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Issue 3 1998

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Accident and Emergency

The mixture of alcohol and young people is putting a huge strain on the National Health Service and action needs to be taken now.

Dr Chris Luke, Accident and Emergency consultant at the Royal Liverpool University Hospital, painted an alarming picture when he spoke at the Alcohol and the Young conference, hosted by the Royal College of Physicians. Dr Luke outlined the burden which alcohol placed on the NHS:

  • 1 in 4 acute male admissions

  • Over 28,000 hospital admissions (figures for 1994-5) due to alcohol dependence or the toxic effects

  • Over 4,000 deaths directly attributable to alcohol in England and Wales (1995) compared with 1,620 deaths associated with other substance misuse

  • Over 33 per cent rise in alcohol-related deaths since 1984 (higher for those aged under 45)

  • Alcohol implicated in 28,000 - 50,000 deaths

  • £164 million on care of related problems (in-patient and general practice)

Accident and Emergency departments are particularly hard hit. Dr Luke gave some stark figures on the relationship of alcohol with emergency medicine, pointing out that in the typical A&E departments of one major city, Manchester, around three quarters of patients attending after midnight are drunk. In addition the following are alcohol related:

  • 50-73 per cent of assault victims' injuries:

  • Around 50 per cent of all serious road crashes

  • Nearly 50 per cent of domestic violence against females

  • 47 per cent of serious injuries

  • 40 per cent of self-poisonings

  • 30 per cent of injuries to pedestrian victims of road traffic accidents (and 53 per cent of serious injuries to drivers)

  • Just under 22 per cent of serious acute orthopaedic admissions (in his own hospital in Liverpool)

  • 20 per cent of inappropriate ambulance calls

As far as young people are concerned, Dr Luke said that alcohol, our society's most problematic drug, is consumed by the vast majority. Although cider and beer are the most popular drinks rather than alcopops, the industry has increasingly targeted young people in the last decade. The '90s have seen alcohol featuring more and more as a gateway to illicit drugs. He emphasised the scale of consumption among young people, stating that:

  • 29 per cent of boys and 26 per cent of girls aged 10 to 13 consume alcohol, three quarters of whom reported being drunk

  • 1,000 children under 14 and over are hospitalised every year with alcohol-related presentations

  • "Virtually all" 15-16 year olds have consumed alcohol

  • 89 per cent of undergraduates drink (28 per cent binge)

  • Binge drinking is a common and hazardous pattern of drinking in 16-24 year olds.

Young women have particular problems caused by alcohol. Among them, professionals in the 18-24 age group drink most and have the highest level of dependence. In the medical world it has been estimated that 10 per cent of nurses have a problem with alcohol or other drug misuse (see Don't Carry On, Doctor, page 8).

Surveys in Liverpool, the city in which Dr Luke works, also indicated that 1.6 per cent of the population had major overt medical problems due to alcohol dependence. This figure was reached from a study of GPs records, for example incidence of alcoholic liver disease or rate of prescribing of librium, heminevrin, and thiamine. Liverpool also shows 29 per cent of drink-driving convictions and 39 per cent of arrests for drunk-disorderly among those aged 18 to 25. In one two month period, 169 patients under 18 years old were admitted to the Royal Liverpool University Hospitals with alcohol-related presentations.

Dr Luke presented evidence from the Royal Liverpool Children's Hospital, better known as Alder Hey. The figures are extremely alarming:

  • 17 per cent of 11-15 year olds drink regularly (at an average of 3.5 pints of beer a week)

  • 10 per cent of boys and 8 per cent of girls aged 15-16 are drinking in excess of the recommended adult limits

  • 30 per cent of boys and 20 per cent of girls have drunk around 6 pints on one occasion

  • There has been a ten-fold increase in alcohol-related paediatric attendances during the past decade.

Dr Luke concluded by saying that "alcohol is a major threat to an over-loaded UK healthcare system". What was needed was "a national co-ordinated alcohol strategy [involving] legislation, licensing, education, enforcement, monitoring, advertising, and research." He said that A&E departments' role was central.

They were the "natural starting points", they constituted a national network, and were a logical place for intervention by way of rescue and rehabilitation. He stressed the importance of training the people who worked there and suggested the establishment of a system of alcohol specialist nurses.

Chris Luke is far from alone in drawing attention to the increasing burden which alcohol is placing on the NHS and Accident and Emergency departments in particular. In an important article in the journal, Alcohol and Alcoholism, *researchers from the Health Education Authority and the Centre for Research on Drugs and Health Behaviour report the findings of a questionnaire sent to 224 A&E departments in England. They looked for information on all attendances related to alcohol, "including acute alcohol poisoning, alcohol withdrawal, alcohol-related accidents in the home and workplace, road traffic accidents, self-injury and assault." There was a 96 per cent response rate and so, it must be assumed, we have an accurate picture of the national problem.

It emerges that there is little systematic recording or enquiry about the involvement of alcohol in any patient's attendance. "Few departments routinely enquire about and record alcohol consumption even where patient records are computerised. The most common screening procedures reported were to note if an attendance was observed to be alcohol-related, judging by smell of alcohol on the patient's breath, or by the patient's behaviour." Enquiries of the patient as to level of consumption were only made "if alcohol dependence/problem was suspected."

Respondents were asked about what interventions hospitals made in cases of alcohol-related attendance. Referral to outside specialist services was the most frequent course taken. It was more often nurses than doctors who gave patients verbal or written advice on services or on alcohol generally. Such advice as was given "was mostly described as information on sensible drinking levels and on units of alcohol." It was not apparent whether any assessment of dependence was made prior to discussing "sensible" levels.

The question as to the proportion of attendances in A&E which were alcohol-related was difficult because of the "lack of procedures and guidelines for consistent record keeping even in departments where patient records were computerised." The estimates provided (from 53 per cent of nurse and 62 per cent of doctor respondents) were based on their own perception, more or less subjective as these might be. The doctors said that, of all attendances, 16.3 per cent were alcohol-related, the nurses 19.3 per cent. This provides a figure of about one in six A&E attendances as alcohol-related. In the case of one particular average-sized hospital in a largely rural area, there were 30,208 attendances in the A&E department in the year 1997/98. This would mean, according to the research, that about 5,000 were alcohol-related. This in turn gives a rough figure for all 224 hospitals of 1.1 million alcohol related attendances in one year.

More than 50 per cent of respondents could not estimate the proportions of the different types of alcohol-related attendances, although all respondents said that assault was the most prevalent. (30-35 per cent).

Nurses were more positive than doctors when asked about any preventative role which A&E departments might play: "Only about one in five nurses thought that there was nothing A&E departments could do to help patients change their drinking behaviour compared with one third of doctors. Equally, attitudes towards intervention in the form of brief advice were favourable." A real need for staff training emerged. 80 per cent of nurses and 65 per cent of doctors said that this was necessary, although it might be seen as worrying that almost a quarter of doctors felt otherwise. It is interesting to note that a third of nurses and doctors disagreed with the statement, "Responding to alcohol-related attendances in A&E requires the presence of a staff member trained in alcohol-related issues." It is often argued that alcohol and other drugs are inadequately dealt with in medical schools.

The authors of the report make the point that "current interest in finding ways to prevent or minimise the harms resulting from intoxication, heavy episodic or binge drinking, or dependent drinking...invites scrutiny of potential for A&E departments to develop a prevention and intervention role in detecting and responding to alcohol-related attendances... The results from the survey of A&E departments in England have established that few departments have detection procedures or intervention practices, and that staff perceive considerable barriers to the adoption of a preventative role." Nurses in particular, however, are positive about improving the way in which alcohol-related attendances are handled. It may well be sensible to utilise the expertise of the specialist agencies in training medical staff at least in skills of identification and the delicate matter of questioning patients - an area in which most respondents found considerable difficulty. Certainly, it is evident that the present methods of ascertaining whether alcohol is involved in any A&E attendance are totally inadequate. They are also more than likely to result in underestimates of the problem. Hard worked casualty nurses may well notice patients who are roaring drunk or who smell highly of alcohol, but those who have sustained injuries as a result of dependent drinking might often not be so easy to spot, given the skills in concealment and high levels of tolerance which accompany the condition.

The report concludes: "Clearly there is potential for A&E departments to play a major role in the response to alcohol related problems. Mobilising and sustaining support for the development of preventive approaches in A&E departments presents a challenge which can only be addressed by the development of clear guidelines for good practice".

More generally, the research highlights once again the need for alcohol problems to be treated in greater depth when training both doctors and nurses. The scale of the cost to the NHS is also implicit in the findings.

*Alcohol and Alcoholism (Vol.33 No4 July/August 1998)

IAS Comment

Alcohol is overwhelming the National Health Service. The problems facing Accident and Emergency staff are increasing as their departments fill with the casualties of booze, often under-age drinkers. As a contribution to the mounting mayhem, the Government is prosposing a thirty-six hours drinking spree to mark the turn of the millennium. One A&Econsultant spoke of Armageddon for the NHS. The language may have been colourful but it reflects a real alarm at the prospect of break-down under the strain of alcohol-related injuries. It is a rich irony that Alan Milburn, the junior health minister, should choose this moment to focus on assaults on NHS staff: "This Government values NHS staff. We are determined that the NHS should provide an environment in which staff can go about their business without fear of violence."

In this edition of Alert the problems facing A&E departments are discussed, as are the plans for the millennium. In contrast, we also report the statement recently issued by the Ministerial Group on Alcopops. In this the Portman Groups comes in for considerable praise and clearly the Government is looking to this drink-industry-funded organisation for a lead in combatting the problem of under-age drinking. It is good that proof of age schemes and other measures are having some success, but essentially this is tinkering with the question. Ask doctors and nurses working in Accident and Emergency departments whether they think that much progress is being made and they would laugh in your face. Teenagers attempting to buy alcohol in an off-licence is a symptom. The real problem lies in a society which implants the desire to drink in the first place. Advertising codes are all very well, but again they deal only with a tiny area. Of course it is wrong deliberately to target the young with images designed to appeal specifically to them. But what about the vast majority of alcohol advertising? The young are susceptible to appeals to sophistication, or to masculine bravado, or fashionabilty, or to their sense of humour as much as they are to cartoon characters or amusing frogs. They are impressed by sporting heroes emblazoned with the emblems of breweries.

The Ministerial Group needs to look further and deeper. And it should listen to the public health lobby rather than the industry.

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Ministerial Group on Alcopops

Government ministers say that they "are much encouraged" by the success of the Portman Group's Code of Practice on the Naming, Packaging, and Merchandising of Alcoholic Drinks. "There are fewer complaints made under the new Code and where they occur and are upheld, swift compliance with the independent panel's decisions is the norm."

The Ministerial Group on Alcopops issued their upbeat statement at a time when there is increasing concern about the extent and effects of under-age drinking, (See Accident and Emergency, page 2).

The group, which is chaired by the Home Office minister, George Howarth, and includes Health Minister, Tessa Jowell, is also pleased with the the expansion of the Portman Group's proof of age scheme. The statement pointed out that the number of cards issued had increased by 25 per cent in the last twelve months. This and other proof of age schemes are "vital in helping to prevent children from unlawfully obtaining alcohol."

The Ministerial Group also highlighted the Justices' Clerks' Society's Good Practice Guide, issued in March 1998, which emphasises the importance of taking account of under-age sales of alcohol when considering licensing applications.

George Howarth said: "The Ministerial Group is satisfied that some good progress has been made in the last year tackling the promotion and sale of alcohol to children, but we cannot afford to be complacent. However, there must be no let up in the fight against under-age problem drinking and the misery it causes. Alcohol misuse by those under age remains a serious concern, and efforts to ensure it is addressed on all fronts must be maintained, by everyone. We must deal with it, for the sake of the young people of this country."

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The groves of academe

Andrew Varley looks at some original research

Brendan Gough and Gareth Edwards, of the University of Sheffield Hallam, had the idea of furthering the study of "hegemonic masculinities" by putting together a group of young men under the influence of alcohol and examining their subsequent conversation. The results have been mocked in the press. Simply quoting Gough and Edwards is to mock them. Having been the perpetrator of similar, if more modest, outrages, I wondered whether their piece of work, "The beer talking: four lads, a carry out and the reproduction of masculinities", was an elaborate spoof. Unwilling to put myself in the ludicrous position of the bishop who attacked "Gulliver's Travels" as a pack of lies, I thought it wise to check with the editor of The Sociological Review, the journal in which Gough and Edwards' paper appeared. He assures me that it is "a serious study of the attitudes towards masculinity, race and sexuality expressed by young males".

In an episode of Fawlty Towers, Basil comments that his wife should appear on Mastermind: "Sybil Fawlty, specialist subject, The Bleeding Obvious." Perhaps she had studied sociology, which, at its lowest level, is little more than the statement of the commonplace expressed in terms which make it sound improbable. Gough and Edwards quote an earlier authority in their discipline as suggesting that "drunkenness may be an aspect of masculinity," which, in its way, is clearly a reasonable observation. It does not require an edifice of pseudo-academic endeavour.

"This study, then," say the authors, "is a detailed exploration of one all male gathering and the ways in which four young white heterosexual men (including one of the researchers - GE) negotiate and reproduce a range of masculinities whilst drinking alcohol." In essence, what happens is that four young men, identified by pseudonyms, George, Dave, Chaz, and Ewan, the latter being the co-researcher Gareth Edwards, get drunk together in a flat. Gloriously, the authors say of these four that "all hail from Manchester," as though they bumped into one another on a blasted heath. I should have thought that the participation of Ewan contaminated the research and they seem dimly aware of the possibility: 
"GE thought of taking field notes as the session progressed. However, as the hour approached this idea was rejected as it was felt artificial and unrealistic (sic)." It could also be argued that there was likely to be little academic value in notes made by one drunk about the aperçus of three others.

The use different groups make of language, how it forms a bond, how it identifies the alien, and how it influences perceptions, is an important subject. The addition of a mind-altering chemical, in this case, alcohol, is more likely to confuse the issue than shed light, unless you believe that veritas lies in vino.

The four young men - they are all twenty-one - hold inarticulate conversations of extreme vulgarity, during the course of which they disparage Welshmen, Asians, homosexuals, and women. The transcripts show them to be uneducated, of the lowest intelligence, and of such meanness of spirit that it is difficult to identify them as members of a civilised society. These things seem to be the most significant thing about George, Dave, Chaz, and Ewan, not that they were drunk. Certainly, it is undoubtedly true that alcohol disinhibited them sufficiently to express a dislike for the alien and a fear of the power of women, or at least to express these things in order to feel part of the group. On the other hand, the alcohol did not transform them into other beings. Like the Devil, it needs raw material. Again, that is not to say that truth is in wine - or in this case, lager: it is possible that, sober, George, Dave, Chaz, and even Ewan, who registers mild disapproval at some of the more grotesque sallies of his pals, were thoroughly ashamed of the sentiments they uttered when drunk and genuinely found them repugnant. By the way, it may or may not, depending on your recent exposure to higher education, come as a surprise to learn that these young men are undergraduates at Sheffield Hallam, two of them, we are told, studying psychology.

If anything worthwhile were to have emerged from this exercise, it would have been necessary to have had a control group of similar individuals - undergraduates of Sheffield Hallam or foul-mouthed morons - whose "discourse" was monitored whilst they were sober. It is surprising that The Sociological Review admits research carried out in such an unscientific way. The authors do offer the comment that a "follow-up interview of the men would, however, be useful to see to what extent their thoughts about masculinity match their masculinity as it is expressed," which, as a statement of the Bleeding Obvious, takes some beating. The assumption is implicit that drunkenness somehow released an essential quality of the men, as though the booze were a tool permitting some kind of insight. But alcohol was an active participant in the research. It informed the "discourse", affected the perceptions of George, Dave, Chaz, and Ewan, and refracted, through its own distorting prism, their sober attitudes.

The authors conclude that "this research can be seen as part of the current attempts to gain a more sensitive understanding of gender and how it shapes and is shaped by individuals". Gough and Edwards introduced alcohol into the equation and took no account of its effects in their answer, such as it is. It would be dangerous were anyone to take this stuff seriously because insights into aspects of personality and the nature of masculinity, or femininity come to that, are not achieved through the bottom of a glass...

...I still can't help feeling that the editor of The Sociological Review and I have been the victims of a hoax.

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Naming and shaming in Wales

A scheme to name and shame pubs and nightclubs where violence tends to occur is being piloted in Cardiff.

The Chief Constable of South Wales, Anthony Burden, said that the police now "have got professionals in the health field willing to contribute information which has not been available to us before." The staff of Accident and Emergency departments record the location of assaults requiring treatment. From this information, tables are drawn up to indicate the high-risk drinking spots, the names of which are made available to the local media. "For the first time," said Mr Burden, "we are getting a true picture of the size of the problem and a reflection of the premises involved."

The police are confident that the information provided by the tables will allow them to use their resources more effectively and, at the same time, improve the standards of those premises where violence is a regular feature. Acting Superintendent Graham Lloyd said that "any pub or club that is identified as having a large number of assaults occurring either within the premises or outside - and where evidence indicates that alcohol or the clientele are a contributing factor - that pub or club is then targeted accordingly. Should licensees or managers not assist after being presented with the relevant research, then other action is taken, this will take the form ultimately of an objection to their liquor licence."

This is similar to the successful strategy recently adopted by the police in Newcastle, New South Wales, Australia, which consisted simply of identifying those places where crimes were most often committed and giving the staff in the bars and clubs appropriate training. As a result assaults involving alcohol have gone down by 15 per cent and malicious damage by 36 per cent during the course of the last year. Police say that they have had to spend 300 fewer hours in investigating incidents in and around licensed premises. A senior officer in New South Wales said that it was a good example of successful co-operation between police and licensees.

In old South Wales, the Brewers' and Licensed Retailers' Association have reacted hostilely to the scheme. A spokesman for the organisation said that there was a danger of uncorroborated evidence of victims being used when this could arise from resentments or commercial rivalry. An essential part of the Australian experience has been the co-operation between police and licensees and the training on offer. These elements are important, not only to avoid any negative effects of "naming and shaming", but to ensure the positive results of a drop in alcohol-related crime and violence.

The scheme being piloted in Cardiff is also under consideration by the police in Central London.

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Don't carry on, Doctor

Drinking at high risk levels and the use of illegal drugs among junior hospital doctors is becoming a matter for concern, according to researchers at Newcastle University.

One year after graduation from Newcastle, junior house officers in hospitals in north-eastern England were questioned. There were 90 respondents, of whom 84 drank alcohol. Results published in The Lancet show that over 60 per cent of both male and female doctors exceeded the recommended safe limits. Almost 12 per cent drank at hazardous levels and more than one in four were binge drinkers (25 per cent men and 29.2 per cent women).

Over 35 per cent of male and 19 per cent of female doctors reported that they were currently using cannabis, whilst 13 per cent of the men and 10 per cent of the women used LSD, hallucinogenic mushrooms, ecstasy, amyl nitrate, cocaine, and amphetamines.

For nearly all the doctors who drank, consumption had increased from the time when they were second year medical students.

The survey also assessed levels of anxiety and depression. High levels of these disorders were associated with work pressures, but not with alcohol or illicit drug use.

The researchers conclude that the levels of alcohol and drug use which they found are unlikely to be confined to doctors in the North East. They point out that this is a cause for concern both for the health of the doctors themselves and for the patients in their care. The question of random drug testing and alcohol screening programmes is raised, although the authors of the survey take the cautious line that there is no evidence that these methods "would be workable or appropriate in the UK National Health Service." Some sections of industry and the armed forces operate a mandatory urine testing and many observers would ask why the NHS, with patients well being at risk, should be exempt or in what way such a course might be inappropriate.

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Parents lead children to drink

English parents are more likely to encourage their children to drink than their French and Spanish counterparts. Researchers at the University of Portsmouth found that English parents are notably more permissive when it comes to underage drinking than parents in Norway, France, and Spain. Norwegians were most opposed to 11 to 15 year-olds drinking whereas in England 40 per cent of parents took a much more relaxed view.

The Adolescent Drinking and Family Life Study in Europe found that there was a strong relationship between parental attitudes to alcohol and teenage drinking. There was a clear need to focus on parents in any education campaigns. They studied children aged 11, 13 and 15 and found that the amount of alcohol drunk by children varied widely. 3 per cent of the children said they had drunk more than 36 units of alcohol in the last week. 58 per cent had not drunk at all and 21 per cent had had between one and five units. Over half of all 15 year olds said they had alcohol at least once a week. 12 per cent of those who drank said they had enough to get drunk. 18 per cent just drank until they felt 'merry'.

The children were asked by the researchers whether their parents drank more than once a week. English and French fathers were most likely to set a bad example with up to 40 per cent of their children saying they drank regularly. For Norwegian children, their parents' attitude to drink was an important factor in their own consumption.

The researchers' findings were presented to a British Psychological Society conference in London.

Children with loving and supportive parents were less likely to try alcohol while those whose parents were less strict about underage drinking were more likely to drink. In France and England, parents' alcohol intake and parental attitudes to underage drinking were key factors in whether children drank. The researchers said their findings showed that there was a need for alcohol misuse groups to target parents. Previous studies have also suggested that parental attitudes to alcohol were more influential than those of peer.

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Cross-channel booze

Three drinks hypermarkets are to be opened in French channel ports by the ferry operators, P&O. At the moment the trade in cross-channel alcohol and tobacco stands at well over £800 million a year and P&O are anxious to establish themselves in the business so as to offset the loss of revenue when duty-free ends next June. At the moment the company takes £200 million in duty-free goods every year.

Over recent years there has been a huge growth in the sale of duty-paid alcohol from hypermarkets such as Eastenders, founded by Dave West ten years ago. The major supermarket chains Tesco and Sainsbury, and the off-licence company Victoria Wine also have outlets in the Boulogne-Calais area and P&O will face tough competition from these established players.

A complicating factor is the issue of fares. The largest rise - 10 per cent is suggested - in the cost of crossing the channel for many years is expected soon. Up until now the profits from duty-free has allowed the ferry companies to subsidise fares in their own internecine price war. Of course, one result of the low fares has been to encourage cross-channel shopping. The ferry companies will have to be careful not to raise fares to an extent which will diminish the hypermarket trade just when they are entering it.

Eastenders is now a £42 million business and Mr West says, "It is very competitive over here. The mere fact that it is a P&O cash-and-carry is not going to convince people to go there without shopping around." The Chairman of P&O Ferries, Graham Dunlop, said that customers would be able to 'phone through their orders before their trip and collect them as they leave for England. The major beneficiaries of this facility, it might be argued, are the bootleggers who order in vast quantities, know precisely what they want, and like fast, efficient operation. A large part of the attraction of the booze hypermarkets to the ordinary tourist, or even the customer who is taking a day-trip to stock up on lager, is the ability to browse and make a selection on the spot.

However it is bought, so-called beer-tourism is costing the Exchequer £195 million in lost excise duty and VAT, according to an answer given in the House of Commons in July, and represents approximately 15 per cent of all alcohol bought by UK citizens in supermarkets and off-licences. In the same answer Geoffrey Robinson, the Paymaster General, informed the House that 70-80 per cent of smuggled alcohol (100 per cent for tobacco products) substitutes for similar purchases in the UK. The inference must be that the 20-30 per cent remaining constitutes additional consumption directly resulting from low prices.

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Lower limit still on?

Lord Whitty, the minister for roads, has refused to commit the government to lowering the drink-drive limit - an intention they stated clearly both before the general election and immediately afterwards. The signs are that pressure to stick with the high 80 mgs per cent have paid off.

Whitty, a former general secretary of the Labour Party, was speaking at a Road Safety and Health conference organised by PACTS (The Parliamentary Advisory Council for Transport Safety). He followed Health Minister, Tessa Jowell, who in a general survey of the problems did not mention drink driving, and Dr Howard Baderman, Accident and Emergency consultant at University College Hospital, London, who identified it as his number one priority in reducing accidental injury. Dr Baderman suggested that it was time to take punitive action against drink drivers and pedestrians who cause accidents whilst intoxicated.

In his speech Lord Whitty referred to the government's 'sensible' drinking policy and said that it was unwise to take alcohol when driving. He pointed out that young men were the greatest offenders. He also said that the rate of alcohol-related motoring accidents had not fallen for five years. A hard hitting Christmas campaign has been launched again this year.

As a consequence the government is looking for new measures and has sought contributions to the consultation process. Lord Whitty has already said that any decision based on this consultation will not be announced until after Christmas. He added that, at the moment, he could not say "which way the wind was blowing" as to what course the government would take. He did, however, say that it was "unsafe to drive with any significant level of alcohol" and emphasised that 80 mgs per cent was the legal level, not the point where driving becomes unsafe. He avoided any reference to the possibility of lowering the limit to 50 mgs per cent, even though he had implicitly stated that, as things stand, it was perfectly legal to drive at an unsafe level of alcohol.

In the question session after the ministers had spoken, a representative of the Institute of Alcohol Studies asked Lord Whitty why the government appeared to be reneging on its previous intention of lowering the limit. Lord Whitty acknowledged that it was clear that a reduction would "reduce accidents and deaths". However, it was a question of what were "the most appropriate" measures, he said, adding that there was a body of opinion which felt that tightened enforcement would have a more direct impact. Lord Whitty accepted that where there had been a reduction this had had an impact. He stressed that there "was no change in the government's position" and that all possible courses would be considered. He did not refer to the fact that the government's position had at one point been definitely in favour of a reduction.

It is worth noting that, since the introduction of the 50 mgs per cent drink drive limit in Germany on 1st May 1998, the number of alcohol related accidents in Cologne has more than halved. The number of drivers caught with a level of more than 110 mgs per cent fell by approximately 25 per cent according to a study published by the University of Cologne. The study was carried out over the period January 1997 - August 1998.

...definitely off?

On the day after the Government's Christmas drink-driving campaign, "Don't Drink and Die", was launched, The Guardian newspaper reported that the Government had abandoned any plans to lower the limit to 50 mgs per cent.

Interviewed at the launch by BBC television, Dr John Reid, the Transport Minister, seated on a bar stool in a pub on Horseferry Road, side-stepped a question about lowering the limit, saying that this was irrelevant since it was wisest not to consume any alcohol when driving. In effect he was pressing the same line as Lord Whitty.

Nevertheless, hours after Dr Reid spoke, Keith Harper, the Transport Editor of The Guardian, felt confident enough to write that plans "to reduce the legal blood alcohol limit from 80 mgs to 50 mgs are to be abandoned by the Government." At the same time Government sources confirmed that between 50 and 80 lives would be spared were the limit lowered.

Although the final decision has yet to be made, The Guardian report says that "ministers appear to have been swayed by the police, who argue that they need more breath testing powers to deal with persistent drink-drivers" If this is the case, then the police have reversed their original position. The Association of Chief Police Officers has been at the forefront of the campaign for a lower limit. It is difficult to see how a lower limit would prevent the police from targeting the hard core of drunks who insist on driving. After all, as John Reid said at the launch of "Don't Drink and Die", 154,000 people were breathalysed last Christmas, 9,700 of whom were prosecuted. There must have been quite a few drivers among the remaining 144,300 who were between 50 and 80 mgs. To a lesser degree, something like these proportions are presumably found during the rest of the year.

The Guardian also states that the Government will not follow up the plan to give police the powers to beathalyse without prior suspicion. In other words, the implication is that there will be no changes at all in the law as it affects drink-driving and the police will have exactly the same ability to target any group of drivers as ithey do now.

At the launch in the Barley Mow pub on Horseferry Road, Dr Reid said, "The intention is to remind the viewer that every day someone dies as a result of a drink-drive accident. I believe that using real cases drives the message home." Those people who die in drink-driving accidents when they are somewhere between 50 mgs and the present limit are real cases.

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Imprisoned by addiction

Peter Bond, the founder of the Rehabilitation of Addicted Prisoners Trust (RAPt), died in August.

It was Bond who pioneered full-time treatment programmes in Her Majesty's Prisons for alcohol, drug, and compulsive gambling related offenders. After three years of lobbying, inmates began the first course run by what was then called the Addictive Diseases Trust in April 1992. Peter Bond himself was a business man who recovered from chronic alcoholism through the 12 Step Programme of Alcoholics Anonymous. He became involved in voluntary work with alcohol-related offenders through the Hertfordshire Probation Service in 1982. Peter was also the founder member of two local alcohol services and was Development Director of Hertfordshire Alcohol Problems Advisory Service (HAPAS).

Having studied abstinence-based treatment programmes which had proved successful in the United States, Bond attempted to sell the idea in the United Kingdom. He approached prison governors, members of parliament, successive Home Secretaries, and even the then Prime Minister, Margaret Thatcher.

The first 18 months were critical. Through patient diplomacy, both the prison staff and inmates came to accept the Substance Abuse Treatment Programme (SATP) as a very effective method of alcohol and drug rehabilitation, which had a dramatic effect not only on the behaviour of inmates who participated in the programme, but also on the prison culture itself. Eventually, a 'partnership' emerged which has developed to the point where the RAPt and HMP Downview have become synonymous. The programme now operates in five prisons in the United Kingdom employing some 30 therapists. Michael Howard, when he was Home Secretary, said that RAPt had done more to promote rehabilitation in British gaols than any other initiative in living memory.

In the last months of his life, Peter wrote an article on RAPt's work, an edited version of which we print with the kind permission of the Editor of Alcohol and Alcoholism.

ALCOHOL AND OTHER DRUGS

More crime is related to alcohol than to any other drug. Most offenders who enter prison with a single problem of alcohol dependence return to the community with an additional drug habit. This is because, although 'hooch' has been brewed by inmates since time immemorial, drugs are easier to acquire than alcohol. In addition, many heroin addicts will, if their regular drug is not available, use alcohol as a substitute, and amphetamine, cocaine, and 'crack' addicts will use alcohol to 'come down'. This has made it necessary to address 'cross addiction' as part of the treatment plan.

The Substance Abuse Treatment Programme (SATP) operated by RAPt has been a pioneer project. In common with AA, we look on addiction as a disease and we explain to our participants, who are called Members, that we regard them as sick people trying to get well, not bad people trying to be good. Clinicians may protest that, by telling addicts they have a disease, we give them a perfect excuse for past behaviour. We would say that possession of this knowledge requires the individual to accept responsibility for the consequences of any return to active addiction.

The focus of the SATP is not on addiction: addiction awareness courses are wasted on habitual alcoholics or addicts, who probably know more about the real effects of abuse than any clinician or research worker. Rather, SATP is about countering the 'mental obsession', as the founders of AA called it. This involves dramatic changes in thought, behaviour, and reaction. It is designed to give the alcoholic or addict a mental defence against picking up that first drink or drug which will perpetuate the decline to infirmity, insanity, or premature death. Therefore, the treatment process is a biopsychosocial model which encourages the Member to adopt a healthy lifestyle to help repair the physical ravages of addiction; to uncover, with the help of group peers, behaviour patterns which need to be altered to avoid relapse; and to acquire the skills to become more socially active with people who are also in recovery or do not find it necessary to use alcohol or drugs. In our experience, all addicts also suffer from low self- esteem. Our job is to help them discover their assets and build on them. It is incredible just how much talent remains untapped, imprisoned by drugs as well as iron bars.

THE TREATMENT PROCESS

In order to deliver the best therapeutic and economical package, the SATP, which started as a 28-day block, has been adapted and developed into a 12-week rolling programme. This means that Members are at varying stages of treatment and those further along help the newcomers to break down barriers to the help available. The following have proved to be the essential and successful elements of substance abuse treatment for prisoners as they have been developed by the staff of RAPt.

Pre-admission group

As the programme developed, the news spread through the prison grapevine and applications poured in. A waiting list was established for both HMP Downview residents and prisoners from other establishments. The impact has been so great that, at this moment, it can take up to 12 months from initial application to actually starting the course. Basic application forms, which give offending and using histories, are often accompanied by a letter from a personal officer or probation officer. All applicants are eventually screened in depth, assessed, and judged for motivation. Successful applicants enter the pre-admission group, preparing them for the intense 12 weeks ahead. It is in this environment that more screening takes place and some suspect aspirants make the decision to quit.

12-Week primary treatment programme

(1) Induction: When Members are inducted, they complete self-assessment addiction questionnaires, sign up to the Rules and Expectations essential to the smooth running of the programme, and are briefed on the 12-week syllabus and weekly timetable. The dynamics of group therapy are briefly demystified and details of assignment expectations are explained. No Member is ever rejected because of illiteracy. Our graduates include total illiterates; a Tibetan with no English; African, Italian, and Chinese Members. We pair them with a 'buddy' or a trainee peer counsellor.

(2) Community group: This is a weekly meeting of all Members and counselling staff and is a forum for reflection. Staff comment on Members' progress or lack of it. Both staff and Members challenge on slipping boundaries. The Rules and Expectations are read around the room so that no Member can plead ignorance. Members take responsibility for the cleanliness of the treatment premises so, at this time, domestic jobs are rotated. Newcomers present a brief life story as an introduction to their peers. Key rings and medallions are presented for Clean Time and the psychological impact of gaining these low-value items is powerful. They are greatly prized by recipients, who may not have experienced the freedom of drug-free living for many years.

(3) Group therapy is the most important and effective tool for change in the entire programme. Apart from breaches of security, threatened self- harm or harm to others, and child sex abuse, absolute confidentiality is guaranteed by the staff and is expected from all the Members. Here, the addict is confronted with their previously unchallenged behaviour. They are encouraged by their peers to drop their defences and the gangster image to let the real person emerge. They learn, through identification and empathy, to give and accept trust. It is in group therapy where social skills and respect for others develop. Issues other than addiction emerge when the Member feels safe enough to disclose and people are relieved to find that they are not alone in suffering from secret behaviours, experiences, and 'hang-ups'. Examples include physical, sexual, and mental abuse, rejection, abandonment, fostering, adoption, and even sexual orientation. Both staff and inmates help to process these potential triggers to relapse.

(4) One-to-one counselling: Each Member is assigned a personal counsellor who may become the first individual with whom they will develop an open and honest personal relationship. The counsellor will tease out from the Member's background details which will assist in developing an individual treatment plan. The counsellor also encourages the Member to take some of his 'secrets' to the group and trust its reaction. The majority of RAPt counsellors are in recovery from addiction. Some have experienced prison. So the excuse, 'You don't know how it is', rarely crops up.

(5) Goals group: Members give one another behavioural changes to work on during the coming week. The previous weeks' goals are reviewed and peers assess whether or not the individual has achieved the target set. As in group therapy, the staff facilitate, rather than participate. Incarceration tends to emasculate inmates, taking away the responsibility for providing for themselves and their families and for making day-to-day decisions. A major focus of the SATP is to try to redress this anomaly by encouraging Members to accept responsibility for their actions and to make better choices rather than blaming other people or institutions for their problems.

(6) Assignments: Assignments of self-examination, which include a detailed and frank life story, help the addict to end the denial syndrome. Only then can they hope to see that their behaviour has been chaotic: it contributed to loss of jobs; to an inability to sustain relationships; it led to crime and, of course, loss of liberty. Cross-addiction with other drugs is examined, enabling the addict to see how quite innocent use (including prescribed and over-the-counter drugs) has led to relapse to the original drug of choice. The life story reveals destructive patterns of behaviour of which the addict is often unaware. These can be modified with the help of the group. Inmates readily admit that criminal behaviour can, for some, also be addictive. This behaviour needs to be examined because, for the majority, alcohol and drug abuse and crime go hand in hand. Assignments are necessary for the staff to assess if what is being taught is being assimilated.

(7) Relapse support group: In order to establish an abstinent, safe environment, and after negotiation with the governor and doctor, drug testing was introduced when it was a very controversial issue politically. All test samples are identified only with an SATP number and results remain confidential to RAPt staff. From the moment we started voluntary drug testing, the dynamics of the environment improved dramatically. Unfortunately, relapse is a hazard of recovery. Nobody is regarded as a failure and the function of the relapse group is to explore triggers and patterns of behaviour which lead back to active addiction. It is called a support group simply because, in the event of breaches of any of the Rules and Expectations, Members are required to stand down for a predetermined time to reflect on motives and re-assess commitment. Members all attend the support group but, as confidentiality is guaranteed, the reason for being stood down is not disclosed to the prison staff.

(8) Peer-evaluation group: Peer evaluation takes place towards the end of the Member's treatment. Evaluation questionnaires contain suggestions for change which are more likely to be noted and acted on coming as they do from those with whom the Member is in daily contact rather than a semi-authoritarian figure such as a counsellor.

(9) Aftercare group: Completion of the 12-week programme is not the end of treatment. The SATP gives a template for the future pattern of behaviour. The weekly aftercare group reinforces what has been learned and the accent is on relapse prevention. One-to-one counselling is available on request.

(10) Peer supporters: Graduates with the right motives are selected for training as peer supporters. They become part of the staff team in every respect, except for access to confidential client information. As well as taking over much of the routine work from the regular staff, they are 'buddies' to the illiterates and the non- English speakers. Available 24 hours a day, they are also invaluable in crisis intervention and have helped to prevent many relapses. They are also excellent examples and advocates for the treatment programme.

(11) Families: "Families who get sick together, need to get well together". With this maxim in mind, immediate families are invited to family conferences. The Member emerging from treatment will be a very different person to live with than the chaotic drunk or addict. A spouse may be a user, which will make life difficult for the Member on release, or may wish to set boundaries for future life together. These issues and many more need to be aired and attempts made to resolve them. Research reveals that even the smallest investment by families in the treatment process has a positive impact on sustained recovery.

(12) Continuum of care: Research and our own experience show that the longer alcoholics or addicts are in some form of continuum of treatment in a safe environment, the better the prognosis for long-term recovery. RAPt maintains contacts with secondary care facilities which follow an abstinence policy and many Members, having pursued this route after release, are now in their own accommodation, in gainful employment, and involved in further education. We always encourage our people to make regular use of the international support of the 12-Step Fellowships which are free.

TUMIN

After 3 years during which the Trust raised £250,000 in order to prove that our programme could run successfully and concurrently with sentence, Her Majesty's Chief Inspector of Prisons, Judge Tumin, inspected HMP Downview. He submitted a glowing report on the project and his team recommended that RAPt be funded for 3 years and that the Home Office fund an outcomes study. Following a 6-month study, Home Office researchers reported over 50% successful completion of the first year and more than 50% of those followed-up in the community were still abstinent and had not re-offended.

EXPANSION

RAPt has been approached by a number of prison governors to replicate the SATP in their establishments. Money is usually the only barrier to these requests. However, with some Home Office funding and some partnerships, programmes are now operating in four other prisons and the 50 per cent plus programme completion rate has been maintained overall.

OUTCOME

Because of the changing culture in HMP Downview, the governor was persuaded to designate areas of 'drug-free' accommodation to RAPt Members, graduates, and the few non-drug users. The landing staff found that relationships with clean and sober inmates were vastly improved, confrontations greatly reduced, and that the residents became more interested in keeping fit and in education. A decision was made to aim to become the first 'drug-free' prison and this was accomplished by having a voluntary cotract with the inmates that total abstinence and submitting to voluntary testing would be a condition of residence at HMP Downview. Positive tests dropped from 98 to 8 per cent and disciplinary incidents fell in proportion. In 1993, the RAPt Fellowship was inaugurated to encourage all those who had participated in the programme to keep in touch with RAPt and with one another. There have been three annual reunions at Downview and on each occasion an increasing number of graduates have returned to a visits area, packed with still serving Members, as living proof that, if the teachings of the programme are practised outside of prison, life without alcohol or drugs can be enjoyable and fulfilling.

CONCLUSION AND COMMENTS

A proposal which was initially rejected as impracticable, unworkable, and unnecessary has been a real success, mainly because the end user, the addict, has voluntarily presented, used, and benefited from the treatment programme. The cost of putting an inmate through the SATP averages £1,500. However, it costs the taxpayer about £20,000 to keep an inmate incarcerated for a year. The SATP has had a dramatic effect on Home Office and Prison Service thinking and policy. At a recent conference held in Bristol on the way forward for treatment in prisons, the programme heading the list flagged up by a Home Office keynote speaker was the 12-Step Model.

We have treated 'lifers', armed robbers, and many other types of violent prisoners and all have to some degree responded to the treatment process. Dr Andy Keay, Governor at HMP Downview, declared that it is the first time in 20 years of prison service that he has actually seen men change. The impact may be slow but SATPs in more prisons can and will reduce the prison population.

Many inmates who recover want to make some reparation to society. At my suggestion, the Governor at Downview has, for the past 3 years, allowed selected inmates to go into schools under escort and share their experiences. Judging by the unsolicited letters from both teachers and pupils, the impact has been dramatic. Youngsters from 8 to 18 have been shaken out of their ignorance of the consequences of the drug culture and, hopefully, some of them will be deterred from substance misuse.

Some graduates have taken up counselling training. Two who have served their sentences have qualified and returned to become valued members of the RAPt therapy staff. Others have chosen further education. More are in gainful employment and are repairing damaged relationships. So the impact radiates outwards from the treated individual.

Of the responses to the most recent Aftercare Follow-up Questionnaire received so far 80 per cent were still abstinent from all drugs, including alcohol and, considering that these prisoners were all long-term chronic abusers, this is remarkably encouraging

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Marking hooligans out of the game

As police warn that that the incidence of football hooliganism is increasing, the Government has published proposals to combat the menace and protect the decent fan.

The proposals were announced by Kate Hoey, the Home Office minister. They include draconian measures to combat the contribution alcohol makes to the problem. It was suggested that alcohol-free zones be imposed on whole towns or districts around football stadiums before and after matches. The chief officer of police would have to apply to the licensing magistrates "for an order to ban the sale of alcohol and the carrying and consumption of alcohol in a public place for a specified location and period of time." The effect could be to criminalise acts of members of the public - carrying the gift of a bottle of wine to a host, for example - who were not football fans. In these circumstances, however, "some consideration may have to be given to the reasonableness of those carrying alcohol and whether there was any connection to the football match."

Pubs, restaurants, and supermarkets in a specified area would be forbidden to sell alcohol and public consumption of liquor could be banned for up to 24 hours. In order to safeguard against excessive use of these powers any order would be subject to the consent of the Home Secretary.

The other major proposals are:

  • Toughening existing powers to stop convicted criminals from travelling abroad, including the surrender of passports;

  • Introducing new powers to stop unconvicted but known hooligans from travelling abroad;

  • Extending existing legislation on ticket touting to cover matches taking place abroad;

  • Toughening existing powers to stop convicted hooligans from travelling to domestic games;

  • Making it an offence for an individual to make racist chants.

Launching the consultation document, Kate Hoey emphasised the need for everyone involved in the game to share responsibility and work together to drive out the hooligan. Miss Hoey said that "millions of people go to football matches each season to watch and enjoy the game. There are still a small minority who ruin things for the decent supporter. They cause mayhem, grab the headlines and divert resources.

"The review is wide ranging and contains some 29 proposals. It is aimed at making sure the decent, law-abiding supporter can enjoy football in a safe and secure environment. Some of the proposals would represent fundamental change.

For example, the issue of travel restrictions against unconvicted hooligans is a significant shift and the introduction of alcohol bans, although intended for use only in extreme circumstances, would also be a serious move. However, following their success at France 98, having a similar power at our disposal will help England's bid for 2006."

Kate Hoey added: "The football authorities and individual clubs have a responsibility to the wider community and must demonstrate that they do not condone bad behaviour on or off the field. Players are seen as role models and also have a responsibility to live up to the best traditions of the sport, leading by example both on and off the pitch."

Arrests for violent football-related incidents including affray, violent disorder and throwing missiles, showed a "marked increase" in the first month of the season compared to the same time last year.

Bryan Drew, of the National Criminal Intelligence Service, said: "Although it is too early to say whether the overall downward trend for football related arrest figures over the past five years is being reversed, the signs are not encouraging."

This season, incidents have included a police charge against Glasgow Rangers fans, a CS-spray attack on Norwich fans by Birmingham supporters in a pub, and a major disturbance on a London to Sheffield train.

The "Review of Football-Related Legislation" may be obtained from The Home Office, Operational Policing Policy Unit, Box 25, Room 541, 50 Queen Anne's Gate, London, SW1 9AT, to which any comments should be sent by 26th February, 1999.

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Gazza's short sharp treatment

Andrew Varley examines Paul Gascoigne's predicament.

Paul Gascoigne's public statements after leaving the treatment centre, where he had been attempting to deal with his alcohol problem, were depressing. It seemed as though the intention of holding a press conference was merely to assuage the appetite of the media with a few scraps rather than an attempt to express himself honestly to the many thousands of people, not only football fans but anyone with a compassionate understanding of his predicament, who wished him well. Gascoigne's resentment against the press was all too evident - "a hint of simmering contempt", as one journalist present described it. For a man in Paul Gascoigne's circumstances, resentments are not a good sign.

There is no doubt that his two week stay in the Marchwood Priory will have achieved something. It is quite possible that Gascoigne has got the message - after all, at the press conference he did say "I will stop drinking" and that he was "a changed man". On the other hand, it is often the case that, after this short a period, many alcoholics in treatment are only just beginning to overcome the formidable walls of denial they have erected during lengthy drinking careers. If Gascoigne attended meetings of Alcoholics Anonymous whilst in the clinic - and that is the usual practice - he will have heard anyone who spoke give their name and add "and I'm an alcoholic." It was noticeable that he avoided using the word of himself when questioned by reporters - although, of course, he was under no obligation to do so and its absence does not necessarily imply its rejection.

There were other remarks made by Gascoigne, however, which were more alarming than any omission. "It wasn't just the drinking," he said. "It was everything. I was stressed and depressed." Some of the press endorsed this theory. Writing in The Times, George Caulkin took the view that his "recent divorce, the death of his friend... and his exclusion from the England team had had a cumulative effect." This was also the line taken by Bryan Robson, the Middlesborough manager and a man around whom many drinking stories have accumulated, when Gascoigne first went into treatment. The problem with this approach is that it is implicit that, when these problems have been overcome, "normal" drinking will be possible.

It is common for people with an alcohol problem to attribute it to any number of outside factors: an uncongenial wife; financial difficulties; loss of employment; depression; a vindictive employer; the painful end of a love affair. For those to whom it is no more than that, a discrete problem, this may be true. Alcohol has the power to dull the pain of all these circumstances for a very brief period and that is why the melancholic, the bankrupt, and the cuckold have, in many instances throughout history, resorted to the bottle. In these cases there was no inevitability. Others hanged themselves, made another fortune, or shot the wife.

The alcoholic, on the other hand, is another matter. All these misfortunes befall him as a consequence of his drinking. They are symptoms not causes. Paul Gascoigne's abusive drinking was a feature of his life before Sheryl petitioned for divorce and before his outstanding skills on the football field were dulled. The unreasonable behaviour and violence of which Mrs Gascoigne complained happened because he was abusing alcohol. The edge went off his game for the same reason. Most men, or women, in this sort of situation do not hate their spouses or children, nor do they set out to perform professional duties in a slip-shod manner. Had it been in Paul Gascoigne's power, presumably, he would have stopped drinking in order to save his marriage or to ensure his place in the England team. But, as the first of the 12 Steps of Alcoholics Anonymous says, "we came to accept that we had no power over alcohol."

In treatment the alcoholic is led towards a discovery of the triggers to his drinking. Some of these may be based on deep emotional scars, others may appear obvious, even trivial. For example, it is usually suggested that old drinking companions and situations be avoided. In Paul Gascoigne's case, this is quite a problem. Professional football as a whole is associated with heavy drinking, as is a North Eastern working-class background. When Paul Merson left Middlesbrough he said that one factor influencing his departure was the club's culture of heavy drinking and gambling. It does appear that things are beginning to change there. Recently, the players' bar went teetotal on the insistence of a sports scientist. Measures like this will help Gascoigne but he needs to take positive measures himself. Well-publicised benders with the likes of Chris Evans are obviously a thing of the past, but unless Evans and similar companions have the insight, compassion, and intelligence to help Gascoigne by changing their own habits, at least when he is around - in other words, if they are his real friends - then they should be avoided. It is ironical that, when Gascoigne joined Middlesbrough, journalists telephoned various experts in the evident hope of receiving confirmation that he would automatically endanger Merson's recovery.

Everything depends on how well he has learned his lesson, how humble he is prepared to be, how far he has abandoned denial and accepted powerlessness, and how therapeutic being back on the football field proves to be If he hits a purple patch, scores a lot of goals, and receives the plaudits of the crowd, then an early departure from the Priory have been justified. On the other hand, an injury, poor form, a sending-off could undo all the good work which has already been done by counsellors, psychotherapists, and doctors.

An addiction counsellor who worked with Paul Merson and Tony Adams, another footballing star in recovery (see opposite), said recently that "Paul Gascoigne will die young if he doesn't change his lifestyle very quickly." It is the choice that faces every dependent drinker, carry on as you were with all the appalling consequences, or gain a new life of real quality. As they say in AA, the misery can always be refunded.

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Legalise cannabis?

When the House of Lords advocated the legalisation of cannabis for medicinal purposes, the Government reacted swiftly to rule out the possibility.

George Howarth, a minister at the Home Office, said, "The safety of patients is our priority, and the Government would not allow prescription of any drug which had not been tested for safety, efficacy and quality through that clinical process." He added that it supported further trials into the benefits of cannabis for MS (multiple sclerosis) and chronic pain.

Whilst the Lords' science and technology committee agreed that the present ban on the recreational use of the drug should not be removed, Lord Perry of Walton, its chairman, said that clinical trials could take up to five years, too long for sufferers to wait. "We felt that the evidence of benefit to these patients with very distressing symptoms was such that we shouldn't make them wait that long," he said, adding that the benefits of the drug had already been proven in some tests on animals.

Lord Perry suggested that cannabis should be moved from the list of "schedule one" drugs, which are illegal to use even if they relieve pain, to "schedule two", from which doctors may prescribe to named patients. Although the Lords' recommendation was welcomed by patients' groups, politicians, and some anti-drug campaigners, the British Medical Association said that making cannabis available on prescription would be a misguided move with the possibility of preventing new, more effective drugs being developed.

In The Lancet which appeared a few days after these exchanges, an article by Professor Wayne Hall and Dr Nadia Solowij, of the National Drug and Alcohol Research Centre at the University of Sydney, set out what appear to be the most likely adverse effects of smoking cannabis. The evidence summarised by Hall and Solowij was considered by the science and technology committee of the House of Lords in reaching their conclusion. Three years ago The Lancet's editorial stated: "The smoking of cannabis, even long term, is not harmful to health" (11th November, 1995). Needless to say, the legalise-cannabis lobby made capital out of the statement. With hindsight, the leader writer now reflects that perhaps they should have "begun...with a less provocative statement." Nonetheless, he goes on to say that "it would be reasonable to judge cannabis less of a threat to health than alcohol or tobacco, products that it many countries are not only tolerated and advertised but are also a useful source of tax revenue. The desire to take mood-altering substances is an enduring feature of human societies worldwide and even the most draconian legislation has failed to extinguish this desire. For every substance banned another will be discovered, and all are likely to have some ill-effect on health. This should be borne in mind by social legislators who, disapproving of other people's indulgences, seek to make them illegal. Such legislation does not get rid of the problem; it merely shifts it elsewhere."

Professor Hall and Dr Solowij provide a summary of adverse effects of cannabis intended as a guide to doctors who need to advise patients on the drug's use:

The Lancet concludes that it should qualify its opinion of three years ago "and say that, on the medical evidence available, moderate indulgence in cannabis has little ill-effect on health, and that decisions to ban or to legalise cannabis should be based on other considerations."

Acute effects

  • Anxiety and panic, especially in naïve users.

  • Impaired attention, memory, and psychomotor performance while intoxicated.

  • Possibly an increased risk of accident if a person drives a motor vehicle while intoxicated with cannabis, especially if cannabis is used with alcohol.

  • Increased risk of psychotic symptoms among those who are vulnerable because of personal or family history of psychosis.

Chronic effects (uncertain but most probable)

  • Chronic bronchitis and histopathological changes that may be precursors to the development of malignant disease.

  • A cannabis dependence syndrome characterised by an inability to abstain from or to control cannabis use.

  • Subtle impairments of attention and memory that persist while the user remains chronically intoxicated, and that may or may not be reversible after prolonged abstinence.

Possible adverse effects (to be confirmed)

  • Increased risk of cancers of the oral cavity, pharynx, and oesophagus; leukaemia among offspring exposed in utero.

  • Impaired educational attainment in adolescents and underachievement in adults in occupations requiring high-level cognitive skills.

Groups at higher risk of experiencing these adverse effects

  • Adolescents with a history of poor school performance, who initiate cannabis use in the early teens, are at increased risk of using other illicit drugs and of becoming dependent on cannabis.

  • Women who continue to smoke cannabis during pregnancy may increase their risk of having a low-birthweight baby.

  • People with asthma, bronchitis, emphy-sema, schizophrenia, and alcohol and other drug dependence, whose illnesses may be exacerbated by cannabis use.

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Off target

Alcohol targets set by the previous government are not being met, is the message being sent out by researchers from the National Addiction Centre and St George's Hospital.* The aims set out in the Conservative government's "Health of the Nation", which have not been formally abandoned by Labour, state that the intention is to "reduce the proportion of men drinking more than 21 units of alcohol per week from 28 per cent in 1990 to 18 per cent by 2005, and the proportion of women drinking more than 14 units of alcohol per week from 11 per cent in 1990 to 7 per cent by 2005."

The researchers sent a questionnaire to a random sample of 20 per cent of all GPs in England and Wales. What emerges is not an "unwilling profession, but a profession lacking confidence. The provision of support and basic training are major factors in how GPs perceive alcohol misusers and their own role in this work." Despite the lack of adequate training for GPs in this field, it is generally accepted by the medical profession and the government that general practice is a suitable place for health promotional work.

The survey shows that there is currently a low rate of identification of patients drinking beyond the "sensible" limits. It appears that one reason for this is that GPs are recognising the more obvious cases - the chronic alcoholic or the self-presenting patient - but missing those with less visible symptoms or whose ostensible reasons for appearing in the surgery were unconnected with drinking. Another reason is the doctors' own attitude to the business of identifying actual or potential alcohol problems. The authors of the research say: "One of the main themes running through research is the negative perception GPs have of alcohol misusers and the efficacy of their work with them." The GPs' view of the adequacy of their local alcohol services influenced this perception. This was certainly the experience of one alcohol and drug counsellor when he opened a day rehabilitation programme in a market town where there had previously been no such service. He told Alert that local GPs had initially been sceptical but later showed themselves willing to listen and to observe. The result was that most of them not only referred patients whom they had diagnosed as needing treatment for dependency but also that their own skills at identifying problems were enhanced.

These patients, however, were severe drinkers. The researchers point out that "more effective strategies to promote greater GP attention to the detection of less severe drinkers must be identified if real progress towards the...targets is to be achieved."

It is twenty years since the last important piece of work in this field was done and the authors of this one find it "disappointing that, for a profession which recognises its potential to do this work, lack of training and lack of support are still so central to their continued low level of therapeutic commitment."

*Low detection rates, negative attitudes and failure to meet the "Health of the Nation" alcohol targets: findings from a national survey of GPs in England and Wales, Deeham et al., Drug and Alcohol Review, September, 1998.

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Drug statistics

One in eight people seeking help for drug problems is under 20 and heroin continues to be the most frequently reported drug, according to statistics recently published by the Department of Health. They refer to the six months ending in March, 1997, and deal with people reporting drug misuse for the first time ever or for the first time in half a year.

Other findings show that there was a 4 per cent increase in the number of people (25,925) presenting to agencies. Over half (54 per cent) were in their twenties and the ratio of men to women was 3:1.

As favourite drug, heroin was the choice of 60 per cent of users, an increase from 48 per cent in 1994. A long way behind in second and third places come methadone and amphetamines, at 14 and 8 per cent each.

12 per cent of users who were known to have injected during the previous four weeks reported having shared equipment.

Information about misuse of alcohol was collected only where it counted as a subsidiary drug.

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And a Happy New Year

If the Government has its way, it will be possible to welcome the new millennium and every New Year thereafter with a round-the-clock drinking session.

Before the general election, Labour indicated that it saw the need to revise the licensing laws and, since the party came to power, the Home Office has set in motion a thorough-going review of the relevant legislation. The previous Conservative Government had made its own attempts to change the status quo as regards drinking hours but was forced to back down in the face of considerable opposition, particularly from its own supporters in leafy suburbs and country towns who did not wish to have their peace disturbed by later closing times.

The proposal is that "the normal limit on opening hours should be relaxed at night for all premises, other than off-licences, and that this relaxation should continue on each subsequent New Year's Eve." The Government's preferred option is that the licensing hours should be relaxed for 12 hours. The alternative is a shorter period of 5 hours.

The consultation paper issued by the Home Office on this topic* makes the point that, as far as extensions are concerned, "a specific application must be made in respect of each set of premises for each special occasion". It is expected that on the eve of the new millennium virtually all the 140,000 licensed premises will want extended hours. A general relaxation of normal hours, the Government argues, on this specific occasion and on all New Year's Eves would remove a significant burden from the licensed trade. The consultation paper goes on to say that the suggested measures "would also benefit the courts and the police service who have to consider each application. For the benefit of the trade and the public, it would also provide for consistent opening hours across the country." Throughout the document the assumption is made that any suitable celebration is impossible without excessive alcohol consumption.

Not all the public would see themselves as beneficiaries of a concerned Home Secretary. The controversy that greeted the modest proposals of the last government are witness to that. There is likely to be widespread concern about noise, violence, and other disturbance. Consultants in Accident and Emergency units are already warning that intolerable stress will be put on the NHS by a 36-hour nationwide binge. Casualty departments are stretched to breaking point most weekends with alcohol-related injuries. The Government's document concedes that "some people may object to the proposals on the grounds of expected noise or nuisance." The intention is to provide a system of restriction orders "which would allow courts to impose earlier closing times on individual premises, on an application from the police or a local resident, in order to avoid or reduce disturbance or annoyance to local residents or disorderly conduct by customers." Clearly the administrative burden of dealing with restriction orders will be considerably less than the huge number of extension applications were the system to remain unaltered.

The Home Office's suggestions may be reasonable when viewed in the light of the cost to the trade and the police, but the extra burden to the NHS should not be ignored. It is certainly the case that, under the legislation as it stands at the moment, the 100,000 or so applications to trade for longer hours at New Year would be granted, but none of these would allow 36-hour drinking.

Concern in the NHS is not only being expressed about an intolerable burden on casualty but about the problem of providing an adequate staff level on the eve of the millennium. NHS Trusts throughout the country are already looking at ways of dealing with a long-descried crisis. Whether they will be able to anticipate this is open to question.

Added to these factors is the infamous millennium bug. The Government is playing down the potential chaos but privately there is a serious worry about a possible dislocation of utilities such as water and electricity supply. A picture emerges of a health service, undermanned and cut off from basic essentials, facing the gratuitous extra burden of the casualties of night-long celebrations.

The question has to be asked as to whether it is sensible, given the difficulties already foreseen, to permit circumstances which will exacerbate the situation. Before proceeding along its chosen path, the Home Office must convince both the public and health service professionals that they have genuinely taken every precaution to ensure that the benefits they claim outweigh the inevitable drawbacks. Perhaps the best way of doing this will be for some of the ministers and officials so keen on the changes to volunteer to assist in their local Accident and Emergency Department as this century draws to its close.

*The consultation paper is called Liquor Licensing Deregulation: Consultation on New Year's Eve Licensing Hours, issued by the Home Office, November 1998. The Government is seeking your views on its proposals. In sending any response please answer the following questions:

  • i) Do you support an all-night relaxation (every New Year's Eve, beginning with 1999/2000?

  • ii) If not, would you support a relaxation until 4 a.m. (every New Year's Eve, beginning with 1999/2000?

Responses should be sent by Friday, 12th February, 1999, to Pratibha Mehta, Liquor, Gambling and Data Protection Unit, Room 1183, Home Office, 50 Queen Anne's Gate, London, SW1H 9AT.

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Adams turns his back on alcohol

Paul Whitaker reviews "Addicted" by Tony Adams. Collins Willow £16.99

"Today I am not just Tony Adams the footballer. I am Tony Adams the human being."

Tony Adams thus concludes his roller coaster journey through his footballing and drinking life. Early in his career few would imagine that Adams would be a candidate for Renaissance man, yet he now spends his leisure time playing the piano, visiting the theatre, and reading poetry and philosophy. Before he faced up to his demons, he was addicted to playing football and getting drunk.

The recent intense media interest and speculation surrounding Paul Gascoigne's problems has provided an interesting contrast to that aroused by Tony Adams' public confession and subsequent publication of his autobiography "Addicted". Adams has bared his soul even further recently by sharing with Radio 5 Live listeners that hitting his own "rock bottom" had led him to even contemplate suicide.

Typically the aspect of the book that the tabloid press concentrated on was Adams' assertion that he, not Alan Shearer, should have captained England during the 1998 World Cup finals. What they didn't concentrate on was that one of the country's most successful modern footballers has relentlessly pursued his career whilst at the same time regularly drinking to excess and eventual self confessed alcoholism.

Football-wise the book is a fairly interesting gallop through a very successful career during some exiting times with Arsenal and England over the last two decades. Unfortunately for Adams, his response to both triumph and disaster was to get seriously drunk and what is amazing is that Adams has managed to, by his account, consume vast quantities of alcohol and still manage to win every domestic honour, a European Cup Winner's medal as well as amassing over 50 England caps. On the down side was the failure of his marriage, his prison sentence following a conviction for drinking and driving, and many lonely hours drinking himself into oblivion. Adams eventually found his way to, and salvation in, Alcoholics Anony-mous, to which he pays glowing tributes. For him his alcoholism is an illness that his addictive personality was unable to control. What is obvious is that the lifestyle of the modern footballer is a lethal cocktail of immense pressure combined with ludicrous amounts of money and seemingly endless spare time.

Football clubs appear to provide little guidance as to how young players should successfully cope with the intense pressures of the modern game. They have a responsibility few face up to,Wimbledon FC being an exception, to ensure the pastoral well being of their players. Adams' own heavy drinking began as a young player well before he was a first team regular.

It is obvious that at many clubs a drinking and gambling culture is tolerated if not encouraged by the management as a macho approach to team-building. For example the recent claim by Bryan Robson, the Middlesbrough manager, following Paul Merson's departure to Aston Villa, that his team were "near teetotallers" and that Gascoigne is suffering from "stress" rather than an alcohol problem is perplexing to say the least. By contrast the current England manager, Glenn Hoddle is derided for his belief that the use of a faith healer can play a role in the spiritual and physical well being of his players.

Adams has faced up to his own challenge and seems to be faring well, he arguably put in some of the best performances by an English player in the France 98 World Cup.

He will face further challenges when his career comes to an end. A poignant reminder came recently in the shape another former Arsenal star Malcolm MacDonald who, struggling with his own alcohol problem, recently emer-ged from a treatment clinic. Paul Gascoigne could do worse than to make Adams' book his bedtime reading over the next few weeks.

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Books

Andrew Varley reviews Out of the Woodshed by Reggie Oliver, Bloomsbury, £25; The Warden: a Life of John Sparrow by John Lowe HarperCollins, £19.99; and Beloved Chicago Man: Letters to Nelson Algren 1947-64 by Simone de Beauvoir, edited by Sylvie de Beauvoir LeBon, Gollancz, £25.

In a famous essay, the late Isaiah Berlin dismissed the possibility of a concept of scientific history. And quite right too. I like to think of him - in a lighter moment, perhaps, in All Souls after the port had passed - as a proponent of the cock-up theory of history. I was converted to this years ago when many contemporaries still slavishly acknowledged Marxist determinism but I had never thought of it as much more than one of those jokes which contain an obvious truth, until a friend, in an inspired piece of cod-scholarship, adumbrated its sub-divisions. An important part of the cock-up theory, she argued, lay in the answer to the question, "Who was pissed at the time?" It is a problem to which few historians have devoted appropriate attention - even those whose personal experience might have been expected to furnish them with some insight. Only a few moments thought is enough to show that the ramifications of the question touch most aspects of human endeavour: political, military, literary, romantic. The list goes on and the subject deserves closer examination than a review allows.

Three new books deal with subjects affected by the question. Stella Gibbons' biographer, her nephew Reggie Oliver, devotes some space to her father's alcoholism and its immediate consequences for the family but stops short of looking for its influence on her life and work. Nonetheless, it is clear that Stella shared many of the traits displayed by children of alcoholic parents. She was an achiever. Security and success were important to her. Perhaps Mr Oliver is correct not to labour the point but to allow the picture of his aunt's ability to cope with her background emerge from the story. Her own marriage and family life were happy and her writing, as with so many authors, provided its own therapy. Mockery can mitigate pain and we all have, lke Ada Doom, "something nasty in the woodshed." Don't we?

John Lowe, in his portrait of John Sparrow, the Warden of All Souls from 1953 until 1976, discusses his period of distressing drunkenness during retirement but does not look very far for its causes. Mr Lowe was a close friend of his subject and wants us to think the best of him. I only met Warden Sparrow once and on that occasion he lived up to the caricatured picture I already had of him. He seemed a bitter man with a tiresomely cruel tongue, though he did not use it on me. John Sparrow had an ambivalent attitude to his own homosexuality, at once despising it and giving it full rein. He had some tortured relationships and throughout his life had the greatest difficulty dealing with his emotions. Although he possessed a fine mind, he left no lasting literary memorial. It is easy to see why he looked for some oblivion in drink and good to know that he had the capacity to put this aside and enjoy a contented old age.

The case of Beloved Chicago Man is different. This is a collection of Simone de Beauvoir's letters to the American novelist, Nelson Algren. Algren is probably best remembered for his warnings-for-life, apothegms such as "Never play cards with a man named Doc." I have no idea who sat round the poker table with him, but clearly Algren did not always follow his own advice since he also said, "Never sleep with a woman who has more problems than you." The main interest of the book is, of course, the illumination it provides on a relationship which was crucially important to a writer of considerable significance. De Beauvoir is inextricably associated, intellectually and sexually, with Jean-Paul Sartre, and the fact that her long (and usually long distance) love affair with Algren has largely escaped notice will make the publication of her letters to him a matter of intense interest. Her niece, Sylvie de Beauvoir LeBon, is the editor and has done a good job. What Mlle LeBon does not discuss, however, is her aunt's chronic alcoholism (see Alert, No.1, 1998) and its inevitable influence on her relationships. Reading the letters, often moving and beautifully written, it is difficult not to receive the impression that Mlle de Beauvoir found some satisfaction in a relationship she could, at least in part, control through her imagination. In the end she alienated Algren by publishing details of their affair, as though it had been a work of fiction in which he was a character to be manipulated.

In all three cases, Gibbons at one remove, Sparrow in one period of his life, and de Beauvoir in full-scale addiction, abuse of alcohol had a major effect on them, on their creativity, and, in very different ways, on their ability to deal with emotions.

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