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?
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!
Best
Will.
***
UPDATE:
This morning I was asked why I hadn't mentioned Portugal, and whether this would be a good idea.
This was my response:
***
UPDATE:
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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