Dr John Marks talks about the controversial Harm Reduction drug treatment programme in Widnes
Aug 19 2010 by Mark Smith, Runcorn and Widnes Weekly News
ASK most people, even those working in the field of drug
treatment, and chances are they have never even heard of it.
But the Chapel Street Clinic in Widnes is known in certain circles from Australia to Canada.
Pioneering but controversial, the clinic helped to form the blueprint of entire nations’ drug policies, has been the subject of fierce international disputes, extensive educational studies, law enforcement seminars, and even an alleged trans-Atlantic furore involving the American Government and Margaret Thatcher which may have changed the course of Britain’s drug war forever.
It is known around the world for one reason and one reason only, the Chapel Street Clinic used to give away drugs
– not methadone
or conventional pharmaceuticals, but legally-prescribed heroin
and crack cocaine
Up until the mid-1990s, the clinic was run by consultant psychiatrist Dr John Marks, who advocated a form of treating drug addicts which involved giving them the narcotics
The theory of ‘harm reduction’ held that while drug-users were kept away from the underworld and from the constant search for money and a ‘fix’, they could live more normal lives – limiting the damage they could do to themselves and society.
The theory was based on a model used in the UK from the 1920s until the 1960s which became known as the ‘British system’ and the clinic saw remarkable successes.
Between July 1988 and January 1990, the then-Cheshire Drug Squad began tracking the criminal records of 112 addicts who entered the drug maintenance program.
It recorded a 93% drop in theft, burglary, and property crimes.
HIV infection rate among injecting drug users was zero, and the incidence of death among addicts – normally 15% a year - was also zero.
One side-effect which Dr Marks did not expect though, was a drop in new users.
The police found that drug dealers simply stayed away from Halton because they knew the local addicts no longer needed their services.
Word of the clinic’s work quickly spread around the globe, attracting foreign journalists and doctors to Widnes.
It became the subject of a United Nations study and inspired a more liberal approach to drug-treatment in several European countries..
Dr Marks – now the clinical director of psychiatry at Gisborne Hospital in New Zealand, told the Weekly News: “The clinic gained the attention of Chief Inspector Bing Spear of the Home Office Drugs Branch in the mid-1980s and he became an enthusiastic supporter.
“From that beginning, the harm reduction policy was formulated and became an NHS model of good practice.
“Similar clinics were rolled out throughout the country and there was a lot of foreign interest.
“Switzerland and Germany modelled their services explicitly on it and eventually there came American attention.”
It was with the visit of US current affairs programme 60 Minutes in 1990 that America’s Republican administration became aware of the little Widnes clinic, and – Dr Marks alleges – then put pressure on the British Government to close it down for ideological reasons.
He said: “After it aired I got a sudden phone call from Bing who said: ‘Why didn’t you let us know about 60 Minutes?’.
“I replied honestly that I’d forgotten all about them among the plethora of other visitors, had no idea that their report had been broadcast nor that the Home Office would be interested in TV programmes about clinics.
“Bing replied ‘That’s a pity. We’re getting real heat from our embassy in Washington and Maggie’s got her knickers in a twist over the whole issue’.
“In short order the Halton Health District was dissolved, Bing Spear had resigned and was replaced by a man called Alan MacFarlane – who later described me as ‘dangerous’.”
Health chiefs at the time said the decision to scrap the programme was due to the prohibitive cost of heroin, citing methadone as a cheaper alternative.
Dr Marks though remains adamant, he said: “It was in deference to American sensibilities that Margaret Thatcher emasculated the whole harm-reduction programme.”
The policy at the clinic ran from 1984-1995 and since its end Halton’s addicts have undergone conventional treatment, usually involving the heroin substitute methadone.
But 15 years later the name Chapel Street is being talked about once again. With funding for police and prison places under threat and with more liberal voices now calling for reform, the traditional approach to drugs is being re-evaluated.
Ewan Hoyle, founder of the national group Liberal Democrats for Drug Policy Reform, said: “I came across the Chapel Street story early in my investigation of drug policy and it served as a stark demonstration of how both addicts and communities can benefit enormously from heroin dependency being treated with compassion.
“I hope mine and my colleagues’ current pleas to the coalition Government to reinstate heroin maintenance will not fall on deaf ears.”
Clinics in Sydney and Vancouver currently follow the Chapel Street model, and in 2009 the German parliament passed a law allowing heroin prescription as a standard treatment for addicts, with two Danish cities set to roll out a similar programme this year.
Last year 100 addicts in London, Brighton and Darlington took part in trials using prescription heroin which were hailed a success.
And on Tuesday, Sir Ian Gilmore, outgoing president of the Royal College of Physicians, called on drug use to be treated as a health problem and not a criminal one.
However, Dr Marks is unsure whether the UK Government will adopt such an approach on a wider scale.
He said: “I think the (coalition) regime may be more open-minded than New Labour – which is not difficult – but drug policy organisations like Transform
are more likely to produce some movement.”
Transcript From 60 Minutes
Rx Drugs - The Liverpool, England method
Transciption of CBS-TV Program, 60 Minutes. Aired Sunday, December 27, 1992
Titled: Rx Drugs
By: Ed Bradley
Ed: Can Britain teach us anything about dealing with drugs? That remains to be seen. But one thing seems certain, there is little or nothing we can teach them. They tried our hard line methods back in the 70's and 80's and all they got for their trouble was more drugs, more crime, and more addicts. So they went back to their old way of letting doctors prescribe whatever drug a particular addict was hooked on. Does it work? If they're ever going to know, Liverpool, where drugs are out of control is the place to find out.
Ed: This is a gram of 100% pure heroin, it is pharmaceutically prepared. On the streets it would be cut 10 to 15 times and sell for about $2,000. But take it away from the black market, make it legal, and heroin is a pretty cheap drug. The British National Health Service (NHS) pays about $10.00 for this gram of heroin. And for an addict with a prescription, it is free.
Ed: In Britain, doctors who hold a special license from the government are allowed to prescribe hard drugs to addicts. Dr. John Marks is psychiatrist who runs an addiction clinic just outside of Liverpool and has been prescribing heroin for years
Dr. Marks: If a drug taker is determined to continue their drug use, treating them is an expensive waste of time... and, really, the choices that I am being offered and society is being offered, is drugs from the clinic or drugs from the Mafia.
Ed: To get drugs from the clinic rather than the Mafia, addicts have to take a urine test to prove they are taking the drug
they say they are. And unlike most other addiction clinics where you have to say you want to kick the habit before they'll take you in, addicts here have to convince Dr. Marks, a nurse and a social worker they intend to stay on drugs come what may. But does Dr. Marks try to cure people?
Dr. Marks: Cure people? Nobody can. Regardless of whether you stick them in prison, put them in mental hospitals and give them shock treatment, we have done all these things, put them in a nice rehab center away in the country, give them a nice social worker and pat them on the head, give them drugs, give them no drugs, does not matter what you do. 5% per annum, 1 in 20 per year, get off spontaneously. Compound interested up that reaches about 50% (50/50) after ten years are off drugs. They seem to mature out of addiction regardless of any intervention in the interim but you can keep them alive and healthy and legal during that 10 years, if you so wish to.
Ed: By giving them drugs?
Dr. Marks: It doesn't get them off drugs, it doesn't prolong their addiction, either. But it stops them offending, it keeps them healthy and it keeps them alive.
Ed: That's exactly what happened to Julia Scott. Although she doesn't look it, Julia is a heroin addict. For the last three years the heroin she injects every day comes from a prescription. Before, she had to feed her habit by working as a prostitute, a vicious circle that led her to use more heroin to cope with that life.
Julia: Once you get in that circle you can't get out. I didn't think I was ever going to get out.
Ed: But once you got the prescription?
Julia: I stopped straight away.
Ed: Never went back?
Julia: No, never. I went back once just to see and I was almost physically sick just to see those girls doing what I used to do.
Ed: Julia says she's now able to have normal relation, to hold down a job as a waitress and to care for her 3 year old daughter. Without the prescription, where do you think you would be?
Julia: I would probably be dead now.
Ed: Once, they have gotten their prescriptions, addicts must show up for regular meetings to show that they are staying healthy and free from crime. But how can anyone be healthy if they are taking a drug like heroin?
Alan Perry: Pure heroin is not dangerous. We have people on massive doses of heroin.
Ed: Alan Perry is a former Drug Information Officer for the local Health Authority and now a counselor at the clinic. So how come we see so much damage caused by heroin?
Alan: The heroin that is causing that damage, is not causing damage because of the heroin in it, it is causing damage because of the bread dust, coffee, crushed bleach crystals, anything that causes the harm and if heroin is 90% adulterated that means only 10% is heroin, the rest is rubbish, and if you inject cement into your veins, you don't have to be a medical expert to work it out, that's going to cause harm.
Ed: Many at the clinic like George still suffer from the damage caused by street drugs. Alan Perry believes you can't prescribe clean drugs and needles to addicts without teaching them how to use them.
Alan: You know the major causes of ill health to drug injectors is not even the dirty drugs they take, it is their bad technique. Not knowing how to do it. In America I have seen addicts missing legs and arms and that is through bad technique. So we show people how to, not how to inject safely, but how to inject less dangerously. We have to be clear about that, you have stoned people sticking needles in themselves in a dangerous activity. The strategy is called "harm minimalization."
Ed: George's legs have ulcerate and the veins have collapsed. To inject he must use a vein in his groin that is dangerously close to an artery.
Alan: When you get in there, do you get any sharp pains?
Alan: If you hit an artery how would you recognize it?
George: By me head hitting the ceiling.
Ed: In the 70's the British were not content with minimizing the harm of drug abuse. They adopted the American policy of trying to stamp it out all together. Prescription drugs were no longer widely available. Addicts who couldn't kick the habit had to find illegal sources. The results: By the end of the 80's drug addiction in Britain had tripled. In Liverpool there was so much heroin around, it was known as "smack city". And then came an even greater threat.
More than anything else, it has been the threat of AIDS that has persuaded the British to return to their old policy of maintaining addicts on the drug of their choice. In New York, it is estimated that more than half those who inject drugs have contracted the AIDS virus through swapping contaminated needles. Here in Liverpool, the comparable number, the number of known addicts infected, is less than one percent.
In an effort to get addicts away from injecting, Liverpool pharmacist Jeremy Clitherow has developed what he called Heroin Reefers. They are regular cigarettes with heroin in them. "Whatever you feel about smoking," he says, "these cigarettes hold fewer risks than needles for both the addicts and the community.
Jeremy: See, we then use this (hypodermic syringe) to put in a known volume of pharmaceutical heroin into the patient's cigarette. And, there we are, one heroin reefer containing exactly 60 mgs of pharmaceutical heroin.
Ed: So, that, the National Health Service will pay for the heroin but not the cigarettes?
Jeremy: Oh, Yes, of course, its the patients own cigarettes but with the National Health Service Prescription in it.
Ed: Addicts pick up their prescriptions twice a week from his neighborhood pharmacy. And how does this affect his other customers?
Jeremy: The patient who comes in to pick up his prescription of heroin in the form of reefers would be indistinguishable from a patient who picks any other medication. The prescription is ready and waiting and they pick it up just as they would pick up their aspirin or bandages.
Ed: But with all these drugs available to most people plus the hard drugs that you have here, what's your security like?
Jeremy: Like Fort Knox. But we keep minimal stocks. We bring the stuff in regularly, frequently. What comes in, goes out.
Ed: And heroin isn't the only stuff to come in and out of here. Clitherow also sells prescriptions for cocaine and that is 100% per free base cocaine. In other words, crack.
Ed: So, in fact, when you are putting cocaine in here you are actually making crack cigarettes?
Ed: In America that has a very negative connotation, but not for you?
Jeremy: Depends on which way you look at it. If they continue to buy on the street, whether it is heroin, methadone, crack, or whatever, sooner or later they will suffer from the merchandise they are buying. I want to bring them into contact with the system and let them get their drug of choice, if the physician agrees and prescribes it in a form which won't cause their health such awful deterioration.
Ed: (to Dr. Marks) And you don't have any problem giving people injectable cocaine or cocaine cigarettes?
Dr. Marks: No, not in principle. There are patients for whome I have prescribed cocaine, and to whom I have then stopped prescribing cocaine because their lives did not stabilize. They continue to be thieves or whatever. But, there are equally many more to whom we have prescribed cocaine, who have then settled into regular sensible lives.
Ed: Michael Lythgoe is one who has settled into a regular sensible life on cocaine. He has a prescription from Dr. Marks for both cocaine spray and the cocaine cigarettes. Before he got that prescription, the cocaine he bought on the street cost him nearly $1,000 a week, which at first he managed to take from his own business, but it wasn't long before it cost him much more than that. .... so you lost your business, you lost your wife, you lost your kids and the house but you kept going after the cocaine?
Michael: Yes, that is what addiction is, that is the very nature of addiction, if the fact that one is virtually chemically and physically forced to continue that way.
Ed: Now, after two years of controlled use on prescription drugs, Mike has voluntarily reduced his does, he has got himself a regular job with a trucking company and is slowing putting his life back together.
Ed: Where do you think you would be now if Dr. Marks had not given you a prescription for cocaine?
Michael: I wouldn't be here talking to you. And you probably wouldn't be interested in talking to me either. I'd be on the street.
Ed: Dr. Marks, how would you reply to critics who say that you are nothing more than a legalized dealer, a pusher?
Dr. Marks: I'd agree. That is what the State of England arranges. That there is a legal controlled supply of drugs. The whole concept behind that is control.
Ed: And there are signs that control is working. Within the area of the clinic, Alan Perry says, the police have reported a significant drop in drug related crime and since addicts don't have to deal anymore to support their habit, they're not recruiting new customers. So, far fewer new people are being turned on to drugs.
Ed: What about dealers around the area of the clinic?
Alan: There are not any around the clinic.
Ed: You have taken away their business?
Alan: Exactly, there is no business there, the scene is disappearing. So, if you want to get really into a problem which presumably all societies do, there are ways of doing it. But you have to counter your own moral and political prejudices.
Ed: (to Julia) What can you say to people who would ask why give addicts what they want? Why give them drugs?
Julia: So they can live, to have a chance to live like everyone else does. No one would hesitate to give other sort of maintaining drugs to diabetics. Diabetics have insulin, in my mind it is no different, it is the same. I need heroin to live.
IN DEFENCE OF HEROIN MAINTENANCE
A User's Perspective
by Maureen Laverty.
In March 1991 I left my home in Scotland, taking only a bag of clothes for myself and boarded a coach to Liverpool where I desperately hoped to find help for my heroin addiction. At this stage my partner was again incarcerated for an offence incurred supporting our habits. The reason I came to Merseyside was in hope of receiving a different type of treatment, as all other past attempts to stay off drugs had failed miserably and like so many women I'd been in jail with, I did not want to lose my baby.
In September 1991 after six months on the waiting list my partner and I were accepted by the Victoria Road Drug Dependency Unit in Widnes. Within weeks on the programme our health improved considerably. I must emphasise that the diamorphine treatment pioneered by Dr John Marks at the Chapel Street Clinic in Widnes has definitely prolonged and enhanced my life for the past four years. I have remained stable, able to concentrate on being a good parent and law-abiding citizen. And now that my daughter has settled happily into school I have started a part-time university degree.
Now our future is in jeopardy due to changes in NHS policy and we are terrified at our future prospects. Last June, due to changes in the structure of the NHS, North Cheshire Health Authority decided it would be more cost effective to prescribe methadone as opposed to diamorphine. I was opposed both on an individual basis, as in the past methadone has made me worse, and because of the harm methadone sold on the street has already done in Warrington.
As a result in November 1994 a group of the clients decided to form a drug users union with a view to having a voice at local and national level and perhaps influence policy decisions affecting the range of treatments available to addicts. Frequently drug users are frowned upon, but it has been proved beyond doubt that given the correct treatment we can lead normal law-abiding lives benefiting not only the addict and their family, but society as a whole. The clinic staff have offered us alternative medication but I am contended and healthy on my current diamorhpine treatment and do not wish to change to drugs which will be detrimental to my well-being.
In June last year I also started corresponding with the relevant complaints department within the Warrington Community Health NHS Trust, with my local MP, a solicitor and many other agencies and individuals whom I thought maybe able to help - but to no avail. I met with the chief executive of North Cheshire Health Authority and attended as many meetings and conferences as I possibly could, because of my family's future is seriously threatened by these prescribing changes.
Apart from the dozens of letters of correspondence with North Cheshire Health Authority and Warrington Community Health NHS Trust my local MP, Mike Hall, has written to the doctor concerned, Dr Ivor Edwards, who ironically advocated on the television the dia-morphine treatment he is now against. It would appear the NHS is no longer about improving the health of the nation but more about the business of saving money regardless of the quality of life. The prospect of reverting to criminality terrorises me and creates stress which is unbearable. For four years I thrived on treatment that prolonged my life and now that life line is being removed. Warrington is becoming like Glasgow, my native city, where there have been two deaths per week from methadone/Temazepam cocktails since 1990. (Scotland on Sunday, Summer 1995).
Julian Buchanan on working with Dr John Marks in Liverpool
see a video discussion about john marks and the widnes clinic here