DHA launch address – Neil Hunt (UKHRA)

Primarily, I am talking here as a Director of the UK Harm Reduction Alliance (UKHRA) but I am also going to draw extensively on my experiences within the treatment service I work for – KCA - and as a researcher with honorary appointments at the University of Kent and London School of Hygiene and Tropical Medicine.

The first thing to acknowledge is that the government has done a number of things that are right. Only a fool would deny that. But as founding members of the Drugs Health Alliance, the UK Harm Reduction Alliance is concerned about how the new drugs strategy can be far better.

The increased investment we have seen in treatment as part of the current drug strategy is welcome and much needed. Outside our urban centres, many towns in counties such as the one where I live - Kent - have been dealing with relatively new drug problems and seen massive escalations in heroin and crack cocaine use in the past 10 years. These have transformed some of our poorest communities. However, demand for treatment is increasingly outstripping what services can provide and many agencies are watching waiting times increase and having to make hard choices about how we ration treatment as there is not enough money or workers to provide the highest quality services we know are needed and want to provide.

On the one hand, we have seen an entirely healthy push to improve the quality of services and work in line with the evidence. But the more powerful message communicated through the allocated treatment budgets – especially in the past year – is that we all have to provide services that are less than they should be, and that we can’t even give to everyone who wants it. It is hugely dispiriting to know that this is the truth whenever someone walks through the door with the intention of making those momentous changes to their drug use that can improve their lives.

The problems are no less serious in our needle and syringe programmes services, which have produced one of the lowest rates of HIV infection among injecting drug users on the planet. Yet in the past year, many agencies have had to engage in discussions about how we can cut services because our budgets are not adequate to the growing demand. And we know that cutting services now, means that in years to come the NHS will be treating more people with serious (and expensive) illnesses.

The lack of acknowledgement of our success in preventing HIV and the fact that we now see rising HIV rates suggest we may now be throwing this success away is tragic. In a field preoccupied by crime prevention, it is verging on criminal.

Despite some of the good things that have come out of the drug strategy – advances that should be protected - the UK Harm Reduction Alliance is concerned about our lamentable failure to invest in many allied health services that can increase the health of the population we work with – some of the poorest and most marginalised members of British society. I’m just going to mention three examples:

Hepatitis C treatment.

Hepatitis C was already endemic when most drug services were set up and this presents a different challenge to HIV/AIDS. Thankfully, we now have effective treatment that can cure many people: treatment that is endorsed within the guidance of the National Institute for Clinical Excellence. But hardly any drug users who need it get it. Not only does this mean people suffer and become ill unnecessarily; it means that people remain infective for longer and the problems persist unnecessarily.

Dental care

I need to acknowledge Sebastien Saville of Release for making me pay attention to the next area: one that literally stares us in the face but is to all intents and purposes ignored. Obviously, the decline in accessible dental services is a national problem. But dental problems are experienced disproportionately by people from deprived communities who have had drug problems. And we know that getting back into work and forming loving relationships are among the most powerful things that can help people maintain their successes when dealing with drug problems. Try going for an interview or having a date with someone with a mouth that would embarrass a gargoyle. This is another important example of the most basic healthcare that helps people improve their lives but has been shamefully neglected because treatment budgets are channelled towards crime prevention.

Family planning

Quite rightly, there is concern about the impact of problem drug use on children. Just like other groups of women – perhaps more so - drug users have some pregnancies that are unplanned and sometimes unwanted. Part of any response to this should be high quality family planning services. And in 2002 the ACMD report Hidden Harms identified the need for high quality family planning services for women who use drugs. Yet these have never materialised. The stigma and particular problems of women who use drugs mean that generic services are poorly equipped to meet these needs. Yet there is effectively no discussion of how we can provide better and effective woman-centred services. Yet another example of neglected basic healthcare investment that could benefit drug users, avoid children being born into misery and the considerable costs to society that arise from that minority of children who require the involvement of social services. Although we seem to talk lots about punitive approaches to drug using parents our drug strategy has been uninterested in developing basic healthcare services that start from the needs of the drug using woman.

Finally, I want to mention the neglect of the development of good research. Given the scale of the problems we have in the UK, and the amount we spend on our drug strategy it is astonishing that we have so little investment in research that examines whether things work, how they work, how they can be improved or whether they should be ditched. I’ll finish by giving two more examples of aspects of our response that we know almost nothing about.

Day programmes

These exist in almost every DAT area. What are the most important components of these? How can they best meet the needs of different groups including stimulant users, women and people from diverse cultural backgrounds? Within these how do you address – on the one hand – the needs of the young homeless injector whose opioid substitution treatment is being stabilised for the first time – with the needs of the 50 year old who is 6 months into a treatment episode and slowly developing new skills for surviving without the street drugs that have been integral to life for the past 30 years? In terms of our evidence base, we haven’t really begun to ask and we should have done.

Targeted prevention with young people

I‘m not talking about school based drug education here. We know which vulnerable groups of young people have the greatest risk of developing drug problems – young offenders, children in care, excluded from school and so on - and there are now enthusiastic, innovative, specialist teams of young persons workers in many areas. Lately we have been hearing that there is little evidence that these work. Of course not. Because we have never properly commissioned research that finds out. Yet these same services now face cuts because they are not underpinned by evidence. Its crazy!

For me, the key idea in all of this is opportunity cost. Within the current drug strategy, our skewed focus on crime prevention work that often seems ill-conceived, is certainly hideously expensive, yet the effectiveness of which is almost completely unexamined, means that we don’t invest in things that do work – the basic services that enhance the health and wellbeing of drug users from impoverished communities and assists them to lead lives that start to encompass some of the things that everyone else takes for granted. This is what we need to do differently in the next strategy and it is UKHRA’s hope that we will.

END