Drugs and Health Alliance

The Drugs and Health Alliance (DHA) is a group of organisations and individuals who support an evidence-based, public health-led approach to dealing with illegal drugs.

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Submission to Drugs: Our Community, Your Say (Drug Strategy Consultation Paper 2007)

The Drugs and Health Alliance

The Drugs and Health Alliance is a group of organisations and individuals [1] who support an evidence-based, public health-led approach to dealing with both licit and illicit drugs.

We believe that evidence shows that a predominantly crime based approach to illicit drugs at home and abroad increases harms associated with their production, supply and use, distorts political and public perceptions of drug use and drug problems, and fails to adequately address significant individual and community harms from drug use.

The political imperative to frame policy around drugs and crime severely limits understanding of the nature of, and response to, drug use and drug problems in the UK. We believe that the Government focus on reducing crime as the basis of its strategy has been at the expense of the public health goals of reducing health consequences of drug use. The DHA welcomes the recent (October 3 rd ) ratification of the Council of Europe's Convention on Promoting Public Health Policy in Drug Control [2], with which it shares many core principles, and hope that the UK support for the convention presages a change in direction for UK drug policy thinking as supported by the DHA.

We believe that the core of public policy on drugs must be public health led and that responsibility for drug policy must be placed with an appropriate public health agency.

Introduction

The Drugs and Health Alliance (DHA) welcomes the increased investment in drug treatment since 1998 and also shares the Government's desire to see a significant reduction in the harms that drugs can cause to individuals, their families and communities.

We think, however, that the Government's strategy over the last 10 years has not delivered in a number of key areas, has neglected others, and that the Government needs to assess the reasons behind this so that it can develop a new strategy that will deliver the results we all want to see.

The drug strategy consultation should provide an opportunity to critically review progress to date and revise strategy accordingly. But the consultation paper is disappointing. Rather than taking - as the Home Secretary states - ‘a radical look ahead' (p5) the document indicates a weakness in thinking about drugs at the heart of government.

After 10 years there is no comprehensive evidence based review of progress with the drug strategy;

We are therefore deeply critical of the way in which the consultation and review process has been undertaken and for these reasons we do not address individually the 39 questions in the consultation document. Rather, we raise a number of issues that we feel need to be addressed in developing the new drug strategy.

The last 10 years – progress to date

The Government has aimed to reduce the availability of illicit drugs at street level by interventions at every stage of the production and supply chain, from crop eradication in Afghanistan through efforts to disrupt major trafficking networks, to handing down tougher sentences to UK street dealers. The Government has also attempted to reduce the use of illicit drugs through “ deterrence ” by criminalising and punishing users and by “ sending out messages ” about the relative dangers of different drugs using criminal justice enforcement as its primary tool. At the same time the Government has attempted to reduce the use of drugs and the harms caused by their use through education and public information, early intervention, drug treatment and harm reduction initiatives.

The Government claims that its approach has been a success because more drugs are being seized than ever before, more dealers are being imprisoned, more people are entering treatment, drug use is falling, and acquisitive crime is down. On the face of it, these claims look like a record of achievement. But if we examine this record more closely, the picture is less convincing.

Availability:

One of the Government's key objectives [7] since 1998 has been to reduce the availability of illicit drugs at street level in the UK. The Government claims its current strategy has been a success because more drugs are being seized, more dealers are being imprisoned, and more criminal assets are being seized. However, these indicators reveal little or nothing about availability, nor do they indicate anything meaningful about the level of overall harms caused by drug use and related drug markets.

The logic behind supply side interventions generally is that if supply is reduced, drugs will be less readily available and therefore people will be less likely to use them. Likewise, the logic would appear to be that increased seizures mean reduced drug availability which translates into reduced use. These arguments do not hold up to close scrutiny. The Prime Minister's Strategy Unit concluded [8] that sustained seizure rates of 60-80% would be needed to put successful traffickers out of business (the share of drugs seized is estimated to be about 12% for heroin, 9% for cocaine and 25% for cannabis [9]).

The report also concluded that, even if supply-side interventions were effective at constricting supply and increasing prices, this “ may even increase overall harm, as determined users commit more crime to fund their habit and more than offset the reduction in crime from lapsed users” and “reduced consumption of one drug may be offset by increased consumption of another harmful drug ”. The Strategy Unit report (phase 2) also prominently notes that:

“Supply-side interventions have a limited role to play in reducing harm - initiation into problematic drug use is not driven by changes in availability or price:

“There is no causal relationship between drug availability and incidence ” (p.81 heading) [10]

The Government has failed to have any significant impact on the availability of illegal drugs at street level. Drugs are cheaper and more readily available than before, most notably for the ones that the Government has described as the most harmful, and the primary focus of enforcement efforts: heroin and cocaine.

Young People:

Another key objective for the Government has been to reduce the use of Class A drugs and the frequent use of all illicit drugs amongst the under 25s, yet:

DHA is disappointed to see the Government claiming that “stable” levels of Class A drug use is a success. We do not believe a strategy which has resulted in higher rates of use for some of the most dangerous Class A drugs and amongst the most “at risk” groups (and prevalence rates which are at an historical high and amongst the highest in Europe) is a success.

The Government has been too quick to claim relatively modest falls in overall drug use as a success for its strategy. In fact, different drugs come in and out of fashion and levels of use fluctuate accordingly, largely independent of enforcement efforts and other policy initiatives. If, as would appear to be the case [15], drug using trends amongst young people are shifting away from cannabis and ecstasy towards binge drinking and/or cocaine use, then this is not a cause for celebration. The continuing preoccupation with overall drug use figures will potentially distort policy priorities; they give little indication of overall drug related harm, often suggesting improvement where more detailed scrutiny of data reveals a worsening problem.

Communities:

The Government has been quick to claim that falls in acquisitive crime are the result of its various drug policy interventions. In fact, recorded falls in acquisitive crime are in line with long-term trends from the mid-1990s which pre-date the Government's drug strategy [16]. We are unaware of any data which show a causal link between the introduction and implementation of the DIP programme and falls in recorded drug related crime – yet this link is made repeatedly in Home Office literature.

Some evidence the consultation document contains is difficult to understand – for example on p.20 there is the claim that the overall level of ‘drug related acquisitive crime' has fallen by around 20%: it is our understanding from a number of ministerial parliamentary answers that the Government does not have statistics on drug-related crime (rather than acquisitive crime per se) [17].

Treatment/Health:

DHA welcomes the increased provision of treatment places, and the increase in resources to drug treatment more generally. However, money spent and numbers entering and retained in treatment are crude measures and tells us nothing about outcomes.

The Government infers good outcomes because of the increasing numbers of users who “ successfully complete or who are retained in structured treatment for 12 weeks or more, when treatment is more likely to be effective ” [18]. This assertion is based on the National Treatment Outcome Research Study which looked at a sample of users who entered treatment voluntarily between 1995 and 2000. These findings cannot be applied to people who are entering treatment today through the criminal justice system [19].

The Government note that drug related deaths have fallen by 2% from 1999 (from 1,538 in 1999 to 1,506 in 2005. There are difficulties in measuring drug-related deaths [20], but latest figures show that recorded drug-related deaths are around 14% higher than they were in 1998 [21].

Not mentioned in the consultation document is a worsening situation with regards to blood borne infections amongst injecting drug users (IDUs). The Health Protection Agency surveillance data show that syringe sharing increased in 1998 and has remained at a much higher level than in the years up to 1998. The prevalence of HIV infection amongst IDUs has also increased in recent years [22] reversing a decline that started in the early 1990s. Rates are highest in London with around 1 in 25 IDUs infected, elsewhere in England and Wales prevalence has risen from around 1 in 400 in 2003 to about 1 in 65 in 2005. Incidence of HIV infection is high by international comparisons. There is also a growing understanding of bacterial infection amongst IDUs from contaminated drugs [23] (more than 70 individuals are thought to have died from a single batch of contaminated heroin in the UK in 2000 [24]). The risks of bacterial infection require a different and very specific public health response.

Nearly half of all IDUs in the UK are infected with Hepatitis C and prevalence has increased in recent years. Incidence of HCV infection is extremely high, with one research study showing a 40% acquisition rate over 12 months in young injectors. The transmission of Hepatitis B continues [25]. 20% of IDUs with Hepatitis C will develop chronic illnesses, including cirrhosis of the liver and the possibility of liver failure [26].

Clearly, these are worrying trends and indicate that the Government has neglected a key area of public health prevention: harm reduction for IDUs has fallen off the agenda.

What is the Government proposing over the next 10 years?

Despite the disappointing lack of concrete policy proposals in the consultation document on which to comment, The Government appears to essentially be proposing a continuation of its current strategy.

The consultation document claims that “ reducing supply means causing shortages of drugs. In those circumstances, we would expect the prices of drugs to rise and the purity to reduce. Sustaining those changes should … contribute to a reduction in the harms caused to individuals and the community by drug misuse and lead to demand reduction ”.

It also claims that “ robust and effective enforcement, including confiscation of assets, demonstrates to local communities that those involved in drug dealing and other associated criminal behaviour will be held accountable for their actions and will not profit from their crimes. ”

DHA is disappointed to see the Government proposing to continue investing billions of pounds [27] on a policy that has demonstrably failed on a systematic basis over a number of decades, and a policy objective that is clearly unachievable, as discussed above. This suggests that, far from the promised ‘radical look ahead', drug policy remains mired in the emotive and highly politicised law and order agenda, whilst pragmatic evidence-based thinking about how to address this issue remains marginalised.

What needs to happen next?

1. A public health based drug policy

Government should place public and individual health and wellbeing at the centre of its strategy. We believe that such a strategy will help achieve the goal of reducing the harms associated with illicit drug use, including crime. A public health-led approach recognises the reality that many people in the UK will use drugs at some point in their lives. It would focus on the realistic goal of reducing drug-related harms as opposed to the unrealistic goal of attempting to eliminate drug use entirely. It is non-punitive and non-coercive. We therefore suggest that:

DHA welcome the recent ratification of the Council of Europe's Convention on Promoting Public Health Policy in Drug Control [28] and hope the guiding principles of this document can meaningfully inform the development of the next drug strategy.

2. Re-orientation of spending priorities

We call on the Government to provide evidence to demonstrate that it can significantly and sustainably reduce the supply of illicit drugs in such a way as to reduce drug use and related harms. And if it cannot, to de-prioritise and dramatically scale back a policy which cannot succeed. And instead to divert limited drug policy resources into areas which are shown to be effective in reducing the harms associated with drug use: investing in social capital, public health based prevention, harm reduction, improved treatment, and reorienting education toward proven risk and harm reduction programmes.

3. The implementation of independent policy evaluation

So that future policy can be built on knowledge of what works and what does not, it is imperative that all strands of UK drug policy spending are fully and independently evaluated for effectiveness and value for money on a regular basis against meaningful and cross departmentally agreed indicators. The current situation is defined by generally poor evaluation that is lacking independent scrutiny, and wider shortcomings in the Government drug policy research agenda that is: woefully under-funded; involves decisions on research budget allocations that lack transparency; broadly fails to provide the knowledge base required for the important decisions that have to be made. We therefore call for:

4. Scaling back of prison for drug offenders

DHA does not believe that more and lengthier prison sentences for drugs offences are the best way to reduce the harms associated with illicit drug use. Since 1998 tens of thousands of people have been imprisoned for drugs offences, thereby fuelling the current prisons crisis. There are currently over 10,000 people in jail for drugs offences in England and Wales alone [30] and a significant percentage of the remainder are in prison for offending related to problematic use of illegal drugs. Most of these people are not major players in the drugs trade, in fact they are the weakest links in the chain of supply (impoverished drug “mules” from transit countries such as Jamaica, and users and low level dealers from socially disadvantaged backgrounds in the UK). Tens of thousands of people are convicted or cautioned for simple possession of drugs each year [31].

Imprisonment does not deter use, and actually create harms – people who are sent to prison risk losing their job, their accommodation, and their children (who are then more likely to become the next generation of problem users). Furthermore they will endure psychologically damaging hardship and mental distress whilst in prison. For those from already marginalised and socially excluded populations a criminal record and/or prison term can only have a negative impact on their future prospects and well being.

Community based sentences are substantially less expensive to the tax payer and more effective in reducing re-offending. They are also much less disruptive for offenders, and their dependents, especially those who are engaging in treatment (people often lose their accommodation when they are imprisoned, benefits are stopped, any children may be taken into care, and any treatment or harm reduction interventions are interrupted). More of the public believe that prison does not work than see it is an effective punishment [32].

Such measures would dramatically reduce the current prison population, ensuring that prison is only used to punish the most serious offenders, whilst providing wider benefits in relieving pressure on an overstretched prison service, currently approaching crisis point.

5. Policy should be focused towards reducing drug related harms

Various recent analyses have pointed to inconsistencies with the current drug classification system within the Misuse of Drugs, and also across licit and illicit drugs. We therefore suggest that:

6. Expanded and improved treatment provision – with treatment as a right

A public-health led approach would ensure that high quality treatment is available, and accessible, to anyone who wants it, when they want it. As it is, after 10 years of increased investment:

Many people are not ready to stop using, or cannot access the services they want, and even when people do enter treatment only a small percentage will leave “drug free” and many will relapse. We also think that the criminal justice link with drug treatment has distorted treatment provision and worsened relations between treatment staff and patients.

DHA recommend that:

7. Expand harm reduction services

The absence of public health competence in government and in government agencies (specifically the NTA and Home Office) has led to a severe neglect of harm reduction services, which have been de-prioritised and marginalised over the last 10 years.

The consequences of this are reflected in the increasing levels of HIV infection, the high levels of hepatitis C infection, and the high incidence rates for these infections among young people. The UK once led the world in harm reduction for HIV/AIDS prevention and successfully avoided the levels of infection that occurred in many other countries. That advantage is in danger of being lost. We are on the verge of moving from a public health success to a public health disaster. The small recent investment of £2m in the new harm reduction action plan announced in 2007 is paltry in comparison to need and to the amount spent on other parts of the drug strategy. We suggest that there be:

8. A refocusing of education and prevention

DHA questions whether the very large sums of money spent on the existing program of general education campaigns represents value for money. There is very little evidence, if any, to show that such interventions are effective in deterring use or reducing harm [38].

It must be recognised that it is simply not possible to reduce all drug use. Human beings have always used intoxicants and always will (for pleasure, in pursuit of creativity and new experiences, and to “escape” physical and mental pain). The dogged pursuit of a drug free society is neither necessary nor productive. The Government needs to draw a clearer distinction in its new strategy between drug use and drug misuse [39] (as it has done, for example, with alcohol) and direct its finite resources towards the minority of drug use which is associated with harms.

Concluding comments

DHA believes that even the comparatively limited objectives in the 1998 strategy have not been achieved. Pursuing a drug strategy on crime reduction has led to an over-investment in ineffective and often counterproductive criminal justice initiatives, and an under-investment in public health and harm reduction led initiatives with a proven track record of reducing the individual and social harms associated with problem drug use.

A radical look ahead requires that we examine the assumptions on which current policy is based, evidence for the effectiveness of the current policy and its components, areas where evidence is lacking and is needed, and for an honest dialogue about what to do about the consumption of licit and illicit drugs and the consequences of their use. Drugs policy has been overly politicised, and serious effort now needs to be made by government to develop a dispassionate, evidence led approach to policy.

References

  1. ^ http://drugshealthalliance.net/members.php
  2. ^ http://assembly.coe.int/Main.asp?link=/Documents/AdoptedText/ta07/ERES1576.htm
  3. ^ http://www.tdpf.org.uk/Policy_General_DrugPolicy.htm
  4. ^ http://www.cabinewtoffice.gov.uk/regulation/comnsultation
  5. ^ Requests for information on this process made when the document was first published from the contacts provided in the document have gone unanswered.
  6. ^ In the 2002 update of the UK drugs strategy (p.3) the Home Secretary described ‘harm minimisation' as one of “our most powerful tools in dealing with drugs”.
  7. ^ In 1998, a key target was introduced by the government “To reduce the availability of Class A drugs by 25% by 2005 (and by 50% by 2008)”. The Home Office claimed in its 2002 Annual that drug availability is “difficult to measure”. This is not the case. Trends in availability can easily be ascertained through a combination of street price data and drug purity data (both of which are routinely collected) combined with systematic surveys of drug users (not routinely collected by any Government agency).

    In 2002, the Key target was changed to “Reduce availability of illegal drugs by increasing: proportion of heroin and cocaine targeted on UK which is taken out; disruption/dismantling of criminal groups responsible for supplying substantial quantities of Class A drugs to UK market; and recovery of drug-related criminal assets”.
  8. ^ No. 10 Strategy Unit Drugs Project: Phase 1 Report: “Understanding the issues” (2003).
  9. ^ Pudney et al, “Estimating the size of the UK illicit drug market” in N. Singleton, R. Murray and L. Tinsley (eds), Measuring different aspects of problem drug use: Methodological developments (Home Office OLR 16/06).
  10. ^ No. 10 Strategy Unit Drugs Project: Phase 2 Report: “Diagnosis and Recommendations” (2003).
  11. ^ According to the British Crime Survey (BCS), 8% of 16-24 year olds reported using any Class A drug in the past year in 2006/07. This is down from 8.6% in 1997, which BCS describe as a statistically insignificant fall.
  12. ^ Reported past year Class A drug use amongst 11-15 year olds has remained unchanged at 4.3% since 2001 (data from previous years not comparable), according to the Information Centre on Health and Social Care (NHS) Statistics on Drug Misuse: England,
  13. ^ BCS 2006/07.
  14. ^ Home Office Departmental Report 2006.
  15. ^ 21% of 11-15 year old pupils reported having drunk alcohol in the last 7 days (their average consumption was 11.4 units). Average consumption among 11-13 year olds who had drunk in the previous week increased between 2001 and 2006 from 5.6 units to 10.1 units. Smoking, drinking and drug use among young people in England in 2006, the Information Centre for Health and Social Care.
  16. ^ The British Crime Survey recorded 11 million offences in its first year (1981). This figure rose throughout the 1980s and 1990s, peaking at 20 million offences in 1995. Since then, there has been a steady decline.
  17. ^ A number of parliamentary questions have clarified that the Government does not collect data on ‘drug related crime' including PQ No. 47717, PQ No.16701, and PQ No.117790 to which the current Minister with the drugs brief Vernon Coaker replied: “Data on offences of robbery recorded by the police are available from the recorded crime statistics. However, it is not possible to determine those that are drug-related as no information is collected on the circumstances surrounding the offences”.
  18. ^ In fact, the National Treatment Outcomes Research Study, which is quoted as the source for this claim showed that better outcomes were achieved when people stayed in residential treatment for more than 90 days. With methadone, people needed to continue with treatment for at least a year.
  19. ^ We note that the author specifically warns people against misinterpreting the results because they “were obtained with a clinical sample of drug misusers who were seeking treatment voluntarily. It is not known whether such finding would have been obtained with other samples, such as drug misusers within the criminal justice system ... in NTORS, heroin users who were facing pressure from the criminal justice system at intake had worse drug use outcomes at follow up”, Professor Michael Gossop, NTA Research briefing: (June 2005).
  20. ^ The Government's figures of drug-related deaths are based on acute deaths recorded on death certificates, they do not include deaths from chronic diseases such as heart disease or from indirect causes such as AIDS or Hepatitis C.
  21. ^ The Government claims drug-related deaths have fallen very slightly (the consultation document describes a fall of 2% between 1999 and 2005). According to the latest Office for National Statistics (Health Statistics Quarterly Spring 2007), drug-related deaths have actually risen by just over 10% from 1,457 in 1998 to 1,608 in 2005.
  22. ^ Shooting Up – infections among Injecting Drug Users in the United Kingdom, October 2006, Health Protection Agency. http://www.hpa.org.uk/infections/topics_az/injectingdrugusers/shooting_up.htm
  23. ^ The HPA now trys to monitor Staphylococcus aureus (including MRSA, which is found among IDUs), Streptococcus and assorted Clostridial infections that cause botulism, tetanus and were also included in the series of deaths in 2000resulting from Clostridium Novyi. (see Shooting Up 2006, ref 23)
  24. ^ see BBC news coverage from 2000: http://news.bbc.co.uk/1/hi/health/792063.stm
  25. ^ Shooting Up – details as above.
  26. ^ Godfrey et al, The economic & social costs of Class A drug use in England & Wales (2000)
  27. ^ see the Transform fact research guide on enforcement expenditure here: http://www.tdpf.org.uk/MediaNews_FactResearchGuide_EnforcementExpenditure.htm
  28. ^ http://assembly.coe.int/Main.asp?link=/Documents/AdoptedText/ta07/ERES1576.htm
  29. ^ We are aware that such research has been undertaken but remains unpublished despite FOI requests.
  30. ^ National Offender Management Service – population in custody, December 2006, England & Wales.
  31. ^ Between 1995 and 2005, nearly sixty thousand people were convicted or cautioned for simple possession of class C drugs, over six hundred thousand for simple possession of a Class B drug, and nearly one hundred and fifty thousand for simple possession of a Class A drug.
  32. ^ A Guardian/ICM poll published on 28th August 2007 showed that 49% of voters believe prison fails to work as opposed to 42% who say it is effective. A Smart Justice poll of victims of crime in 2006 also found that nearly two thirds believed that prison did not reduce non-violent crime. Instead, respondents overwhelmingly supported programmes that focus on prevention.
  33. ^ http://www.theyworkforyou.com/debates/?id=2006-01-19b.982.0#g982.1
  34. ^ The Government's reply to the fifth report from the House of Commons Science and technology Select Committee session 2005-06 HC1031 http://drugs.homeoffice.gov.uk/publication-search/drug-strategy/drugclassification?view=Binary
  35. ^ For example, research on the impact of the South Australian Cannabis Expiation Notice (CEN) system, which having commenced in 1987 is the longest running and most researched Australian scheme, concluded that rates of recent (weekly) use by adults, and rates of use among young adults and school students had not increased at a greater rate in South Australia than other States which maintained criminal penalties (Donnelly, Hall, & Christie 2000).

    However, the social costs of a criminal conviction were greater than those of a civil penalty system in terms of adverse impacts on employment, further trouble with the law, relationships, accommodation etc., yet criminal penalties were no better than civil penalties at deterring the use of those apprehended (Lenton, Christie et al. 1999, 2000).

    Other useful studies include:
    1. Donnelly N, Hall W & Christie P (2000) The effects of the Cannabis Expiation Notice scheme on levels and patterns of cannabis use in South Australia: evidence from National Drug Strategy Household Surveys 1985-95. Drug and Alcohol Review, 19 (3): 265-269.
    2. Lenton S, Christie P, Humeniuk R, Brooks A, Bennett P & Heale P (1999) Infringement versus conviction: The social impact of a minor cannabis offence under a civil penalties system and strict prohibition in two Australian states (monograph No. 36). Canberra: Publications Productions Unit, Commonwealth Department of Health and Aged Care, National Drug Strategy.
    3. Lenton S, Humeniuk R, Heale P & Christie P (2000) Infringement versus conviction: The social impact of a minor cannabis offence in SA and WA. Drug and Alcohol Review, 19: 257-264.
  36. ^ Heroin prescribing: what's the evidence? JRF 2003 http://www.jrf.org.uk/knowledge/findings/socialpolicy/943.asp
  37. ^ See the Beckley Foundation / Drugscope briefing on drug consumption rooms here: http://www.internationaldrugpolicy.net/reports/BeckleyFoundation_BriefingPaper_03.pdf
  38. ^ Advisory Council on The Misuse of Drugs ‘Pathways to Problems' 2006
  39. ^ DHA is concerned to note that the Government often fails to make a distinction between drug use and drug misuse. Vernon Coaker, for example, in his recent response (of the 25th May 2007) to an opinion piece by the DHA (on 16th May 2007) in The Guardian, said “our strategy needs to consider how best to reduce drug use” and “Drug use destroys individuals, families and communities”. All drug use is not as destructive as the Minister professes to believe, only problematic use.
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