THE TRUTH ABOUT DRUGS - book on drug addiction by Dr Patrick Dixon Ch1

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A friend of mine found Tom sick in his council flat, lying on a bed covered in a dirty blanket.No furniture.No radio.No TV.No carpet.Just a bed and some clothes in a corner on the floor.Everything he had in the world apart from that had been taken and converted to heroin, temazepam, diconal - anything he could get.Swallow, snort, sniff, inject - whichever way, however he could.But Tom is now dead.

Tom is just an official statistic, just one of hundreds in a big city among hundreds of cities.An ordinary kind of guy who made decisions that some years later led him to lose his life on the end of a needle.

International drug trade is a $400 billion mega-industry. Drug taking used to be confined to small groups but is now a global obsession, almost beyond control in many countries.Despite three decades of rapid growth few governments have accurate figures of use. UNDCP estimates that around 4% of the world's adults use illegal drugs in a year.

In most countries drug addicts inject heroin, cocaine and other drugs, and HIV has been transmitted as a result in more than 80 nations. Around 5% - 10% of all HIV world-wide is drug-related, that's 2-4 million extra AIDS deaths as a direct result, plus extending networks of sexual partners of drug injectors at risk, as well as babies in the womb.

Globalisation is making flow of drugs easier, with non-existent border checks and unrestricted money flows between many nations. Armed conflicts around the world are also powering the drugs trade as arms are often traded direct for drugs.

The US has the highest rate of illegal drug use in the industrialised world. That is why we are seeing such a huge shift towards fierce anti-drugs policies by American companies who can no longer afford to throw away profits by ignoring the problem. As we will see later, widespread drug misuse can make all the difference between staying in business or going bust.

These companies are operating in a climate which is worried about drugs, and of all those most concerned, parents of teenagers top the list.Around six out of ten American adults believe that drugs are the number one problem facing children today, followed by crime and family breakdown.Around half of all adults know someone who is abusing drugs. Yet in all the bad news there are surprises.

The huge US drugs problem is often used by pro-drugs campaigners to prove not that more should be done, but that the "war is lost" and that control efforts should be abandoned, with Marijuana legalised as a start.But the truth is rather different, and they are flying in the face of reality in the workplace and in schools.

Sales of alcohol or cigarettes are easy to measure because both are legal and regulated, however hard figures on illegal drugs are scarce. Surveys on drug or alcohol abuse are notoriously unreliable. Some people exaggerate - especially as teenagers, while others deny all use.Official registers of - say - heroin addicts are always incomplete, and many people fear confessing to illegal activity.However well designed research, gathering every source of information together, helps build a far more accurate picture.While we may be less certain about absolute numbers, the trends are very clear - and they have beendownwards in the US.

Illegal drug taking is rapidly going out of fashion - or was.Numbers taking drugs in the last month have halved in the last twenty years - 25 million down to 12.8 million or 0.6% of the population.60 million Americans no longer take illegal substances.Less than 1% are now using cocaine, inhalants or hallucinogens.Despite these recent falls, more than a third of Americans over 12 year olds have tried an illegal drug in the past of which 90% was Marijuana.A third took cocaine or a prescription drug for non-medical proposes.A fifth took LSD.

But drug use is now rising once more, after a spell when public awareness and concern has fallen with less profile on TV, radio or in the press. Drug use by teenagers has rocketed by 70% since 1992. And attitudes are softer this time round. Half of all "baby-boomer" parents expect their own teenage children to try drugs and are fatalistic about it. 40% believe that there is little they can say or do as parents to change things.Nothing could be further from the truth as we will see.Parents can have a huge positive influence on decisions their children take.

In America drug use is often associated with the underclass, black ghettos, the socially marginalised. Whilst it is true that poorest neighbourhoods are often where drug-related crime is most obvious, every strata of society is affected.

530,000 Americans addicted to cocaine or crack

Half a million people try cocaine for the first time every year - but that is only a third of the early 1980s figure. The total number using it each year has fallen 74% from 5.9 million in 1985 to just 1.5 million. However consumption is much the same, because most of the market is taken by a smaller number of heavy users and those numbers are unchanged at 580,000 of which 250,000 use crack.

Around 600,000 people in America are addicted to heroin,more than in the previous two decades. The majority are older adults with long term addiction, but growing numbers of teenagers and younger adult are trying it. Most users inject low-grade heroin, but snorting or smoking is becoming more common as heroin purity has risen.As a result, consumption per person has increased dramatically.

These 600,000 people are spending $6 - 10 billion a year on heroin, just fighting withdrawal symptoms that threaten to overwhelm them every twelve hours of every day.And most of that money is probably raised from crime - from others around from whom they steal.

In 1995 an estimated 9.8 million Americans smoked marijuana of which 5 million did so at least once a week on average, down from 8.4 million in 1984.However the number of new users a year has climbed steadily to reach 2.3 million in 1994.So more people than ever are trying it for a short time and then giving up.Marijuana use is a phase of American adolescence and early adulthood.

4.9 million Americans have tried amphetamine.Other illegal drugs are used by a further 2.5 million of the population - for example Rohypnol and other "club drugs" such as ketamine, Quaaludes, xanax, MDMA and LSD.

Tobacco and alcohol are the big killers (Return to Index)

In comparison to illegal drugs, tobacco and alcohol are the big American killers. More than 400,000 people die every year in the US from smoking - more than from alcohol, crack, heroin, murder, suicide, car accidents and AIDS combined.61 million Americans smoke and first year students are smoking more cigarettes - not less. 16% smoking regularly - almost double ten years ago.

$104 billion of alcohol was sold in 1995, of which 61% was beer, 28% spirits and 11% wine. Beer sales have risen steadily from 1970 to 1995 at the expense of spirits while wine drinking has remained relatively stable. Around $1 billion is spent every year on advertising alcoholic drinks, almost all of it on network and cable TV.

So then, there's far less drug taking in the US today than there was. Fashions come and go.The massive, overwhelming crack epidemic never came.Nevertheless, levels of abuse remain high enough to affect day to day life for millions of people and in some cases are rising again.

Teenagers are in the front line of addiction. Many are nicotine addicts before they arrive, and smoking is often for them just the first step into a whole new world of illegal and dangerous experimentation. High school smoking prevention campaigns are often far too late.Pupils need to targetted several years earlier.

15 billion cigarettes are smoked every day world-wide - mostly by adults who became addicted as children.In almost every case it's children, not adults, that make the critical decision to start smoking. The only reason we think of smoking as an adult addiction is because millions of adults are broken by the overwhelming power of a nicotine habit they first acquired as kids.Not only is the drug extremely addictive physically, but it also takes over emotionally.Many smokers are double-minded.They think they should stop but they don't want to, because they like what a cigarette does for them.They are psychologically hooked, as well as physically dependent.

Every day 3,000 children in America begin smoking cigarettes regularly, and as a result a third will have shortened lives. Around 5.5 million children in the US smoke,that's a third of high school seniors, with more than 20% smoking daily, higher than any time since the 1970s.Almost half of all 9-12 grade students smoked in 1996.

Nicotine is one of the most addictive drugs in the world, yet pushed for free at children as young as eight by friends in the playground or outside school.Tens of thousands of small retailers regularly and illegally supply this killer drug to underage children, and the tobacco industry for a generation has spent millions of dollars on high-profile, glamorous sports sponsorship deals, likely to appeal to sports-conscious teenagers.

Children who smoke are the future of the tobacco industry.If a single ten year old boy or girl in a school can be persuaded to start, the total extra sales will be up to $100,000 over 70 years.Ten pupils are worth a million dollars.So the entire tobacco industry - from growers to cigarrette manufacturers to wholesalers and corner shop retailers - is dominated by the number of new children who can be hooked onto nicotine.

They are soft, highly lucrative targets.Easy to tempt.Every instinct drives them to experiment as part of growing up, as an expression of independence or rebellion.Cigarrette companies are aided by an enthusiastic, national volunteer sales force of millions of other child smokers.They need no organising, just regular supplying through a lax and irresponsible retail system.

So then, our kids are being allowed to grow up in a society where by the age of 18 up to half of them are already addicted to a drug that some say is more difficult to break free from than heroin, more dangerous than all the combined hazards of Marijuana, Ecstasy, amphetamines and LSD.What have we done?The answer is not enough.Something has to change.

Adults make millions out of hooking kids on tobacco - every shareholder in a tobacco company, or in retail chains selling cigarettes is benefiting from this childhood epidemic.

Smoking in the past is a major risk factor for future Marijuana use - up to 20 times in one study.

Alcohol abuse is also a major teenage problem - often copied from parents.One in four 10^th grade students and a third of 12^th graders reported having at least five alcoholic drinks in the previous two weeks in 1996.The average age for a first drink has fallen from 17.4 in 1987 to 15.9 years. Huge amounts of class room time has been given to illegal drugs or smoking while basic facts about alcohol have been ignored.For example, 2.5 million American teenagers do not realise that a person can die from a severe alcoholic overdose such as a drinking challenge.

The younger an individual starts drinking and the greater the frequency and amount, the greater the risk that the person will go on to smoke tobacco or use illegal drugs.The same is true for child smokers or Marijuana users: each of these increases the risk of trying other things.One experiment leads to another.

Exactly the same arguments go through a teenager's mind over whether to try dad's whisky bottle, mum's cigarettes, or a friend's joint.The only difference is that the first two are often copying behaviour and the third is usually rebellion. Some US children are starting to drink at 10, use prescription drugs at 11, try hallucinogens at 12, cocaine and crack at 15 and 16.

Exact numbers vary between studies, but the indications are that teenagers using illegal drugs each month have doubled in five years. 11% of all teenagers between 12 and 17 used illegal drugs in the past month in 1995, up from 5% in 1992, which was the low point from the 1979 peak of 16%.

A quarter of all senior high schoolstudents use illegal drugs at least once a month, while 7% take drugs every day.In most cases the drug will be Marijuana, a drug which we know accumulates in the body so that the drug is detectable for weeks after last use.Pupils taking drugs of any kind on a daily basis are likely to be affected mentally throughout every school lesson to one degree or another.This will result either from the intoxicating action of the drug itself, or from the destabilising effects on emotions and concentration as the brain restores its own normal equilibrium between doses - for example of amphetamines and barbiturates.

So then, on average, one in ten older pupils are likely to be significantly affected almost every day by their daily intake of illegal drugs.This is a major crisis in US education. Even if the damage is entirely limited just to those pupils, it's serious enough.But the knock on effect is likely to be far wider across the rest of the peer group.This level of drug consumption undermines everything a school is trying to achieve.It robs teenagers of their future by wrecking their ability to achieve good grades.It adds to the underclass, to those who leave school virtually unemployable.It adds to the cost of welfare.

Average figures hide huge variations. In some classes of twenty there could be five or ten using illegal drugs most days, and other classes where drug use is almost unknown.A teacher could find that a single class of thirty contains a heroin injectors, three who snort crack and fifteen who take speed, Ecstasy or LSD as well as Marijuana.

Most large schools will have heroin or crack addicts whether they know it or not.And that means pupils who may be injecting on site. If a user has run low he may be withdrawing as he walks into school.He can't wait.

And what happens when money is scarce?Everything hangs on goodwill from friends for a free shot, or making money fast some other way.That means a loan, or theft, selling to someone else (and maybe taking a risk with a bum deal, cut to the limit with rubbish), sex for a favour or worse.

Three hundred senior pupils and thirty of them drug-taking daily adds up to a big "drug-infected" group, many of whom will associate together, supply each other, teach each other and take drugs together, mainly out of school, at home, at a friend's or nearby.And of course, every user has a financial interest in seeing the other 270 become users too.Even if the existing users sell for the same price that they buy, the more users there are, the more they can buy at one time and the lower the price is for everyone.

A 10% drug-taking group is like a cancer in a school.If not dealt with it is likely to spread, placing the other 90% right in the firing line at the most vulnerable time in their lives.We are failing our children by shying away from tough measures.As we will see later, the primary aim should not be to throw drug users out but to encourage them to change, using similar methods to those being used in the workplace.

Despite all we have seen about the serious level of drug taking in school pupils, fewer parents than ever are talking about these issues at home - just 30% in 1995-6.Ostriches with heads in the sand. Drugs should be a common topic of conversation in any home with teenagers - after all, it is at school, so why make it a "no go area" at home?We have to talk about these things, before they become issues and problems for our children.

Almost one in four high school seniors used marijuana in the last month in 1996 - only 10% used any other drug as often.Since most Marijuana users smoke it in tobacco, almost all the 25% of high school seniors using Marijuana are among the 50% of high school seniors who smoke.Marijuana use among non-smokers is uncommon.First use of marijuana is getting younger. From 1991 to 1996 the number of 12-17 year olds using marijuana doubled. The number of 8^th graders trying it rose from 10% to 23%.In 1987 the average age for first use was 17.8 years.By 1996 it was 13.5.But that is an average.It means that some are trying Marijuana when they are as young as nine or ten.

The figures are bad enough without exaggerating them, yet that is exactly what teenagers themselves do - both users and abstainers.Surveys show that they are all convinced that 75% have tried Marijuana and 25% are regular users - a dangerous distortion we will return to when looking at prevention.The 25% figure applies only to the oldest pupils and abstainers are in good company, not an eccentric minority.

The typical attitude is that "no one has died from taking pot". Marijuana use is seen as low risk.However, as we will see in a later chapter, there is overwhelming evidence that for a good 24 hours after use a student's brain will not be functioning correctly.More seriously, as we will see later, brain function can remain abnormal for six months or more after the last dose in those who have been regular users for a long period.

So here we have one in four of all senior High School pupils taking a drug which we know damages their mental ability the following day, and in more subtle ways in the longer term.And the brain areas affected are exactly those a student most needs to be able to do well in class.For example, Marijuana use makes it more difficult for a pupil to focus in on what the teacher is saying, ignoring other distractions.

5% of high school students use stimulants on a monthly basis and 10% have done so in the last year. LSD was used by 8.8% of 12^th graders in the past year.Unlike amphetamines, LSD is capable of causing terrible long term flashbacks. Not a good way to begin adolescence.

In 1996 2% of 12^th graders were current cocaine users, 70% lower than the 6.7% high of 1985. However, cocaine lifetime use almost doubled in five years among 8th graders, reaching 5.5% in 1996.The mean age for first cocaine use is falling, from 23.3 years in 1990 to 19 in 1994. Senior high school pupils using cocaine at least once in their lives shot up from 7.1 to 8.7% in a year.

A 1996 survey found that 1% of 12^th graders had used heroin in the last year and 0.5% had done so in the last month.That implies that many teenagers have tried heroin a couple of times and didn't want to carry on, giving up before addiction became established.Numbers ever using heroin doubled among 8^th and 12^th graders between 1991 and 1996, reaching 1.8% and 2.4% respectively. While heroin use in the last year fell from 1.6% of senior pupils to 1.3%.One in fifty 8^th to 12^th graders said that they had used heroin at least once in their lives. So heroin is a significant problem in pre-adults and a growing one, likely to increase further as prices fall following bumper harvests.

Among 6-12^th graders the least common place to take drugs is school.Compared to other settings, school remains a protected place.

Most drug use occurs outside school hours at night or weekends when in theory parents are in charge.However school is where people talk about drugs, taking them, where to get them, how to get them, what they do, when to meet up again.

It raises a big question about parental awareness.If a 13 year old boy goes round to a friend's house, one might assume that there is an element of parental supervision when he gets there.But is there?And what if your own children invite someone back?Is there an adult in the house?Of course, young people can do whatever they want wherever they want if they try hard enough, and cannot be supervised every moment of the day or evening, but there are times when one wonders if a drugs problem has not been made worse by long absences ofparents or guardians.

Drug use is getting heavier, as well as frequency.Teenagers are getting higher than before as well as using drugs more often.Almost three out of four seniors said they got "very high, bombed or stoned" when smoking marijuana compared to only six out of ten eight years earlier.

The net result of all this drug use is that by the end of 1997, one in four of all senior high school pupils would have found it difficult or impossible to pass a pre-employment drug test. So you can't get a job or go to work without risk of being sacked, but you can go to school.Yet one might argue that education is just as important as productivity in the workplace, and that use of illegal drugs by pre-adults is such a serious matter that the school environment should be stricter than the "adult" factory floor or office.The reality is that in most schools the risk of detection is effectively zero, whether for buying and selling on the school premises, or for consuming drugs before, during or after school.

However this level of drug abuse among teenagers has brought new tensions.Fights, feuds and gang warfare has swept off the streets and in through the school gates, whether in the US or the UK.When significant numbers of young people are addicted to an illegal and very costly habit there is likely to be trouble.

In 1996 around one in twenty US high school pupils said that they had carried a gun to school while 12% had joined a gang.42% said that they had threatened to harm someone and a quarter had been in trouble with the police.There is a direct link to drug abuse by those at school:more common among those bringing in guns, joining gangs, or in trouble of other kinds.

So then, the writing is on the wall.We cannot ignore the current situation in US High Schools.It requires urgent, multi-level action as outlined in later chapters.But is the US a special case?Could the same happen elsewhere, in Britain for example?The answer is that in Britain schools, the situation is already alarming, a reflection of drug use across the country.

British surveys suggest that 45% aged 16 to 29 have used illegal drugs, 24% have done so in the last twelve months and 15% in the last month. Levels of drug taking were relatively stable from 1994-1996.Some estimates are that 1.5 million doses of Ecstasy are taken every week in Britain.

The Home Office believes that heroin addiction alone accounted for £1.3 billion a of property crimes in 1997.One in five of all people arrested are heroin addicts.Heroin is getting cheaper, following large harvests of opium poppies by 200,000 farmers in Afghanistan.The price of a "wrap" of heroin fell sharply in 1998 to as little as a pint of beer, while heroin seizures leapt 135%.

So then, a total of perhaps 8% of all men are abusing alcohol or illegal drugs - that's almost one in ten of the entire male workforce, and around 2.5% of women.Mostly its very well hidden, but the effects are there or will be in the future.

Drug addiction has soared since the early 1980s, yet by 1984 the British Medical Association conference was already suggesting that drug misuse was no longer an epidemic but a plague. In the previous year there had been 142 deaths from misuse of controlled drugs, 5,000 deaths from alcohol abuse and at least 100,000 premature deaths from cigarette smoking.

The number of addicts notified to the Home Office is always a fraction of the total, despite the legal requirement until 1997 on all doctors to report all those they know or suspect to be addicted to controlled drugs.

Official figures for those addicted to heroin, methadone or cocaine were 37,200 in 1995, and 43,500 by 1997.True numbers are probably five times that - well over 200,000. The steepest rises have been in the under 21 age group. 75% of new addicts are under 30 years old. One in four of registered addicts are women. 16,000 addicts inject drugs, although the number is falling (68% in 1988, 51% in 1995).

Similarly, while official records show 1,600 drug-related deaths in 1994, the true total was probably at least twice that (excluding alcohol and tobacco).Doctors fail to recognise the cause or use a variety of terms on death certificates.

Around 100,000 a year are arrested for drugs offences in Britain, 90,000 for possession of Marijuana who are mostly just cautioned.Around one in five of all arrests are for drug trafficking. Between 1994 and 1995 there was a 42% increase in heroin offenders to 4,200. 90% of all offenders are male and 35% are under 21.The average age is falling.

Drug addiction is most often found in the poorest and the wealthiest in Britain.

48% users of illegal drugs from household headed by non-manual worker compared to 42% for manual workers

Highest lifetime abuse in those with household incomes of less than £5,000 a year

High lifetime abuse among in those with household incomes of more than £30,000 a year

Professional and skilled workers are more likely to take illegal drugs (and continue to take them) but unskilled workers taking drugs are more likely to take them frequently and to inject.

Drug use varies from area to area. Seizures rates are highest in London, Wales, Merseyside, North West England, Glasgow, Edinburgh and Dundee. Scottish notifications rose 140% since 1991, faster than any other region, with 40% coming from Greater Glasgow. 55% of all adults in Scotland have used illegal drugs in the past.

In some parts of Scotland young people are being offered free drugs such as crack or cocaine by addicted friends keen to recruit new users. In parts of London crack users are boldly targeting teenagers on the street with offers of drugs.

One in 25 people in Britain are dependent on alcohol, twice as many as are dependent on drugs.This figure is an average for men and women.Average consumption has almost doubled over the last 35 years.

Total expenditure on alcohol is £27 billion a year, of which £10 billion is regained by the government through tax.The average adult drinks 7.2 litres a year of pure alcohol, the equivalent of around 140 pints of beer, 14 bottles of wine and a few bottles of spirits.

The problem of alcohol dependency in teenagers has been made worse by products such as alcopops, designed to appeal to younger tastes. 17% of 11-15 year olds drink regularly. Children are also affected by parental alcohol dependency, which is a common factor in family break-up. Indeed, marriages where one or both partners have a drink problem are twice as likely to end in divorce.

It is highly fashionable to be an addict in Britain, especially among teenagers. Smoking in 11-15 year old girls is higher than for 15 years, encouraged by glamorous models on catwalks holding cigarettes. Every day 450 children in Britain take up smoking.

13 million smoke cigarettes in the UK - and numbers are rising again. Every year since the 1970s an average of 500,000 smokers have given up, but during 1996 and 1997 numbers rose by 340,000: high earners, those in their late thirties and early forties.

In summary then, Britain may not have a drugs problem as severe as the US but it is highly significant and is already having a major impact on at least 10% of all households, or some five million people, as well as on others in the workplace.What about British schools?

There are around 750,000 children in each school year.Based on the figures above a total of 1.75 million school pupils have used an illegal drug at least once, of which at least 300,000 are doing so regularly. A survey of 27,000 pupils found that among 15-16 year olds, 14% of boys and 11% of girls had taken drugs in the previous week.More than 60% knew at least one drug-taker.Drug-takers were more likely to be pupils who were confident, outgoing, sociable and had part-time jobs.They were likely to be less studious than abstainers.

How does this compare to the US. As we have seen, 11% of 12-17 year olds in the US used drugs in the previous month - but that's less than the British figure of 15-16 year olds for the previous week. The figures are not directly comparable but if we assume that 15-16 year old figures are not far off an average for a wider age range, then it suggests that drug taking in British schools is catching up fast with that in the US.

Therefore the same arguments apply as in the US for strident action to combat the drugs menace in secondary school education.We will return to this later.State and privately funded schools alike are being out-run by the drugs problem.Most have poorly developed strategies to cope, limited mainly to suspension or expulsion of a pupil caught in possession of illegal substances on school premises.Since this is extremely difficult without a tip-off, and since most pupils who know are far too scared to tell for fear of very violent retribution, the chances of a supplier being caught are exceptionally low.

The levels of intimidation in an average British comprehensive school are high.A headmaster was stabbed to death recently in London trying to break up a fight and pupils regularly carry knives into school to threaten and protect themselves.Fights with knives are common outside school gates, on estates and outside homes, where punishment is carried out away from teacher interference.Death threats are common, often perhaps in jest, made not by individuals but by groups against individuals.

I was in a school recently addressing several classes on issues including drugs. I was assured by the most senior teachers that drugs were not a significant problem.But how could that possibly be so?Are their pupils drawn from a different city - a different country even - than every other school in the area? After the lessons were over I told them to think again.If a school says they have no problem, it is usually just a reflection of poor leadership and even poorer pupil-teacher communication.The result will be in many cases a growing and uncontrolled problem.

A huge barrier to dealing with drugs in British schools is the fear of loss of reputation if - say - the press run big features following the break up of a drugs ring inside the a school.Hence many schools have an unofficial policy of cover up and denial.The aim is to deal with these matters discretely. But this makes aggressive action far harder to take because it is harder to justify.

Such schools are being held to ransom.There is an unspoken acknowledgement that rooting drugs out of the school could result in the school being punished by those who are caught.Any one of them could greatly damage the reputation of the school, revealing the truth about the size of the drugs problem:"I'm not the only one - they just picked on me."

There is only one way forward: embrace the problem together with other schools in the area so that none are humiliated by being singled out and as far as possible agree collective drugs policies which are applied rigorously and consistently, with the backing of governors, teachers and above all parents.Pupils should also be consulted widely on these matters.The difficulty is introducing a change.Once it has been done, all new prospective pupils and their parents can be asked to sign up to the drugs policy as a condition of admission.We will return to these issues in later chapters.

One fact should provide encouragement.As we have seen in the US schools, while one-off experimentation is common, it is still a minority experience. Even among the oldest pupils, abstinence is the dominant lifestyle.Two thirds of those who have tried illegal drugs no longer use them. Women give up faster and younger.Numbers of male and female users are equal at school, while adult users are mainly men.

There is less difference between White and Afro-Caribbeans than people think. Afro-Carribeans between 30 and 59 years old have a higher lifetime use than whites (25%compared to 22%), but this is reversed in 16 to 29 year olds, (34% compared to 43%). Younger Afro-Carribeans are rejecting lifestyles of their parents generation.

However among 16 - 29 year olds 4% of Pakistanis and Bangladeshis are taking heroin and 3% crack, 4% cocaine, 2% steroids - higher rates than any other group.

In summary then, Britain has a very serious and growing drugs problem, particularly in the younger age groups. We have looked at the impact of schools, and compared the lack of controls there to tightening restrictions at work, particularly in America.We need to look further at this important change.

Market forces rather than morality will have the greatest impact on drug taking in America over the next twenty years. Drug addiction among workers will flare up into a major third millennial human rights issue, with company owners insisting that addicts damage profits and wanting to test, identify, counsel, treat or sack "bad risks" - not just addicts, but regular users too. Among the American workforce 24% of men and 13% of women aged 16-25 use illegal drugs, falling to 16% and 9% for those aged 26-34.All will be targets in future, as will those whose blood tests suggest heavy alcohol use.

Drug-related accidents and lost productivity costs around $100 billion a year. Employers in America are already turning to draconian anti-drug policies, with drug-testing at the heart.Other countries with significant drugs problems will be sure to follow, or else they will lose business.

Expect a loud backlash, with angry workers indignant at what they see as gross abuse of human rights and totally unwarranted invasion of personal privacy.But employers will win, every time - on simple economic grounds.Expect a revolution in workplace attitudes - not in a day or a year but over the next decade. Anti-drugs employment legislation will be in wide use in industrialised nations by 2015, as companies fight to compete with others with stricter drugs-free employment laws, drugs-free work forces and higher productivity.

The new anti-drugs push will not be law-based but sanction-based with promotions and jobs at risk.The same has happened already to an extent with tobacco.It has now almost impossible for a heavy smoker to get a job with a US Federal Agency. Work-place restrictions on smoking are so severe that a serious nicotine addict cannot survive without suffering withdrawal symptoms, which interfere with productivity.

This new "market morality" against drugs is based on a series of US studies which found that substance abusers (including alcohol) are on average:

These figures are averages - but what about the impact on an individual company?The US Postal Service found amongworkers who used illegal drugs

General Motors found that drug-using staff averaged 40 days sick leave a year compared to 5.5 days for non-users. Utah Power and Light found that new staff testing positive for drugs at interview were 5 times as likely to have accidents at as those who tested negative. The State of Wisconsin calculated that their addicted staff members were running up extra costs and productivity losses equal to 25% of each person's salary. Often the effects of addiction are not so obvious to those running the company - or at least the real reason for problems with performance:

Drugs programmes at work help staff retain their jobs, improve productivity and morale - and save money.The State of Ohio found that comprehensive drugs programs in the workplace resulted in:

These are spectacular achievements at relatively low cost. However, the fact remains that employers will be keen in future to do all they can to make sure that they recruit new team members who are "drug free".

What company wants to employ a drug user or an alcoholic if there's someone else who is just as qualified for a new position?It's not just efficiency and safety of others, but also general health.That means lower premiums for companies providing health cover or pensions and other benefits. Insurance underwriters are already asking about anti-drugs programmes and are imposing penalties on companies without them.The stricter the regime, the lower the premiums.In future companies won't be able to afford not to implement full anti-addiction programmes.

Alcohol-related problems alone cost British industry an estimated £2 billion a year from absenteeism and poor work performance (not including 25% of work-place accidents linked to or caused by alcohol).Alcohol-related sickness absence alone accounted for £1 billion. Recent studies have found:

7% of men and 3% of women admit that their work has been affected by drinking over the last year

4% of men and 2% of women have taken time off work with a hangover in the last year

7% of men and 3% of women said that their work has suffered because of drinking in the last year

The drug-work problem is particularly serious in Scotland where65% of all 18 - 25 year olds have used controlled drugs and 25% of those taking drugs are holding down jobs.

Drug addiction affects millions of people every year whose lives depend on the skills and judgement of others - whether being driven in taxis, on buses, crossing the road, or visiting the doctor.Indeed the medical profession is just one of hundreds of examples where addiction affects the welfare of the public.I want to look at addicted doctors in some detail, as an example of issues which apply to many other groups.

Alcohol abuse among doctors is common and placing patient's health at risk.This has long been recognised.In 1986 the Royal College ofGeneral Practitioners declared that doctors had three times the rate of alcoholic liver cirrhosis than the general population. A 1985 study found that 12% of male and 45% of female GPs were drinking dangerous amounts of alcohol. In the mid 1980s it was estimated that there were between two and three thousand alcoholic doctors in England and Wales alone.

Although doctors abuse other drugs less often than alcohol, a significant proportion of those abusing alcohol go on to develop a drug habit.In the US, one survey found that half of all alcoholic doctors became addicted to illegal drugs. Another study found that one in fifty anaesthetists were drug addicted.

The latest report by the British Medical Association says that one doctor in fifteen is addicted to either alcohol or drugs.That amounts to more than 7,000 doctors. However the BMA news review recently put the figure at 13,000, more than one doctor in ten.These reports rely on self-assessment questionnaires so the real total is likely to be even higher.

So how do you feel about the thought that if there are two doctors assisting in an operation plus an anaesthetist, the risk of you being cared for while unconscious by an addict-doctor is on average 30%, by a doctor who may be intoxicated now, or suffering withdrawal or from a hangover?Yet there is no testing mechanism and doctors are past masters at being able to hide their own symptoms.

Doctors are particularly at risk of drifting from alcohol abuse to self-prescribing of controlled drugs. They are often highly stressed,the taboo against injecting and opiates has been eroded and they have easy access to supplies.

The big question is what to do?The other day a medical friend of mine told me a colleague had turned up to a lunch-time meeting stinking of alcohol.But what should she do? If he was too drunk to drive a car, surely he was too drunk to making life and death decisions about treating sick people?She could secretly inform the British Medical Association, but what would they do?If they started making checks the suspicion would probably fall on her, in a small medical team, and working relationships could become impossible.

My own view is that I do not want a drunken surgeon to operate on me, nor do I want a heroin or cocaine addict to make decisions about what dose of medicines to give my young child.It is absurd that with almost one in ten doctors addicted to alcohol, cocaine, heroin or other drugs, there are no agreed methods for detecting and dealing with addiction.

The only satisfactory solution is for every doctor to be subject to random drug and alcohol testing, as a condition of employment. Health authorities must have the right to randomly breath test any doctor at any time while on duty, with or without suspicion.There should be severe discipline for someone at work who is "over the limit" for alcohol - as for driving a car.There should also be tough sanctions for a doctor testing positive for illegal drugs, if in the view of the disciplinary committee judgement is likely to have been impaired with matters of life and death in patents' lives.

As in any such situation, discipline and compassionate care for the individual should go hand in hand.But the current situation is intolerable and must be affecting patient care.There is no need to forbid a doctor to practice because of overstepping the mark.

The best course would be to offer a severe warning, perhaps with a fine of some kind, administered by the General Medical Committee, with agreement that random testing will be more frequent. The costs of re-tests should be paid by the doctor.There should also be compulsory counselling, offering treatment and support.If the doctor is intoxicated again while at work, he or she should be suspended immediately until the GMC is satisfied that the problem is dealt with.

Unfortunately at present drug and alcohol testing is so lax that it is almost impossible to prove where medical mistakes are linked to abuse.Cases comes to trial years later, and no tests are conducted at the time.This is wrong.Whenever a serious medical error is spotted immediately, the doctor should be required to give a blood sample.

Access to treatment needs to be made easier.Treatment should take place at a specialist unit alongside other addicted health care professionals and post-treatment supervision needs to be closely managed.

But if we say that doctors should be randomly tested and subject to discipline as well as offered help, then why not others? Bus drivers, railway workers, dentists, engineers, fairground operators, life guards, dentists, nurses, security guards, bankers, financial advisors, car mechanics, airline pilots, cabin crew, ground maintenance staff, lawyers, accountants, electricians, gas fitters, machinery operators, factory workers - all these and more affect the health, safety and welfare of others if performance falls.

One concludes that employers in countries such as America and Britain with big addiction problems have a public duty to begin testing employees on a random basis, as part of a comprehensive addiction programme.We will look at some of the huge ethical dilemmas involved in a later chapter.

In summary, drug and alcohol abuse is widespread and has a colossal impact in school, at college and at work.All three places will need to consider urgent introduction of new policies to identify, help and support those with an addiction and to discourage new users and non-addictive use.

In a world where most things are measured in money, we need to look further at the true cost of addiction to society.Thenarguments aimed at governments about spending big money on drugs programmes begin to make economic sense.