Drugs: who cares?

On an ordinary Monday morning, 11 year old James and his mother visited the surgery. James's medical record contained a referral letter with a reply, about some behavioural problems he was having a year ago, from a community paediatrician. The surgery is located in a poor neighbourhood in Nottingham, and these kind of referral letters are familiar to me, even though I have been working as a junior doctor here for only two months.

Before I can even introduce myself, the mother starts talking about the hopeless situation with James and the way it affects her own depression. After listening for 15 minutes, I know that James has been suspended from school several times because of fighting and bullying, that he has no playmates, that he steals from his mother, and that there is absolutely no corrective measure that affects this behaviour. James looks uninterested and laughs about these stories.

After the consultation, my supervisor shares my worries about James's future. If and when James encounters drugs, which is very likely in this kind of neighbourhood, the result is likely to be devastating for him, his family, and the community in which he lives.

Maybe I was worried because the story of James resembles the sad early life stories of many of the patients who regularly visit us for their methadone prescriptions. When considering possible ways to prevent a similar scenario for James, I become even more concerned. What care is to be expected from his teachers, the school nurse, the community paediatrician, the general practitioner, and the government? Who cares, and how?

James's problem reminded me strongly of a book I recently read. The famous Wir Kinder vom Bahnhof Zoo [We Children from Bahnhof Zoo], first published in 1979, tells the story of a 13 year old heroin addict in Berlin in 1979.¹ An incorporated letter of a German psychologist points out that drugs (heroin) are the product of a disrupted social system, more specifically, the product of a disrupted family life. His main conclusion was that "the drug problem can neither be solved by care workers (therapeutics) nor by the law (police)."

The United Kingdom has a tough package of recently proposed antidrugs measures.² This included powers for police to order (expensive) ultrasound or x rays scans for drug swallowing dealers and measures to force more addicts caught behaving criminally into compulsory treatment. This policy fits well into the internationally accepted strategy of harm reduction.³

This "creative" new bill, like many others, shows the inadequacy of governments to tackle drugs misuse. There is also communal inability to manage individual life problems that might lead to drug addiction. Seeing patients such as James makes me believe that effective prevention of drug abuse is more about positioning a patient in a clean life and family environment than other factors. The depressing letter in Wir Kinder vom Bahnhof Zoo still seems very much up to date. And if nothing has changed for 25 years, who cares?

1. F C, Hermann K, Rieck H. Wir Kinder vom Bahnhof Zoo. Düsseldorf: Stern-Verlag, 2004. (In German.)
2. Home Office. Breaking the link between drugs and crime: home office publishes drugs bill. London: Home Office, 2004 Dec 17. (Press release 393/2004.)
3. Allan C, Wright N. Harm reduction: the least worst treatment of all. studentBMJ 2004;12:92-3.