Heroin Herald

Possession of Illegal Drugs

Possession means having drugs in your physical possession or having control of drugs. If you leave drugs in a suitcase in a left luggage office, you do not possess drugs physically, but legally, you still have control of the drugs.

Legal possession of drugs involves knowledge.

A left luggage attendant holding a suitcase belonging to someone else may not know that the suitcase contains drugs, and will therefore not legally be in possession.

Intention is very important. Not everyone in possession of drugs will be guilty of an offence. Conveying a drug to someone who is entitled to have the drugs in their possession is not an offence. Nor is taking possession in order to destroy them.

A teacher, for example, confiscating cannabis could flush it down the loo. If, however, the teacher held onto the drugs, and did not destroy them, and offence of possession would be committed.



Common types of possession

Simple possession

In order to prove possession, the presecution have to identify the drug precisely - cannabis resin or amphetamine sulphate, for example. Normally, this is done by sending drugs away for scientific analysis.

If you identify a drug to the police - for example, "this is lorazepam" - they may be able to use your identification as evidence, on the basis that you have behaved as it is Lorazepam.

If you have already tried the drugs, it could be said that you have formed an opinion about the nature of the drug, even though you are not a scientific expert (Bird v Adams 1972, Wells 1976). Each case must be judged on the facts.

If you are in possession of, for example, a quantity of white powder which you think is cocaine, you may be charged with possession of cocaine, even if, on analysis, it turns out to be amphetamine sulphate.

The prosecution must prove that you had physical custody of the drugs, or controlled them in some way, and that you knew or suspected that drugs were present, and that they were illegal. Seeing someone else use a drug, or being close to drugs does nor amount to possession (Searle 1971, Bland 1988).



Joint possession

If you own a pool of drugs with other people - cannabis for example, then handing a joint round the group does not amount to supply. Each person draws from a common pool, and therefore each person has control (Searle 1971).

Someone offering a cannabis smoke to another person not already in possession of the drug could be said to be supplying even if the joint is not handed over permanently. However, it would be difficult for anyone to act independently in controlling the drug (Moore 1979).



Traces

At one time you could argue in court that minute quantities of drugs were not "usable". The courts have decided that "usability" is not relevant to drugs possession cases (Boyesen 1980).

There are some problems in prosecutions involving traces. Accurate analysis and identification of minute quantities of drugs may be difficult. Knowledge may also be a problem. Someone in possession of, for example, cannabis in a jacket pocket may not know that the drug is present.

Used syringes and needles may contain traces of illegal drugs. People using needle exchanges should check with local drugs agencies about the attitude of local police, who may agree not to prosecute in certain circumstances. The public interest may be taken into account by the police, who are able to exercise considerable discretion in enforcing the law (R v Metropolitan Police Commissioner 1968).

Traces of drugs found in urine or blood cannot be used as evidence to support a charge of possession of drugs.

(Hambleton v Callinan 1968.) But many people found in possession of traces may be tempted to admit past possession of drugs to the police.



Past possession

Traces of drugs can be used as evidence of past possession.

Such prosecutions can be regarded as oppressive (Pragiola 1977). More often, prosecutions for past possession use statements and admissions from suspects who have admitted taking illegal drugs in the past. The courts can rely on admissions of guilt by defendants in drugs cases with little corroborative evidence.

An occupier who saw people injecting heroin or freebasing cocaine on their premises would be under no legal obligation to stop them, provided they did not actively assist them. But the same occupier would have to stop the consumption of cannabis.

Occupiers of premises

The MDA places special obligations on occupiers of premises, who may not knowingly allow drugs production or supply. The law in this area is under review, and may change to make it an offence if an occupier does not stop the use of any illicit drug.



Premises

Premises can mean anything from a house to a boat or caravan which is not moving. An open field does not count as "premises".

Responsibility for premises lies with occupiers, not owners. A person who is in a position to invite or exclude visitors, holds the key, or takes responsibility for premises will count as an occupier (Tao 1976).

People sharing houses or flats are in a difficult position. If one person uses cannabis with the knowledge of others, then the co- tenants could be prosecuted for allowing the premises to be used for smoking cannabis.

Knowledge

"Knowing" that drugs are being used, supplied or produced on premises mean deliberately or recklessly disregarding the obvious.





Supply of Drugs

Supply of drugs, or "trafficking" is a serious offence. It does not necessarily mean large scale dealing for profit. Simply handing certain controlled drugs to another person can count as supply, and may attract heavy penalties.

Possession with intent to supply

This is one of the most common "trafficking" offences. Possession with intent to supply includes all the elements of simple possession, and additional evidence about intent.

The prosecution may try to establish intent to supply in various ways. In some cases, the quantity of drugs involved is obviously too large for personal use.

In other cases, intent to supply can be established through statements and admissions made by suspects.

Evidence of drug paraphernalia such as scales, packaging and cutting equipment may be used as part of the prosecution. Police evidence on patters of drug use may be called. This evidence may be contested by calling more sympathetic experts for the defence.

Where a person has left drugs with a friend for safekeeping, anticipating that they be handed back on demand, the friend looking after the drugs is guilty of supply if the drugs are handed back, or they intend to hand them back. (Maginnis 1987)



Supply

"Supply" means different things in different cases. Sometimes, the courts concentrate on the physical transfer of drugs from one person to another (Delgado 1984).

At other times, the courts look at whether the person receiving the drugs has benefitted (Dempsey 1986).

Some drugs supply cases involve evidence from police observation, in which drugs are not fully identified.

Suspected suppliers may make admissions to the police, along with the people buying the drugs. Sometimes, purchases of drugs are are persuaded to give evidence against contacts who supplied them.



When several friends pool money to buy drugs, then the person making the actual purchase and delivering the drugs will be supplying, even if all considered themselves to be jointly involved in the purchase (Buckley and Lane 1979).

Injecting someone with their own heroin is not a supplying offence, assuming that the drugs never leave the control of the person taking them, and the person injecting them is simply assisting (Harris 1969).

Sometimes, people who are not supplying drugs are charged with "being concerned" in supply. This means some kind of identifiable assistance such as telephoning a contact or similar helpful act.



Supplying intoxicating substances

The intoxicating Substances Act covers the supply of substances other than controlled drugs, such as solvents and lighter fuel.

Supply is illegal is the substance or its fumes are to be used to intoxicate a young person under 18.

A supplier must know or suspect that the young person concerned is under 18. People under 18 who supply to one another should not be prosecuted unless they are selling substances as part of a business.

 


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Why the world needs an international network 

of activists who use drugs.

We are people from around the world who use drugs. We are people who have been marginalized and discriminated against; we have been killed, harmed unnecessarily, put in jail, depicted as evil, and stereotyped as dangerous and disposable . Now it is time to raise our voices as citizens, establish our rights and reclaim the right to be our own spokespersons striving for self-representation and self-empowerment:

• To enable and empower people who use drugs legal or deemed illegal worldwide to survive, thrive and exert our voices as human beings to have meaningful input into all decisions that affect our own lives

• To promote a better understanding of the experiences of people who use illegal drugs, and particularly of the destructive impact of current drug policies affecting drug users, as well as our non-using fellow-citizens: this is as an important element in the local, national, regional and international development of these social policies.

• To use our own skills and knowledge to train and educate others, particularly our peers and any other fellow-citizens concerned with drugs in our communities.

• To advocate for universal access to all the tools available to reduce the harm that people who use drugs face in their day-to-day lives, including, i) drug treatment, appropriate medical care for substance use , ii) regulated access to the pharmaceutical quality drugs we need ii) availability of safer consumption equipment, including syringes and pipes as well as iii) facilities for their safe disposal, iv) peer outreach and honest up-to-date information about drugs and all of their uses, including v) safe consumption facilities that are necessary for many of us.

• To establish our right to evidence-based and objective information about drugs, and how to protect ourselves against the potential negative impacts of drug use through universal access to equitable and comprehensive health and social services, safe, affordable, supportive housing and employment opportunities

• To provide support to established local, national, regional, and international networks of people living with HIV/AIDS, Hepatitis and other harm reduction groups, making sure that active drug users are included at every level of decision-making, and specifically that we are able to serve on the boards (of directors) of such organizations and be fairly reimbursed for our expenses, time and skills.

• To challenge the national legislation and international lconventions that currently disable most of us from living safe, secure and healthy lives.

Well aware of the potential challenges of building such a network, we strive for:

• Value and respect diversity and recognize each other's different backgrounds, knowledge, skills and capabilities, and cultivate a safe and supportive environment within the network regardless of which drugs we use or how we use them

• Spread information about our work in order to support and encourage development of user organizations in communities/countries where there are no such organizations

• Promote tolerance, cooperation and collaboration, fostering a culture of inclusion and active participation.

• Democratic principles and creating a structure that promotes maximum participation in decision making,

• Maximum inclusion with special focus to those who are disproportionately vulnerable to oppression on the basis of their gender identity, sexual orientation, socioeconomic status, religion, etc.

• to ensure that people who use drugs are not incarcerated and that those who are incarcerated have an equal right to healthy and respectful conditions and treatment, including drug treatment and access to health-promoting supplies such as syringes and condoms and medical treatment or at least equal to that they would receive outside

• to challenge execution and other inhuman treatment of people who use drugs worldwide

Ultimately, the most profound need to establish such a network arises from the fact that no group of oppressed people ever attained liberation without the involvement of those directly affected by this oppression. Through collective action, we will fight to change existing local, national, regional and international drug laws and formulate an evidence-based drug policy that respects people's human rights and dignity instead of one fuelled on moralism, stereotypes and lies.

The International Activists who use drugs

30 April 2006, Vancouver Canada

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Good News for Hepatitis C Treatment

New NICE guidance approves treatment for mild to moderate hepatitis C, but all is not rosy in the primary care PCT back yard where a public health time bomb awaits...

SMMGP welcomes the extension of the current NICE technical guidance issued in August 2006, which gives patients affected by mild to moderate disease the opportunity to be treated during the early stages of hepatitis C, before measurable damage occurs to their liver (Ref 1). This change to the guidance is welcomed, as it offers increased access to treatment for those with hepatitis C (prior to this NICE advised that only those people with moderate to severe symptoms were to be treated (Ref 2)). It is also now recommended that the decision to treat early should be made by the patient after full discussion with the treating specialist. The decision to treat need not depend on having a liver biopsy in all cases, a procedure that may have acted as a barrier to treatment for many people. Also people who continue to inject are no longer excluded from treatment.

Treatment of hepatitis C with pegylated interferons, ribavirin and alfa interferon is successful in 40-80% of cases. The success rate is dependent on a number of factors, including genotype, age, and alcohol consumption. Between 0.4% and 1% of people are infected with hepatitis C in England and Wales.

But all is not rosy with hepatitis C in primary care and PCTs

But all is not rosy! Out of the total population infected only about 67,000 (10%) have been diagnosed as HCV antibody positive in the UK (Ref 3) and only about one in 20 receives treatment each year (Ref 4). Of the total number infected this treatment rate falls to only 1-2% (Ref 5) Unfortunately, the new NICE guidelines fail to discuss the potential benefits from screening and testing people, there is no mention of the role of primary care in managing patients with HCV infection and there is little information on how the guidance should be implemented in practice. However, as the All Party Parliamentary Group on Hepatology (APPGH) point out. Hepatitis C represents a public health problem time bomb in the UK (Ref 6).

"Hepatitis C represents a public health problem time bomb in the UK"
(Ref 6)

We know that the current understanding of hepatitis C is poor, both in the general population and in primary care (Ref 7, Ref 8). Screening, testing, diagnosis and onward referral for treatment (and hence awareness of the NICE guidance) is limited by this poor knowledge base. Additionally, we know that PCTs have not yet fully implemented the Hepatitis C Action Plan for England which stated, "Chief executives of primary care trusts should be able to demonstrate that there are adequate services and partnerships at local level to enable models of best clinical practice to be followed, as set out in this Strategy for England." (Ref 9). Results of the APPHG survey showed a 63% response rate and that the strategy had only been implemented effectively by just 16 PCTs (8%), to some degree by 107 PCTs (56%) and not at all or minimally by 68 PCTs (36%). Only 64 of the responding PCTs (34%) have a protocol in place for the testing and/or screening for hepatitis C, and only 49 PCTs (26%) have a process in place to monitor treatment (such as how many patients are receiving treatment, its success rate, serious adverse events, how and where it is delivered and any delays encountered in delivery) (Ref 10).

Despite the fact that HCV is moving up the political agenda with current NICE guidelines recommending more patients having access to HCV treatment, funding limitations (including the infrastructure to administer treatment) continue to restrict treatment in practice. With so many PCTs in budget deficit, it seems that it will be difficult for them to accept the initial cost implications to the local healthcare economy despite an awareness of the likely cost implications of severe liver disease in 20 years time if HCV goes untreated.

Improving practice in primary care

In short, there is much work to be done in primary care to improve on the current situation. There are a number of things that we need to do first before we can expect to see the new NICE guidance fully implemented. We need to:

(1) Improve knowledge amongst healthcare professionals in primary care

• Improve the knowledge base in general practice by improving training for all undergraduates and postgraduates.
• Increase the hepatitis C element of the RCGP Certificate in Drug Dependency parts 1 and 2 by developing a separate 'e-module' for part 1 relating to HCV infection.
• Increase the role of consultants in helping to raise awareness of the NICE guidance amongst local GPs.

(2) Identify the large pool of patients who are currently undiagnosed

• Increase screening and testing for HCV.
• Distribute the proforma to help with what to cover in the pre-test discussion before testing patients for Hepatitis C (available on the RCGP web site.
• Target the huge number of patients with chronic hepatitis C who are currently undiagnosed.
• Ask all registered patients about past and current drug use (about 90% transmission through injecting drug use but some through 'snorting').
• Recognise other risk factors (e.g. born in a developing country; blood transfusions before 1991 or abroad; tattoos) and offering testing.
• Offer testing to all patients with abnormal liver transaminase levels even in the absence of obvious risk factors.

(3) Improve knowledge amongst patients

• Highlight the success of the new treatments and the fact that it is not always necessary to have a liver biopsy through awareness campaigns.
• Consider advertising in surgeries to encourage testing of at-risk patients, without discrimination, after appropriate discussion and assessment.

(4) Complete the development of RCGP guidance for the management of hepatitis C in primary care

• This is due to be published towards the middle of 2007 but is currently available in draft form for comment (NB if you would like to comment please ask us for a draft).

The need for more structured multidisciplinary working patterns

Only a fraction of people diagnosed with HCV infection are referred on and an even smaller number pass through the system for treatment (Ref 11). New structures of working will be required to improve upon this situation. The development of clinical networks, as used in the management of cancer and HIV is vital, will encourage good communication and knowledge sharing between primary and secondary care. Nurse specialists already have a key role in some areas and this could expand.

Conclusion

The NICE guidance effectively makes treatment available to all who want it, assuming there are no contraindications. However, the patient's perspective is important and treatment should not be imposed on anyone who does not want it; equally treatment should not be denied to anyone who wants it (Ref 7).

So, in summary, the change in the NICE Guidance is welcome, but there is much that can be done and needs to be done in primary care before they will be implemented.

- Dr Chris Ford SMMGP Clinical Lead & Kate Halliday, SMMGP Associate Advisor

References

1. National Institute for Health and Clinical Excellence (NICE). Peginterferon alfa and ribavirin for the treatment of mild chronic hepatitis C. NICE technology appraisal guidance 106. August 2006. www.nice.org.uk

2. National Institute for Health and Clinical Excellence (NICE). Interferon alfa (pegylated and non-pegylated) and ribavirin for the treatment of chronic hepatitis C. Technology appraisal 75. January 2004.

3. HPA. Hepatits C laboratory reports:England and Wales, 1992-2004

4. European Report Meeting, 31st May 2005

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A history of drug prohibition and a prediction for its abolition and replacement

This timeline contains a selection of events that were felt to be of significance in the history of prohibition and the campaign for drug law reform. It is not intended to be a historically comprehensive document, but to give a sense of narrative and progress; to shed some light on why we are where we are with regard to the drug laws, and more importantly, how we can use this experience to move forward.

The final section 2007-2026 looks into the future and contains Transform's predictions for how absolute prohibition will be replaced by regulated drug markets over the coming years.

References are given where available / appropriate. This is a work in progress and comments and suggestions would be much appreciated. Please email info@tdpf.org.uk

A special thanks to Transform volunteer Majeed Neky for his invaluable work on this document during his summer 2006 internship, and Ben campion for the web layout

Quick Links

• 1800-1959
• 1960-1996
• 1997-2006
• 2007-2026

Key: red = United Kingdom; green = United States of America; blue = United Nations.

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http://www.hepcuk.info/data/UserContentRoot/Home/

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Will we lose our Incapacity and Housing Benefit?

My husband has hepatitis C and is on Incapacity Benefit paid by Income Support. Last month I started working part time (21 hrs a week) and my salary is about £500 a month. We have been told that because I am earning this amount of money the income support for my husband will stop and also the housing benefit. Is this true?

Your husband's Incapacity Benefit paid by Income Support will continue as long as he satisfies the medical conditions to claim. What will stop is any monies he had claimed for yourself. As you are working 21 hours a week you should now claim tax credits from the Inland Revenue (0845 300 3900) and make a claim for Housing Benefit and Council Tax due to your change in circumstances. But until your claim is sorted out I advise you to pay whatever you can afford towards your rent and Council Tax. I would advise you to contact a personal adviser at the Job Centre to make sure you are receiving everything you are entitled to and also to speak to someone at your local Advice Centre.

Statutory Sick Pay/Mortgage Relief/Resigning from Work?

I am currently taking time off sick due to the side affects of treatment  (in the 3rd month ). I've used up my full sick pay entitlement of 2 months and my 2 months at half pay will be coming to an end soon. After that if I'm still not well enough to work I will be on statutory sick pay - is this correct?. As a married man with two children (my wife does not work outside the home) we claim child benefits and family tax credit. We have a repayment mortgage - will there be any help with this?
I have asked my employers for re-deployment to lighter duties - are there any benefits in resigning from work on grounds of ill health and can they ask me to resign for this reason?

SICK PAY - Once your two months at half pay finishes your employer will pay you statutory sick pay. Then if you are still sick on the 23rd week of your entitlement your employer has to complete and send you (SSPI) form (changeover form) to help you transfer onto Incapacity Benefit + send this to the DSS with a medical certificate.
After 28 weeks on SSP you will go onto the higher rate short-term Incapacity Benefit if you satisfied the National Insurance contribution conditions. The amount is the same as SSP and you can claim for adult dependants. As I don’t know all your circumstances I can’t calculate what benefit you will receive. As it’s based on your  N.I. contributions paid. You will continue to get child tax credits. You will have to tell tax credits ( 0845 300 3900) so that your working tax credit stops as they don’t treat you in work once your SSP stops and this will stop you getting an overpayment of working tax credit.
I would also advise you to claim Income Support at the same time as you put in your claim for Incapacity Benefit. This is on an A1 form. If you are refused Incapacity Benefit you will be entitled to Income Support if you don’t have capital over £8,000. If you are refused, claiming this is helpful as you can then reclaim help with future housing costs on your 39th week of your Income Support being refused if you have been on SSP/Incapacity Benefit. Regarding other help available you can try and claim Disability Living Allowance (see benefits) and I would advise you to make a claim to your local Authority for help with your council tax.
I would advise you to get an appointment at your local advice centre or contact Community Legal Services (020 7759 0000) who will give you contacts in your area who specialise in benefits.

MORTGAGE PAYMENT - They will pay 100% of the interest on your property. But the DSS mortgage rate can be different to what you pay. I would inform your mortgage lender about your situation and they might be able to sort something out regarding paying reduced mortgage payments.
 
RESIGNING FROM WORK - Regarding your employment I would advise you to contact the ACAS Helpline (0845 747 747). They are the experts in employment matters and can advise you what good practice your employer should be doing. Also if you are in the Union I would contact them. I would not resign from your employment because you could lose out if they decide you are not able to return to your job + can’t give you a lighter job. They might offer a settlement if you have to leave work.

Home Help Entitlement on Treatment

I'm due to start treatment soon and I am concerned that if I suffer from severe side effects I will be unable to look after myself properly. Would I be entitled to any kind of home help? and secondly, would a friend or family member be able to become my carer and receive carers allowance?

You can ask for an assessment regarding your difficulty managing at home, from your Social Services (adult) care team. They will normally arrange to visit you at home. You might have to wait for a few weeks for a visit or assessment by phone. However, even if a local authority is unlikely to provide a service because of resource constraints you should not be denied an assessment.
The assessment should look at the range of community care services, your capacities and incapacities, your preferences, what support you have and other sources of help.
You should be informed in writing of the result of your assessment and have a copy of your care plan. If you are not given a written result you should ask for one.
If your needs are urgent, services can be provided before an assessment, which should then be carried out as soon as possible.

A friend or family member can become a carer and apply for Carers Allowance.
You would have to apply for Disability Living Allowance and receive this benefit middle care/high care before someone can receive carer’s allowance. I would advise you to go to a Citizens Advice Bureau or local advice centre in your area to get help with completing the forms, as the benefit is not easy to get.


Disability Benefit while on Treatment

I have had Hepatitis C for over 10 years. I am about to start 6 months of combination treatment and will realistically be out of action for this period. I recieve incapacity benefit and am wondering if I will be able to get disability benefit, considering I am symptomatic.

I would advise you to claim Disability Living Allowance if you are on treatment and you then experience problems with your health. The benefit is quite hard to get and the form is not very easy to complete as you have to fit your illness around the questions.

The benefit is for helping you look after yourself and if you have difficulty with mobility. It is in two parts:

Care Component           –   for help with personal care needs and can be paid at 3 different rates.
Mobility Component       –   for help with walking difficulties paid at  2 rates.
 
You can start off your claim by phoning the Benefit Enquiry line on 0800 882 200 and asking them to send a claim pack to you.

I would also advise you to make an appointment at your local advice centre or contact Community Legal Service (020 7759 0000) which will be able to tell you who specialises in Benefits in your area, and can help to complete the section at the back of the form.

Also if you have any other health problems, do include these on the forms. I would not advise you to complete the forms without any help.


Low Income

I have had to reduce my hours at work and have a family to support and am getting into debt with our rent and council tax.
We are in receipt of wages, child tax credit, working tax credit and child benefit. Our working tax credit has been adjusted due to the change in circumstances.

My advice to you is to claim rent and council tax benefit from your local authority. Most local authorities have a combined form for housing and council tax benefit. You can phone them and ask for a form to be sent to you. It should be returned to them within 4 weeks. The date of your claim is when you hand the form into them and the date from which you will receive any benefit awarded – so the quicker you get it in the better.

They normally ask for lots of information. They will want the following proofs:
Wage slips – for the last 5 weeks
Child benefit
Bank details – last 2/3 months statements
Any capital you have
Up to date notifications of your tax credits etc

When you take the form into your local Council make sure to get a receipt from them as proof of delivery (forms can and do get lost) If they request more information you will only have a limited amount of time to get it back to them.

I would also advise you to contact the rent and council tax departments and make an arrangement with them to start paying back the arrears (they will usually accept a small weekly amount). This is important as if payments are not kept up to date you run the risk of losing your home and of the council tax debt going to bailiffs.

Also contact your local Advice Centre which should be able to help you with all of the above.

Voluntary Work

I am thinking of starting to do some voluntary work to ease me back into the work mode. As I feel I am now well enough to do something with my time. I receive Incapacity Benefit.

If someone is in receipt of Incapacity Benefit - You are allowed to do voluntary work for anyone other than a parent (or in-law or step-parent), son/daughter (or in-law/step), brother, sister, or their partner. You must not be paid for your work other than expenses - ‘reasonable expenses’ – this can include travel, child minding or costs for use of a telephone. There is no limit on the number of hours you can volunteer for.

If someone is in receipt of Income Support – You are allowed to do voluntary work without your Income Support being affected. For this purpose a volunteer is someone who performs a service without expectation of payment. The only payment yourget or expect to get must be to cover your actual expenses.
If the Department of Work & Pensions thinks it is not reasonable for you to provide your services free of charge they may treat you as having notional earnings.
If if you work 16 hours or more a week and you receive any monies other than expenses you are treated as in paid work and excluded from Income Support. If your benefit is stopped get benefit advice from your local advice centre or contact Community Legal Services on 0207 7590000.

Fares to Hospital Entitilement

I'm due to start treatment soon and I'd like to know if I can get help with any transport costs that may occur from the necessary visits to the hospital for check ups etc...

You may be able to get help with fares or other travel expenses for yourself (and for someone who has to go with you if you are incapable of getting to the hospital on your own) if you:
Are getting income support or income-based jobseeker’s allowance or
Are getting working tax credit and child tax credit

Help with Electricity Bill

Are there any funds available for someone with hepatitis c who's had their electricity disconnected?

There are no funds available specifically for people with Hepatitis C.  But if you have your gas and electricity account with British Gas you could apply to the British Gas Energy Trust, PO Box 42, Peterborough, PE3 8XH for help with debts. Also some water companies have trust funds that might be able to help with bills. The other option, if on benefits, is to access a DSS crisis/budget loan.

DLA Question
I have active hep c and cirrhosis, enlarged spleen and arthritis type pains with depression and anxiety, I am 50 and live alone.   I filled in my own Disability Living Allowance form a few years ago, had a visit from a doctor and got the lowest rate care component for not being able to prepare a meal on my own (despite all my other descriptions of disability and the care I eeded). That was when I was on my first treatment which was 3 interferon injections a week. When that failed I was put back on the treatment and re-applied for an upgrade as I felt I was getting worse, another doctor visited me and took away my DLA altogether! He insisted on looking at the soles of my feet to see if the skin was soft and if I really was unable to walk very far. At the time a DLA advisor said I was best off starting the whole thing again and putting in another claim, but I didn't and went to the tribunal.   I got some help from a different agency (which in retrospect was not very good) and attended the appeal tribunal where they said they would give me back my benefit (low care) as I sat in the waiting room and that I did not need to come in to the tribunal. However I said I wanted to but even after the tribunal they still only awarded me low care again. This has been set now for the next 2 years. I had a third 6-month course of unsuccessful therapy (which gives chemotherapy-type side effects) My questions is - I am loathe to disturb a benefit which has been so hard to win and at least assures me some extra money for 2 years, should I have gone on to appeal against the decision? I was too tired and ill to fight it. Now all my treatments have failed and I am left with cirrhosis - I wonder if I would have even less chance of increasing my dla now? Shall I wait until the 2 years comes to an end and try for a higher disability or do something now? I feel I need a mobility component and did read a lot about how to fill the forms in but the decision makers seemed to ignore this - it is hard when you live on your own with a chronic disease to name a specific carer or explain how you do need the care when there is no one there to give it.

My advice to you is, if you apply for the mobility rate of Disability Living Allowance you can ask that they don’t look at the care award of the Disability Living Allowance. BUT they have got a right to look at your existing care award and you might lose this.

I would advise you to visit your GP and ask if he/she will support you if an application was made.

If your walking ability varies from day to day you may have difficulty qualifying for the mobility component. You must also show you are virtually unable to walk, have been for 3 months before your claim and are likely to remain like this for at least 6 months.

It helps to keep an accurate diary. The fact that you can walk on some days might not disqualify you. The question is whether evidence about your walking abilities would allow a decision maker to consider that, taking your physical condition as a whole, it would be true to say of you that you are virtually unable to walk and have been so for the 3 months before your claim.

If an occupational therapist/physiotherapist has assessed you for equipment and adaptions to your home or you have been getting therapy from one of them, they may be willing to write a report on your outdoor walking ability for your claim. I would advise you to go to a Citizens Advice Bureau or local advice centre in your area to get help with completing the form and contact your local Council – they can advise you on centres near you.

angloadvocate999 at 19:46:43 o'clock GMT Link to this entry | Blog about this entry |  Add to del.icio.us |  digg this This entry has 0 comments: Add your own

  Songs About Heroin

A (very) brief selection...

• Neil Young : The Needle and the Damage Done
• Rolling Stones : Dead Flowers
• Red Hot Chilli Peppers : Under The Bridge
• Velvet Underground : Heroin
• Guns N' Roses : Mr Brownstone
• The La's: There She Goes
• Dandy Warhols : Not If You Were The Last Junkie On Earth
• Sinéad O'Connor and U2 : Heroin
• The Stranglers : Golden Brown
• Wolfsheim : Heroin, She Said
• Pink Floyd : Comfortably Numb
• Placebo : My Sweet Prince
• Velvet Underground : Waiting for the Man
• The Ramones : Chinese Rock
• Lou Reed : Perfect Day

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Confessions of an English Opium-Eater
Opium Smoking and Paraphernalia: a bibliography

angloadvocate999 at 15:53:47 o'clock GMT Link to this entry | Blog about this entry |  Add to del.icio.us |  digg this This entry has 0 comments: Add your own

Phone me David Wright on 01633 254872 and I will call you back. I am a trained drug advocate and a freelance writer. My work can be found in Drink and Drug News magazine and on the WIRED website.

angloadvocate999 at 00:22:48 o'clock GMT Link to this entry | Blog about this entry |  Add to del.icio.us |  digg this This entry has 0 comments: Add your own

angloadvocate999 at 18:36:22 o'clock GMT Link to this entry | Blog about this entry |  Add to del.icio.us |  digg this This entry has 0 comments: Add your own

Methadone Patients and the Treatment of Pain
J. Thomas Payte, M.D.

METHADONE TREATMENT WORKS:

A Compendium For Methadone Maintenance Treatment

Part I

December 1994

A Compendium of
The Chemical Dependency Research Working Group
The New York State Office of Alcoholism and Substance Abuse Services

Resources for compendium production were provided by
The Aaron Diamond Foundation through a grant to
The Medical and Health Research Association of New York City, Inc. (MHRA)

Literature produced by the Chemical Dependency Research Working Group (CDRWG, formerly the Cocaine/Crack Research Working Group, C/CRWG) is published by the New York State Office of Alcoholism and Substance Abuse Services (OASAS). Resources for literature production and mailing were provided by the Aaron Diamond Foundation, Inc. through a grant to Medical and Health Research Association of New York City, Inc.

For further information about the activities of the Chemical Dependency Research Working Group contact Herman Joseph at (212) 961-8491.

Marguerite T. Saunders, Commissioner
NYS Office of Alcoholism and Substance Abuse Services

Addie Corradi, Associate Commissioner
Health and Planning Services

John Perez, Assistant Director
Bureau of Methadone Planning and Policy

Chemical Dependency Research Working Group
NYS OASAS
55 West 125 Street
New York, NY 10027
(212) 961-8491

Chemical Dependency Research Working Group Project Staff

Herman Joseph, Chair and Executive Editor
NYS OASAS, Bureau of Methadone Planning and Policy

Joycelyn Sue Woods, Managing Editor
Medical and Health Research Association of New York City, Inc. (MHRA)

MONOGRAPH POLICY

Opinions contained in this compendium are those of the author(s) and are not necessarily endorsed by the Aaron Diamond Foundation, Medical and Health Research Association of New York City, Inc. (MHRA), or the New York State Office of Alcoholism and Substance Abuse Services (OASAS).

CDRWG Monograph Number 2: December 1994

Methadone Patients and the Treatment of Pain*
by J. Thomas Payte, Elizabeth Khuri, Herman Joseph and Joycelyn Woods

Opiate addiction and the most effective treatment for it, methadone maintenance, are not well understood within the medical profession. The reasonsfor this are complex and can be traced back to the Harrison Narcotic Act of 1914.Physicians were the first group to be persecuted by this legislation which did not consider opiate dependence a legitimate medical condition and forbade the prescribing of opiates solely for the purpose of maintaining dependence. At the time the majority of opiate-dependent persons were middle class women (housewives) and physicians or other medical professionals who had access to drugs. Nevertheless, many physicians attempted to pursue a humane course of medical treatment by continuing to prescribe their "necessary" narcotics. Authorities were determined to make an example of these mostly family doctors, so many physicians were arrested, imprisoned and lost their medical licenses and practices. It must be emphasized that these were not unscrupulous physicians, rather many were concerned about the patients they had treated for years.
Over the years, the medical profession's early experience with the Harrison Narcotic Act has evolved into the dictum "stay away from addicts" they are nothing but trouble and addiction is not a doctor's domain. By the 1930s, this attitude became prevalent in medical schools with physicians receiving little or no training in addiction, which remains to this day. The lack of training on addiction, drug dependence and prescribing medication for pain has resulted in much confusion among clinicians (Portenoy & Payne, 1992). Added to this confusion is the strict regulating of narcotic drugs whose main impact has been to cause the under prescribing of narcotic drugs for the relief of pain. Physicians have become concerned about addiction when prescribing for pain relief. Yet the fact is that when morphine is taken to relieve pain it rarely causes addiction. However, there is evidence that the medical profession is changing. Addiction treatment has recently become a subspecialty within the American Medical Association.

J. Thomas Payte, M.D. is Chair of the American Society of Addition Medicine (ASAM) Committee on Methadone Treatment, Editor of the Journal of Maintenance in the Addictions, Adjunct Instruction in Pharmacology at the University of Texas Health Science Center, and Founder and Medical Director of Drug Dependence Associates, a methadone maintenance treatment program in San Antonio, Texas.

Elizabeth Khuri, M.D. is Clinical Director of the Adolescent Development Program, Associate Professor of Public Health and Pediatrics atCornell University Medical Center, and Associate Physician for The Rockefeller University in New York City.

*A version of this article has been submitted to the Journal of Maintenance in the Addictions for publication.

The unwarranted fear of addicts and the fear of prescribing opioid analgesics has been given a name, addictophobia. The education of physicians in the pharmacology of opioids and their ability to relieve pain, along with training the basics of addiction, will help eliminate these attitudes. However, belief that addiction is a behavioral problem will no doubt persist until the biological causes are discovered and understood.

Clarifying Terminology
Tolerance is a pharmacologic property of all opioid drugs and is characterized by the need for increasing doses in order to maintain the original effects (Jaffe, 1985). Tolerance to the reinforcing effects of opioids, and the need to increase the dose in order to maintain the initial effects, is considered an important aspect of addiction. The belief that tolerance will develop to the analgesic effects of opiates in the opiate-naive patient and thus interfere with analgesic efficacy continues despite evidence to the contrary (World Health Organization, 1969). Studies have demonstrated that tolerance to the analgesic effects of opiates occurs only in patients with chronic and worsening pain (Foley, 1985; Twycross, 1983). Patients treated for prolonged periods with opiate drugs for nonmalignant pain fail to demonstrate the need for escalating doses in order to achieve pain relief (Portenoy & Foley, 1986; Portenoy, 1989).
Physical dependence is also a pharmacologic property and is defined solely by the abstinence syndrome or what is more commonly known as withdrawal (Jaffe, 1985). Much of the misunderstanding about physical dependence and addiction occurs because these terms are often erroneously used for one another. Physical dependence is a pharmacological property of all opioid drugs, as is tolerance while addiction is identified based on psychological or behavioral manifestations of the underlying disease.
Narcotic addition as we know it, is characterized by drug craving, compulsive use, deviant behaviors and most commonly relapse after withdrawal from the drug. It is interesting to note that methadone has a significantly lower potential for abuse than heroin, morphine, etc., based on its slow onset of action with a relative lack of reinforcing effects. Theterm drug abuse is used to define any compulsive drug-taking behavior that is not within accepted societal or cultural mores. However, experts in the field are beginning to use this term less because of the moral implications, and prefer to use the term "drug use" in its place. It must be stressed that the behavior associated with compulsive drug taking is quite different from the behavior of a patient with a history of illicit drug use who requests medication to relieve pain.
It must be emphasized that it is unjustified for physicians to be reluctant to prescribe a sufficient dose of medication in order to relieve pain. Since medically caused addition to opiates rarely occurs, their application to relieve pain should be pursued aggressively and early in order to promote health and healing. Furthermore, it is illogical for physicians to under prescribe opiate analgesics for patients suffering with the pain of terminal cancer or any other fatal condition for fear of addicting them. For these patients the focus should be on relieving the pain of the disease and dying and thus allowing them to live out their final days with their family and in comfort.

The Opiate-Dependent Person and Pain
Methadone patients who are hospitalized with acute or chronic pain conditions are at high risk for receiving inadequate medication for relief of pain. There are several major reasons for this. First, many health professionals incorrectly believe that methadone patients will obtain pain relief from the methadone. Secondly, attitudes of the medical staff about illicit drug use may overwhelm the need to provide adequate pain relief and complaints from the patient are perceived as manipulations to receive opioids for other than pain relief. Another potential factor for under treatment is the failure of the medical staff to recognize the potential for tolerance in methadone-maintained patients. The result is that a large majority of methadone patients who have needed medication for pain relief did not receive an adequate dosage, or even any at all. As former drug users methadone patients often perceive the medical profession as unsympathetic and prejudiced based on earlier experiences. The rehabilitated methadone patient very often continues to be excluded by those responsible to provide comfort and relief. Whatever factors may contribute to the under treatment of methadone patients the end result is the undermining of the therapeutic alliances.
Some clinicians incorrectly assume that the methadone-maintained patient has no need for pain relief. Patients maintained on methadone have developed a tolerance or resistance to the narcotic, analgesic (pain killing) and tranquilizing properties of methadone. Consequently, they feel pain to the same degree as persons who are not maintained on methadone and need adequate doses of morphine or other narcotics to relieve acute and chronic episodes of pain.
These authors know of no studies that have evaluated the effects of tolerance and its potential in reducing the efficacy of analgesics (Portenoy & Payne, 1992). Several studies have found that the usual regimen used to provide pain relief for the non opiate tolerance patient can also be used to treat those maintained on methadone (Kantor, Cantor & Tom, 1980; Rubenstein, Spior & Wolff, 1976). However, these studies did not assess directly the relief of pain, or evaluate the role of tolerance in achieving analgesia (Sawe, Hansen, Ginman et al, 1980). Since these factors were not considered these authors encourage clinicians to evaluate dosage in consultation with the patient in order to ascertain that adequate analgesia has been achieved for proper healing and health of patient.
Some methadone patients who have been hospitalized for surgery have reported that their methadone doses were lowered in the hospital and as a result they experienced withdrawal symptoms while hospitalized (National Alliance of Methadone Advocates, Inc., 1994). Other reports have been received that some patients were even told to detoxify from methadone prior to surgery since it is incorrectly believed that methadone may interfere with analgesia or their health condition (Payte, 1994). In summary it must be emphasized that the opiate-dependent patient must be treated with the same dignity and respect as any other patient. When treated humanely and with compassion the opiate-dependent patient is no more difficult to treat than non dependent patients, although they may be a little more distinctive than the ordinary patient.
Methadone patients or opiate dependent individuals should never be given mixed opiate agonist/antagonist drugs as this will precipitate the abstinence syndrome and can cause serious problems. Commonly used drugs in this class include Talwin, Nubain and Stadol.
The methadone-maintained patient is easily treated for chronic pain. Physicians need not be concerned with those methadone patients maintained ona blockade dose of 80 mg/day or greater to feel any euphoric effects from short-acting narcotics (Dole, Nyswander & Kreek, 1966). The methadone will block it. Even lower doses of methadone will produce a partial blockade effect. It must be emphasized that in order to produce adequate analgesia in methadone patients short acting narcotics may have to be prescribed in higher doses and greater frequency than that needed for the opiate naive patient. Since, methadone patients at a blockade dose are protected from respiratory depression so the concern of the physician should be to achieve satisfactory analgesia.
Usually a sensitivity to narcotics can be determined through an interview with the patient and in these cases the initial dose of pain medication can be given in small increments while observing the patient until analgesia is achieved. Treating the methadone patient for pain on a blockade dose is easier than the patient whose dose only provides a partial blockade. Inadequate pain relief may result in the former illicit drug user to seek additional drugs for the relief of pain, thus placing them at a great risk of relapse. Illicit heroin and cocaine are readily available in urban and rural locales land therefore easy to obtain for hospitalized patients in pain.

Fears of Patients with a History of Illicit Drug Use
Many former illicit drug users may be fearful of losing control and thus refuse any analgesia. First and foremost their request for no pain medication should be respected. However, in some patients eventually pain may overcome this fear and a request for pain medication may be made. Before this point is reached the clinician should discuss and make clear all the issues with the patient. Methadone patients receiving a blockade dose should be assured that their daily dose of methadone will block any euphoric effects of the drug and that analgesics will only produce relief of pain. Methadone patients on lower doses can similarly be advised of a partial blockade and that in all probability they will feel very little euphoria, if any at all from pain medication. Furthermore it should always be emphasized that analgesia for acute pain will probably only be necessary for a short time and that relief of pain is essential for a quick and healthy recovery. Some methadone patients may fear that their maintenance dose will have to be increased. Again these patients should be reassured that this problem has been studied and that an increase in their maintenance dose will not be necessary (Kantor, Cantor & Tom, 1980). Ultimately, the final decision should always rest with the patient, and the attending physician should make sure that these requests are respects.

Protocols for Pain Relief
There are several regimens that can be used with the methadone-maintained patient. None of these protocols have been demonstrated to be superior to the others, and physicians should rely on their own experience and observation, as well as listening to the patient. A common protocol and probably the easiest, is to continue the base line maintenance dose of methadone and supplement it with intermittent increments of a shorter-acting narcotic. Opiate-dependent individuals will metabolize narcotic analgesics faster and can rapidly develop tolerance to the analgesic effects of a short-acting narcotic and will probably require an increased dose and a more frequent dosing schedule (Kreek, 1983). The best advise to follow is that of the late Dr. Marie Nyswander who taught physicians to "listen to the patient."
Other regimens are somewhat problematic, but may be useful for some instances. One strategy is to increase dose of the long-acting narcotic, namely methadone, until the desired pain relief is achieved. In order to produce a sustained analgesia with methadone for a non opioid dependent patient, at least three doses per day are required. There is no advantage in using methadone for analgesia since the analgesic duration only lasts about four to six hours (Sawe, Hansen, Ginman et al, 1981). Methadone-maintained patients will quickly develop tolerance to the analgesic effects of methadone making this method only useful for short periods, if at all (Selwyn, 1992).
A final method is to completely abandon the long-acting narcotic methadone and institute a regimen to completely meet the needs of the patient's pain relief. Again another problem arises since short-acting opioids will probably be metabolized quicker in patients with a history of opioid drug use. They will rapidly metabolize short-acting opioids and develop tolerance to the analgesic properties faster thus making it difficult to achieve a maintenance dosage without development of some symptoms of the abstinence syndrome (Kreek, 1983).
Should these later two protocols be utilized and a problem occurs, such as the patien