“No sign of him I’m afraid,” shrugs the policewoman. A filthy blanket crawling with tiny biting insects lays abandoned on the splintered floor of a dank allotment shed. We enter, cautiously avoiding the broken glass and as our eyes adjust to the murky interior there is more; a child’s colouring book and some felt-tips, a long-dead crow, a laceless boot and a few torn carrier bags spilling their confused contents into the assembled hoard. Sadly there’s no sign of their owner, my patient, Eddie. We’re worried about him. Last night he was sighted in a highly distressed state talking to himself at the top of a car park. Eddie’s descent into mental illness began a decade ago when his marriage broke down. His small business folded shortly afterwards. In desperation he sought solace in skunk peddled by predatory dealers. Yet he maintained his place in his local community until a couple of years ago…until he took Spice.
Zombie, Annihilation, Black Mamba, Scooby Snax – the synthetic cannabis Spice goes by many names and the constant stream of new varieties featured among the list of “legal highs” until May 2016 when the Psychoactive Substances Act came into force in an attempt to restrict the production, sale and supply of the newly dubbed “novel psychoactive substances”. Spice has been Eddie’s nemesis. As a consultant psychiatrist I never thought I would be an advocate for illegal drugs but, in his case, his graduation from cannabis to Spice has been devastating; a return to cannabis would be a relative blessing. His unpredictability reflects that of the contents of the Spice he smokes. We receive regular reports that he’s either catatonic or profoundly paranoid in public. He is well known to the police and paramedics who are often called when he is found collapsed on the pavement, having seizures, or when he is spotted wandering in traffic, aggressively remonstrating with passing motorists. Occasionally he is admitted to psychiatric wards, yet the aggression from his “drug-induced psychosis” is usually short-lived. However, his symptoms have become more persistent and when he is discharged he takes progressively less time to enter yet another spiral of chaos. I see many patients whose use of Spice affects their mental health. They respond poorly to treatment and I have little doubt that this is contributing to the increasing number of hospital admissions due to or contributed to by illicit drugs. This increase in admissions has been accompanied by deep cuts to addiction service budgets.
Eddie’s Spice dependence has put him on a path of persistent begging and shoplifting which in turn has led him into the criminal justice system. In prison he is preyed upon by heartless dealers just as much as when he is living rough in the community. It is becoming clear that Spice is a significant problem in prisons and there are even recent reports of prison staff requiring medical attention after their exposure to the drug.
Eddie is usually too ill to engage with the bureaucratic systems that would see him safely housed, receiving benefits and accessing the mental health and rehabilitation support that he desperately needs. And he is not alone. Spice is wreaking devastation upon the homeless community. In his lucid moments Eddie can reflect on his situation and he desperately wants to avoid the fate of his street friends whose lives have been cut short by their drug use, a sadly familiar story. But these moments never last long.
The risks associated with the combination of mental illness and illicit drugs are indisputably grave. According to the 2017 report of the National Confidential Inquiry into suicide and homicide by people with mental illness, in over half of patient suicides there is a history of harmful drug and/or alcohol use. Another key finding of this report was that: “In all four UK countries, most patients convicted of homicide also have a history of alcohol or drug misuse, between 88% in England and 100% in N Ireland. In other words it is unusual for mental health patients to commit homicide unless there is a co-existing problem of substance misuse.” And of all the drugs I see, Spice is definitely one of the worst.
My experience is that patients with a diagnosis of drug-induced psychosis often have the most complex difficulties, ranging from life threatening physical illness to homelessness to criminality, but this diagnosis represents a pejorative label which continues to provide us all with a convenient excuse for inaction. It creates a facade that these patients are wilfully choosing to destabilise their mental health and therefore the authors of their own misfortune. In reality however they are ensnared within a vicious cycle from which they often find it impossible to escape. Surely the time has come to suspend our judgement as it will only be by reaching a deeper understanding of the complex relationship between drugs and mental illness and by approaching the myriad needs of patients with greater sophistication and compassion that we can hope to avert this mounting public health crisis.