Ian Sherwood is a volunteer at Transform. He worked in drug treatment from the mid-1980s in voluntary and statutory sectors as a clinician, manager and commissioner, and served three terms on the ACMD. This piece originally appeared in shortened form in Drink and Drug News (DDN).
The distressing reality of drug dependence per se alters little over time, but society's response to drugs and drug users has changed markedly over 30 years. I think it's time to revisit the field's long term avoidance of the drug reform debate including decriminalisation, legal regulation and the role of criminal sanctions in treatment.
There were good reasons why – with a few notable exceptions - the avoidance of this debate occurred. The even-handed position we took was usually a pragmatic one arising out of what was the priority at the time; firstly to argue for the existence of services for drug users in the 1980s, and then to argue the necessity and priority of Harm Reduction in the 1990s. Treatment providers were urgently distancing themselves from the moral panics stirred up in the tabloid press about Drugs and about HIV/AIDS, placing themselves within a safe, rational, medico-therapeutic narrative.
For those on public platforms, or official business, representing treatment services, it was a necessary but painful tactic to close down legalisation questions quickly to ensure that the message about services wasn't derailed by being accused of being ‘legalisers, soft on drug users’. A statement such as "My organisation is involved in treatment not politics", or if time allowed, the studiously neutral, "On the one hand... and on the other", became a default position. The Drugscope legacy website still has the "on the one hand" debate in seven sentences!
It now appears that the parameters of acceptable debate have shifted to 'recovery' and little else. Despite a major upsurge in overdose deaths, talk of ‘Harm Reduction’ is increasingly taboo - and completely absent from government communications. The term 'recovery' has become a banner for anything broadly related to care, self-help, therapy, coaching, training, social support, treatment and mutual aid. ‘Full recovery’ is the Government’s preferred term, signalling a shift away from methadone towards abstinence-based interventions.
'Recovery' embraces a broad spectrum of interventions from the traditional fellowship models of AA/NA to the mental health model of the user defined journey. Importantly, this allows people who see their own drug use as problematic to place themselves on a positive continuum of change, in a way that is meaningful to them. But in policy terms, does this positively and assertively embrace harm reduction? I don’t think so – I believe that the deployment of ‘recovery’ to mean everything to everyone leads again to the avoidance of debate and an inability to take positions. In 2015, this feels distinctly out of step with most informed opinion and global debate, disdainful of service user arguments for equality and social justice and ultimately negligent in reducing the risks and harms of drug use.
We all know that drug dependence only affects a very small minority of the many people who use drugs to the extent that they may require significant interventions. It is these clients of drug treatment services in the community and in prison that are cited by ministers as the justification for the Misuse of Drugs Act, and thus why legal regulation will not be entertained. The treatment sector is therefore in the debate, but only by implication, not by intent.
The fears that treatment providers have of biting the hand that feeds may have a strong historical justification, especially where there has been a high profile, Government-led direction of policy and funding. But I would argue that the factors prohibition creates, such as a thriving black market with easy credit and violence, undermines the ability to provide treatment, undermines the communities in which drug use is most prevalent and demonises people who use drugs. Now that’s what I call an obstacle to recovery, and it’s time for the field to find its voice. It’s time to recognise that between those in recovery and those who provide treatment, care and support, there is a tremendous expertise that could articulate a way forward that is broadly based, constructive and reformist.
Disappointingly, it seems that the sector is content for almost anyone else to lead the way in this debate - even though it has potentially profound implications for them and their clients. Most recently, Police and Crime Commissioners have provided the headlines on this topic, and it is not a lone voice but the considered view of a conference organised by the Derbyshire PCC Alan Charles, which called for a “comprehensive review of strategy” in a letter to the Home Secretary. The PCCs for Durham, Dorset and Surrey concur with the reform call along with a brace of Chief Constables.
Durham Constabulary was the first police force to declare that those growing cannabis for their own consumption would not be targeted.
How will it look in the UK if the Irish Government Minister for Justice, Aodhán O'Ríordáin, completes his review of current legislation and concludes that the priority is a health response and Portugal-style decriminalisation, not the tired old status quo? Of course Ireland is in Europe and they do things differently there.
When Portugal decided to decriminalise possession and replace it with a health response it wasn’t because they had discovered a radically effective approach to treatment, it was because they saw the criminal justice led response as being both ineffective and harmful. In adopting a health-based policy they were choosing to use the treatment approaches that have been used in the UK for more than 25 years (Methadone, Rehabilitation, Detox, Care Planning, Social Reintegration, etc.) where people may still drop out of treatment, but then may re-engage later but without the threat of criminal sanctions. Let’s face it, good quality, effective treatment works without the threat of criminal sanctions.
In this debate there is always a voice that says, “Well it’s not just down to us, we have obligations under the U.N Single Convention, etc.”. William Brownfield, head of the US' Bureau of International Narcotics and Law Enforcement Affairs said last year: "How could I, a representative of the government of the United States of America, be intolerant of a government that permits any experimentation with legalisation of marijuana if two [now four] of the 50 states of the United States of America have chosen to walk down that road?” “…we believe the international community should…tolerate different national drug policies, to accept the fact that some countries will have very strict drug approaches; other countries will legalize entire categories of drugs. All these countries must work together in the international community”.
The recent statistics on overdose in the UK are a depressing but timely corrective to the complacency regarding the success of drug treatment in the UK. Furthermore, it seems very peculiar that no one is arguing for anything other than Naloxone and training. It appears to be an older cohort who are dying, and their deaths are probably linked to the increased availability of imported heroin.
There hasn’t been any mention of Drug Consumption Rooms (DCR), a widely researched, effective Harm Reduction intervention, again commonplace in the EU (and also found in Switzerland, Australia and Canada). Paul Hayes, ex-CEO of the National Treatment Agency (who remains an influential voice since his retirement), argued in a comment on the Russell Webster Blog that cost effectiveness in preventing overdose was more important than effectiveness alone because it could detract from funding other interventions. I understand the technocrat position, but it would now seem that those other, supposedly more cost effective interventions, aren’t working, and aren’t preventing overdose as a basic first response to drug use. Maybe it's important to state again that dead people don’t recover.
Drug consumption rooms such as the one pictured above (photo credit: TalkingDrugs) provide a safe place, and privacy, for users.
Similarly, is anyone arguing for Supervised Injectable Heroin? SIH is a well-researched intervention that comes under the heading of legal regulation. Surely if we are serious about wanting to stop people using, and dying from, illegal heroin we would look at Cochrane-quality, evidence-based interventions for the hard to reach and the even harder to keep in treatment. Both DCR and SIH have the ability to do this, but whatever the value of a life lost to an opiate overdose they must be too expensive to help on this metric.
Another voice in the debate is those who have been bereaved by drugs. The Families for Safer Drug Control group, who now go under the banner of Anyone’s Child (www.anyoneschild.org), are simply people who had lost a loved one to drugs, and found the prohibitionist rhetoric hard to reconcile with their experience that in no way are drugs actually ‘controlled’ in the UK. There are laws for sure, but all they seem to do is make drug use more risky, and create vastly profitable, often violent illegal marketplaces, which create the greatest burden in the most socially deprived areas. These are the unintended consequences of the war on drugs as found by the UN Office on Drugs and Crime in 2008. Go to www.countthecosts.org for a full exposition of these consequences.
As the plentiful supply of illegal drugs, particularly heroin, prevails, homelessness rises and social support and welfare are savaged; the illegal free market is the norm. This, I would suggest, is the reality that most drug users, their families, service user organisations, the police and treatment providers see every day, but it’s only the treatment providers that aren’t talking and taking positions about this. The honourable exceptions who are in the debate, such as the Blenheim Project, WDP and Kaleidoscope, are able to express strong pro-reform views, have done for many years, and still provide good services that drug users want to access. I do believe that many providers share the view that reform is necessary, but feel unable to express this for a range of reasons.
Does your organisation take a position on drug reform? Could your organisation sign up to the Count the Costs of the War on Drugs campaign? If so, you will be in esteemed company. The website is an in-depth resource for anyone interested in the reform debate. It’s a fully referenced compendium of facts and figures, and also provides an opportunity for organisations to sign up to a full assessment of the costs of the war on drugs and realistic effective alternatives.