nearby litterbin.   

If it was Thursday, he would return to the main shopping area and at the edge of the counter extract from his anorak a large wodge of bank notes, mostly £20 notes, and studiously sort them into three neat piles.

The largest was rolled up and placed into a zipped pocket in an inner jacket. The medium one was rolled and stuffed into a trouser pocket and the smallest pile was rolled and put into the outer pocket of his anorak. All the while he fidgeted, stepped back and forward, and was oblivious to all around him.

I remain fascinated by the tragedy that is drug addiction or substance use disorder (SUD) as it is now known, that less pejorative, not so stigmatising, more caring moniker.

The incredible power of a molecule to take control of a person, so absolutely, so completely, is something truly to be feared. Addiction remains poorly understood which is surprising given the excessive and obscene investment in addiction research over recent years.

We still only, it seems, have a general idea, a lot of ideology, plenty of empathy and some small hope for those caught in this unfortunate snare of the human condition. It’s accepted that addiction is an artifact of brain structures which develop due to a combination of genetic predisposition and environmental stresses.

Dopamine, ‘the molecule of more’, is key to the emergence of the brain systems of addiction at the cost of personal wellbeing, family and community. The addict is more selfish than a two-year-old in a toy shop.

Dopamine should be, and for most of us is, a positive molecule. It is responsible for identifying preferred options, making plans, setting goals and motivating the chase towards these goals. Where dopamine gets over-egged, we get problems.

Harm reduction

Community Pharmacy has, over the short period of my career, totally changed its attitude towards the addict. For a profession set up to control access to addictive drugs while retaining professional empathy, before the 1980s, we mainly policed access.

We retain this role of course, but now we also support addicts with clean needles and other drug taking paraphernalia, distribute naloxone and observe substitution medicine-taking so they can get some relief from the horrors of withdrawal and hopefully move into recovery.

Pharmacy is core to the harm reduction approach. In addition, addicts are provided with sufficient money so they don’t need to revert to criminal behaviour.

Pharmacological treatments exist for opioids, tobacco and alcohol. But no medication is approved for treatment of cocaine or other stimulant use disorders. Yet, even when pharmacotherapy is used, success rates are modest.

Too late for some

For JB or JV, it’s too late. He came to us some years ago before prison and was doing well on supervised methadone. He had a slip on his road to recovery.

Prison opened up myriad new drug options and on release, cocaine was his problem. When he died at the age of 33, on a Sunday in April this year, cocaine, alcohol and benzodiazepines were identified in his blood. Poly-drug deaths are now the norm.

I do worry we are too focused on the harm reduction approach. For a society wishing to ignore the “pests” on the streets and not have them break into our homes and steal our TVs, it might be the convenient policy.

For the addict, greater focus on the more difficult and, let’s be honest, less palatable and potentially more expensive recovery approach will be necessary if we really want to meaningfully save lives.   

Terry Maguire is a leading pharmacist in Northern Ireland.