At the centre of the drug problem is the problem of psychic and physical pain
People with mental illness turn to alcohol and drugs to lessen their distress. When adolescents and young adults use a substance to ameliorate their social anxieties a pattern of lifelong alcohol and drug misuse can be set in train. People managing to live in the community with psychosis have high life-time rates of alcohol and cannabis/illicit drug abuse/dependence – 40% to 60% – with males at the top level.
About one in five people experience continuing pain. Access to a specialised pain clinic is virtually impossible for large segments of the population. Where a public clinic exists, waiting lists are 5 to 6 months before an initial assessment can be made. Who then can blame a person turning to a drug to manage their unremitting pain?
The common image of homelessness is the “derelict alcoholic”. Think for a moment of how a street-living person has to survive the problems of rough sleeping, pain and mental illness. Legal and illegal drugs, especially cannabis and alcohol, become the way poor people and homeless people manage their lives as they have few other options. Crystalline methamphetamine “ICE” is often used to deal with physical pain as well as mental pain.
This area is complex for clinicians. It is not helped by the way pain-relieving drugs are classified and controlled. Opioid analgesics are on the Poisons List of governments; the emphasis is on harms and penalties not therapeutic value. Unfortunately, legislation of this kind frames the clinician’s approach to managing patients experiencing chronic pain.
A recent global study of the barriers to accessing opioid analgesics sponsored by the UN and International Narcotics Control Board described the impediments to access, some of which are relevant to Australia – inadequate health professional training, fear of dependence, fear of diversion to others and onerous regulation.
Contrary to common belief, patients taking opioids to control pain would prefer not to be taking these drugs and resent being labelled as addicts, as they commonly are. On the contrary, the level of addictive behaviour in these patients is relatively low – of the order of 5 to 10% – and very few of these patients divert their medications to others in Australia.
Drug problems should not be seen as issues of pharmacology, or the legal status of a substance, but as inherently people problems and the problem of suffering. Our response should be shaped by pragmatic humanistic principles not by heavy-handed legislation. In doing so, much of the unintended consequences, the harms, which typify our current approaches to pain, drug regulation and mental health should be reduced.
Ian Webster is Emeritus professor of Health and Community Medicine at UNSW and patron of the Alcohol and Other Drugs Council of Australia. He was formerly a National Mental Health Commissioner and Chair of the Australian Suicide prevention Advisory Council.
Ian W Webster AO is Emeritus Professor of Public Health and Community Medicine of the University of New South Wales. He has worked as a physician in public and regional hospitals in Australia and UK and in NGOs dealing with homelessness, alcohol and drug problems and mental illness.
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