Wednesday 13 March 2019

Consultations on drug policy

A couple of days ago, I was asked by email for some comments on the current health and social care select committee (HSCC) inquiry and Black report consultations on drug policy.  Tonight, on my own time, I drafted some thoughts.  I've copied these below and would welcome comments.

Just to give some context, the questions in the Black report at this point are as follows:

·       What are the demographics and characteristics of drug users and drug suppliers and how have they changed?

·       What causes individuals to become involved in drug use and/or drug supply?

·       What are the evidence-based approaches to preventing and reducing drug use and drug supply?

·       What causes drug related serious violence and how can it be prevented?

·       What are the most important evidence gaps relating to drug use and drug supply and what further work would be needed to address them?

And those for the HSCC inquiry are:

Health and harms:   

  • What is the extent of health harms resulting from drug use?  

Prevention and early intervention:   

  • What are the reasons for both the initial and the continued, sustained use of drugs? This refers to the wide spectrum of use, from high-risk use to the normalisation of recreational use. 
  • How effective and evidence-based are strategies for prevention and early intervention in managing and countering the drivers of use? This includes whether a whole-system approach is taken. 

Treatment and harm reduction:  

  • How effective and evidence-based is treatment provision? This refers to both healthcare services and wider agencies, and the extent to which joined-up care pathways operate. 
  • Is policy is sufficiently geared towards treatment? This includes the extent to which health is prioritised, in the context of the Government’s criminal justice-led approach.  
Best practice: 

  • What would a high-quality, evidence-based response to drugs look like? 
  • What responses to drugs internationally stand out as particularly innovative and / or relevant, and what evidence is there of impact in these cases? 
If you want to respond yourself - and I think this is something everyone with an interest should get involved in - the HSCC consultation closes on Monday.

So here goes my response.  I should point out it's not a formal response; just some thoughts that have occurred to me over a glass of my favourite intoxicant.


Having read through this, I think the fundamental questions are relatively similar, so here’s my stream of consciousness, which reflects the views of an academic rather than a commissioner.

Most drugs in themselves carry relatively low risk to the individual concerned when used in known dosages and purity, under safe conditions without forming patterns of substance use disorders.  Therefore the health harms resulting from drug use per se are relatively low.  Issues are most likely to arise when purity and dosage are unknown and where people have poor information about how to use more safely (or do not act on this information, sometimes due to the stigma or fear associated with the illegality of certain substances).

People come to use drugs initially due to a mixture of factors, with (anticipated) pleasure of some kind linked to availability.  What people find exciting, comfortable or pleasurable varies, and the effects of different drugs varies and is affected by setting, and so the reasons are as varied as people who use drugs themselves.  In understanding why people continue to use drugs, a functional approach is helpful: these substances serve a function for the people who use them, whether that is to have new experiences (‘psychonauts’), distance oneself from previous experiences or thoughts, or simply experience a ‘rush’.

For most people, trauma and poverty / lack of opportunities drive people towards problematic drug use and dealing.  Those involved in dealing are getting younger.  The violence associated with the drug market is the consequence of the substances being illegal, and violence increases when a gap in the market appears – i.e. when existing, stable dealers are arrested and imprisoned.

(But I understand the Black review has been instructed not to consider the legal status of drugs.  And in any case, the police will be more expert than me on this.  I hope Neil Woods from LEAP will be submitting evidence.)

Prevention of pursuit of intoxication and use of psychoactive substances per se is a somewhat futile task.  All societies, to our knowledge, have made some use of intoxicants or intoxicating practices.

Evidence suggests that the most effective approaches to prevent harm from substance use is not to focus on substance use or dispense information and advice, but to educate young people in relation to decision-making and safekeeping strategies, and to discuss these issues with adults in terms of the effects on their wider lives (e.g. improving parenting skills).  Such work should be integrated into broader process/practices, e.g. mainstream education, general healthcare and social work practice.

In terms of treatment, while there is relatively strong evidence that high-quality treatment and harm reduction initiatives can reduce crime and reduce the transmission of blood-borne viruses, there is a lack of evidence regarding ‘what works’ in fostering long-term recovery.  Therefore a priority for government should be to commission and support research that takes a robust, longitudinal approach to evaluate different treatment options and approaches in terms of their effectiveness.

As to whether currently commissioned treatment services are provided in line with this evidence, there are questions to be asked as to whether services engage enough people to make a difference at a population level, and whether, once people are engaged, they receive treatment in line with this evidence, much of which is based on either lab-style settings in terms of talking therapies, or US-style ‘methadone clinics’ in relation to opiate substitution treatment (OST).  What evidence there is suggests that dosages of medication dispensed as part of OST are not generally in line with evidence, supervision regimes are not applied consistently, and talking therapies are not delivered in line with tight guidelines.  In most cases there is certainly not joined up health and social care provision for the client group who have run into issues with substances, with services commissioned and provided by separate organisations, operating to different priorities and policies, and using different IT systems.

This is not to say that services are not appropriate and effective, given the limited nature of the evidence base.

The biggest challenge to delivering quality services is currently capacity.

Treatment services have been more than decimated in recent years, with cuts in most areas of at least 20% to budgets since 2013, and prevention work has become patchy and hard to monitor with the change how schools are overseen.  At the same time, resources expending on addressing the supply of drug use, for example through ‘county lines’, have increased in areas such as Dorset.  This is currently a ‘zero sum game’, and therefore it would appear that resources are being focused at less effective points in people’s lives, given that we know treatment can help reduce the burden problematic drug use and associated acquisitive crime can place on the criminal justice system.

A high-quality, evidence-based response to ‘drugs’ would be regulate all substances and therefore permit use that is in line with good harm reduction advice: i.e. where people can know and control the dosage and purity of the substance, and the manner in which they ingest their preferred intoxicant.  There would be more accessible treatment, better integrated with different elements of the health and social care system, a better evidence base by which to judge the performance of this system, and more resources to support the oversight of the system in relation to quality.

As for international comparisons, no country has this cracked, partly because opportunities for innovation are hampered by international treaties and the position of the UN and particularly the USA.  In general, we know that harm is not simply determined by a country’s regulatory or treatment system, as confirmed by the Home Office report a few years ago.  Each country should take a tailored approach to each substance, based on its history and starting point today.  Social and cultural context play a key role in determining problems and appropriate solutions – just look at trends and approaches to alcohol use in different countries around the world.  An approach that is perfectly reasonable and successful in one context can be destructive in another.  However, to focus on specifics, the approaches adopted by Uruguay and Canada for cannabis seem to me the best models for effective regulation introduced so far, though they will need careful monitoring to evaluate their impact, particularly in comparison with the various alternative regimes in operation across the US.  These initiatives could and should go further, however, and cover all intoxicating substances – though with regimes tailored to the particular risks associated with each drug.

As you’ve probably guessed, I’m writing this on my own time, as it may not be what you were looking for!



This morning I was asked why I hadn't mentioned Portugal, and whether this would be a good idea.

This was my response:

Personally, I think we're not far off the Portugal model in the UK, with treatment offered for most people who commit drug-related acquisitive crime and very few people (in the grand scheme of things) imprisoned for possession. The greatest harms (DRDs, child exploitation, cuckooing) wouldn't be solved by decriminalisation, but only legalisation.

But you're right that it at least reflects an achievable step, and highlighting it could convince people that change is possible.

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