23 November 2003

'Poverty' Chief takes up top job at Drugscope

Martin Barnes, currently Director of the Child Poverty Action Group, takes up the post of Chief Executive of Drugscope in the New Year. The move came following Roger Howard's move from Drugscope to Crime Concern.

Barnes has been Director of CPAG for 11 years. In this time, CPAG had expanded with a threefold increase in expenditure from the late 90's to the present. However, his departure from CPAG coincides with a period of internal disgareement at CPAG. The charity made the news as staff walked out on strike following management decisions to reduce terms and conditions of employment for new starters. While there has been no indication that the move to Drugscope was related to these internal issues at CPAG, it is to be hoped that Barnes' arrival at Drugscope will only be a boost to staff morale, rather than a portent of less good things.

CPAG has described itself as a "critical friend to Government" and traditionally CPAG has occupied a close position to Government in briefing on how economic strategy is liable to impact on poverty. It would be fair to describe CPAG as a strong campaigning body with good access to Government. They have however, had minimal contact with drugs.

It will be interesting to see if Barnes' arrival at Drugscope heralds a shift of focus. Over the past few years, Drugscope has embraced the Government's "drugs and crime" agenda; it is to be hoped that Martin Barnes will bring a shift instead to the "drugs and social exclusion" nexus instead. A focus that lifts people and communities out of poverty, and an agenda that looks at opportunity and involvement rather than punishment would be welcome.

The drugs field urgently needs strong,confident and informed voices to lobby and campaign for urgently needed reforms to policy and law. We hope that Martin Barnes can provide this voice and remains a critical friend of government.


Water, water everywhere and not a drop to fix:

Confusion has become apparent with the changes to the Paraphernalia Legislation initiated this summer. The changes to the legislation were discussed below.

At the time we highlighted these concerns and it has become obvious that these were well-founded.

A big concern was the lack of additional budget to fund these additional costs. The Government has effectively acknowledged the health benefits of revising the paraphernalia laws, but has not matched these with funds to purchase the resources. As a consequence, around the UK, exchanges are restricting what they give out because of the funding issue. These concerns were highlighted by Druglink and have been extensively discussed by UKHRA.

The second concern relates to the ongoing situation with water for injection/sterile water. The phrasing of the amendment, restricting water distribution to "water for injection" within the terms of the Medicine Act has resulted in a number of services feeling hampered in their distribution of water. This has been an especially big problem in areas where the local exchange is not linked to the NHS and so finds it more difficult to secure prescribed 'Water for Injection.'

Exchange Supplies have been working extensively to circumvent this problem, and are producing a guidance sheet to outline the current position.

Similarly, the arbitary stupidity of the decision to make citric lawful for distribution, but not ascorbic is just daft.

The other area of concern is a lack of clarity within the DLEU about what the law actually means. When asked to clarify what "utensils for the preparation" meant, the DLEU replied to us that they were not in a position to define this as it would be for a court to decide. They did however say that the terms was open and not resctricted to the examples cited.

However, others who have contacted the DLEU have received different answers, being told that some items were forbidden. Such lack of clarity in the DLEU, combined with the inadequate drafting of the legislation need to be addressed and further revision is now essential.

15 September 2003

ACPO and Cannabis

Reclassification: all smoke and mirrors?

The proposal to reclassify cannabis from Class B to Class C comes a step closer with the publication of the ACPO guidance to police on how to process cannabis-related offences.

In reality, the proposals from ACPO are a mixed blessing. On the one hand, the number of people put before the courts (approximately 80,000 per year) for cannabis offences will undoubtedly be reduced. Less prosecutions, less criminal records, and less resultant long term consequences: these are welcome and long overdue developments.

On the other hand, there are serious and substantial flaws within the way the cannabis reclassification has been handled and these are reflected in the ACPO guidance. Unfortunately, ACPO has not seen fit to place the guidance on their website, and it has yet to appear on the Home Office Website. We are therefore relying on information from the media to understand what is in the guidance. A selection of links is included at the end of the article.

The draft legislation currently passing through Parliament makes possession of Class C drugs an arrestable offence. There is nothing in law to shape or restrict under what circumstances this power of arrest should be utilised. This has been left to the guidance prepared by ACPO.

In an ideal world, the Home Secretary would have had the courage to simply reclassify cannabis, and possession of it would have ceased to be arrestable offence. Instead, under pressure from senior police officers, Blunkett appears to have acquiesced to a compromise that sees cannabis reclassified but leaves power of arrest wholly at discretion of the police.

The guidance produced by ACPO does state that there should be a "presumption against arrest" for possession of cannabis, unless the possession is aggravated by one of a number of factors:

· Smoking cannabis in public:
· Repeat offenders: Where an officer is aware of a person repeatedly dealt with for possession of cannabis, he or she may arrest him or her.
· Local policing problem: Where a fear of public disorder is associated with cannabis use, the police may arrest rather than warn.
· Young people: Those aged 17 and under will be dealt with under the Crime and Disorder Act 1998, and not the guidelines - they will be arrested.
· Adults with cannabis inside or near schools or premises used by young people

However, these "aggravated" situations are solely guidance and the decision whether or not to arrest is solely at the discretion of the police officer.

The net outcome of the ACPO guidance is a regional lottery that means different police forces can choose to adhere to - or disregard the guidance as they see fit. Further, individual officers can choose to arrest or confiscate and caution at their discretion. Such an approach is wholly inconsistent. The risk is that certain groups in society - young people, especially from black and other ethnic groups - will be disproportionately arrested. Others will be happy recipients of a confiscation and a caution.

Such an approach leaves too much discretion in the hands of the police. Even though an individual may feel that they have been treated unfairly - that they should have simply received a warning, there is no legal recourse available to them. This is the problem when guidance is used in place of robust legal protection.

Juveniles remain especially disadvantaged by the proposed legislative changes, Thanks to confusing messages from the media and from Government, many young people already believe that cannabis has been reclassified and effectively depenalised,. Few are aware that post-reclassification, they will still be arrested and, unlike older users, will not simply receive an informal warning, Instead, depending on previous offending histories, they will end up before Youth Offending Teams or before the courts, and liable to receive criminal records.

As with other recent changes to drugs legislation the Government has taken a momentous step - in this case to reclassify cannabis. But as with changes to Section 8 and to paraphernalia legislation the Government has then wavered in their resolve and turned the changes into a poor, misguided compromise that will cause confusion and inconsistency.

Paraphernalia Legislation- Welcome changes marred by restrictive drafting:

The Government has amended the legislation relating to drugs paraphernalia. The changes increase the range of equipment that can be given out by drugs workers and allied professionals. The legislation ameliorates the situation created by Section 9a of the Misuse of Drugs Act 1971, which made it unlawful to distribute equipment other than hypodermic syringes and needles for the administration of controlled drugs unlawfully held.

The changes to the legislation are contained in Statutory Instrument Number 1653, and follow recommendations made by the Police Foundation review and the ACMD. It also follows extensive lobbying by harm reduction groups including The Exchange, UKHRA, Lifeline and others.

The changes and their ramifications are considered in detail in the revised KFx publication "Injecting Equipment And Sharps Bins - Legal and Practice Issues (September 2003.)" The key changes are that certain professionals can distribute certain equipment as detailed below:

Clearly, there is much to welcome here. The Government has recognized that the legislation impeded effective harm reduction work. Further, it recognizes that it is unacceptable that workers should be obliged to work on the wrong side of the law, even if prosecution is unlikely. The various groups and individuals who have lobbied, provided the evidence base and stuck their necks out to achieve this change deserve praise for facilitating this change.

However, as with many other recent changes or developments within the drugs field, the amendments to the paraphernalia legislation have been marred by an overweening desire to maintain 'control' on the part of Government. This tendency has been apparent through the proposals to amend Section 8(d) of the MDA, the reclassification of cannabis, and now the present example. In each case, rather than choose a simple revision or rescinding of the relevant legislation, the Government has chosen a response that on the one hand changes or relaxes the legislation but which simultaneously introduces new restrictions and ambiguities.

The revisions to the paraphernalia legislation are a case in point. Rather than removing the existing restrictions entirely, the amendment makes provision for a handful of additional items to be made lawful for distribution by a limited range of professionals.

The outcome of this is an inconsistent piece of legislation, which results in the following:

· It is lawful for doctors, vets, pharmacists and others undertaking "lawful" drugs treatment work to give out specified paraphernalia. However peer supply of this paraphernalia remains illegal. So on the one hand a drugs worker commits no offence by giving citric acid to an injector but the injector would commit an offence if they passed some of that citric on to a partner. To compound this confusion it is not illegal for a peer to distribute on needles and syringes to peers, but it is illegal for them to pass on other paraphernalia such as citric or utensils.
· The list of items that can be distributed is at some points inclusive and at other points exclusive. The legislation specifies that it is now lawful to distribute citric acid. However, it remains illegal to distribute other acidifiers such as ascorbic acid.
· Conversely, the list of 'utensils for preparation' designated in the legislation gives a few examples but is not an exhaustive list. It mentions 'spoons, bowl, etc,' but this does not exclude other equipment being distributed. However, by specifying utensils for 'preparation' this would appear to mean that the distribution of items for consumption (other than syringes and needles) remains illegal. This means that the distribution of foil, pipes etc remains illegal.
· The Government has not seen fit to amend the Medicines Act, and so water for injection remains a prescription only medicine. This impedes the ability of some agencies, especially those working outside the NHS, to secure satisfactory arrangements for its legitimate distribution.

The paraphernalia legislation, like much of the Misuse of Drugs Act 1971, has become a hindrance to harm reduction work whilst having a diminishing benefit in terms of law enforcement. Across the country, innumerable shops and market stall sell drug paraphernalia with virtual impunity. The only bodies that are substantially impeded by the legislation are those seeking to undertake harm reduction work.

In reality, the paraphernalia legislation has never been an effective piece of legislation and is routinely flouted. But rather than accept this and rescind the legislation, the Government has instead tinkered with it, as it has tried to tinker with Section 8 of the Act, and with cannabis reclassification.

The resultant legislation continues to restrict practice, and throws up new ambiguities. It is unclear exactly who it applies to. The Drugs Legislation Enforcement Unit within the Home Office is unclear itself as to who the legislation applies too. They intend that it should extent to all parties engaged in drugs work, even if not directly employed as drugs workers. So it is intended that the legislation should also apply to housing workers, police or others engaged in drug treatment initiatives. However, the DLEU also acknowledge that this is not explicit within the legislation and the exact interpretation of bodies authorized to distribute equipment under the legislation would need to be decided by a court. Similarly, the DLEU were not in a position to determine the scope of the term 'utensils,' and this too would be open for interpretation by a court..

In further worrying comments since the amendment was passed, it has become apparent through discussions on the UKHRA board, that serious concerns are being raised regarding the resources available to ensure adequate distribution of equipment. Some commentators have noted that distribution of equipment is hampered less by law than by fiscal concerns.

Unless the relaxation of the law is matched by additional ring-fenced funds to purchase equipment and ensure that it is distributed effectively alongside informed harm-reduction information, then the changes to the law will remain a cosmetic exercise.
While the changes to the paraphernalia legislation are to be welcomed, and represent a step on the incremental process of legislative change, this welcome is tempered by unhappiness that the changes remain restrictive, in terms both of the equipment and the groups covered. It enfranchises professionals while excluding users themselves. It allows for some equipment but forbids others. And neither it nor the accompanying guidance places any onus on services or those commissioning them to ensure that this extended provision is made available across the UK.

07 July 2003

Ian Duncan Smith and Oliver Letwin on drugs

At the start of July, Letwin and IDS launched the Conservative's strategy on drugs, and there was substantial media coverage as a result. While the Tories are hopefully still unelectable, the strategies that they are outlining are the source of great concern. Not least because, if drugs become a political hot potato on the run-up to an election, it seems likely that the ever-flexible David Blunkett could find himself dragged off down an increasingly reactionary drug strategy dead-end.

The media reporting on the Tory strategy highlights the extent to which it has not been effectively thought out or priced. Unfortunately, rather more commentators commented on the latter aspects ("how will it be paid for?") than the former ("is it a viable way forward?")

Letwin and IDS have clearly been influenced by the Swedish model, and are seeking to copy this:
"... rehabilitation, as we have seen in Sweden and many other countries, where they have reduced addiction, cut the levels of crime. We are going to copy that."

Rather than just focussing on the issue of Class A drugs, the model used in Sweden is robus against all substances including cannabis. Possession or use of cannabis amongst young people is a trigger offence which means that young people are required to accept treatment.

Given that levels of cannabis use in the UK are variously estimated between 16% and 40%, this would mean creating capacity for some 3 million young cannabis users. At various points, Letwin and IDS have said that they want to model policy on both Swedish and Dutch models. These two models are mutually exclusive and demonstrate more about Letwin and IDS's fundamental lack of grasp as to how the systems work. The Netherlands adopt an approach that creates a clear seperation between cannabis and other drugs. No such seperation is made within the Swedish approach. Dutch treatment options are varied but do include high-dose methadone maintenance and experimental use of Diamorphine. Engagement and harm reduction through needle exchange and consumption rooms is also part of the provision, along with a high level of user and activist involvement.

The Swedish Government has vigorously opposed such developments and has been lobbied extensively by bodies such as HNN Sweden, who in turn were largely responsible for obstructing moves within the European Parliament and at the UN convention in Vienna to embrace such harm reduction principals.

Mr Letwin rejected the idea of prescribing hard drugs on the NHS to help drug users abandon their habit. "If you have maintained addicts you will have a permanent dependent population paid for by hard-working people. That is intolerable,"

This appears to suggest that Letwin rejects the international evidence that supports the prescribing of Class A drugs such as Diamorphine or Methadone either on a reduction or maintenance basis. It suggests that he is pursuing a forceful detoxification regime followed by a period of enforced rehabiliitation.

Finally, the proposals are substantially under-costed, as discussed in the media. But far more worrying than this is the huge shift in thinking that IDS and Letwin's approach would suggest. Many of the gains made over the past fifteen years would be eroded by such as a policy, and while not billed as such, this is still a war on drugs.

30 June 2003

GHB becomes a Controlled Drug

The Home Office announced that GHB would become a controlled drug with effect from 1st July 2003. A number of other substances were also added to the list of Controlled drugs.

The ACMD had recomended that GHB be added to the list of controlled drugs and the Government had consulted on the proposals. The move came in part because of the suggested links between GHB and drug-assisted sexual assaults.

Class and Schedule:
GHB becomes a Class C, Schedule 4.i drug. This means that possession without prescription will be unlawful, and at present, the maximum penalty for possession will be two years and supply will be five years.

However, until the Criminal Justice Bill 2002 completes its passage through parliament, POSSESSION of GHB will NOT be an arrestable offence. Once this bill becomes statute, the penalty for the supply of GHB (and other class C drugs) will increase to 14 years and possession of class c drugs will become an arrestable offence.

Strange comparisons:
While the addition of GHB to the list of controlled drugs is welcome, it does highlight the inadequacies of the current classification system. Once cannabis is reclassified, it will also be a class C drug. By placing both GHB and cannabis in class C, this suggests some sort of comparabilty in risk/safety between the two substances. This is clearly erroneous, and educators will need to stress that there is no equivalence between the two substances.

The Government postings on the reclassification are at:
HOC 39 - Misuse of Drugs Act 1971 (Modification) Order 2003 (SI 2003 No.1243) - Misuse of Drugs Regulations 2003 (SI 2003 No. 1432) 303kb

Changes to the Misuse of Drugs Legislation - Control of GHB and Seven Other Substances (Correspondence)

23 June 2003

Blunkett leaves UK drugs policy on disarray (again!).

A series of leaks and ad hoc policy decision, fuelled by sloppy reporting in the Sunday papers, have left the UK's drug policy in confusion once again. Having effectively killed off the prospects of extended diamorphine prescribing last week with their restrictive "guidance" document, the Government created further confusion over cannabis and premises legislation.

Since Blunkett first announced his intention to reclassify cannabis, the process has been mired in confusion and incompetence. The simplest move would have been to move cannabis to Class C, and make possession of it a non-arrestable offence but leaving supply an arrestable offence.

But rather than adopting this approach, the Home Secretary, either for personal reasons or under pressure from senior Police Officers, decided it was important that the power of arrest was retained, and so went through a series of half-thought through measures to achieve this.

Sine then, a variety of measures have been proposed: there was a proposal to create a three-strikes and your nicked approach to cannabis policing. Given that such an approach would have required a rather substantial data-base, such a plan seems to have been quietly dropped.

The second approach was to make cannabis possession an arrestable offence in certain limited settings, described as "aggravated possession." This included the notorious "blowing smoke in a police officers face" and other similar situations.

But the bottom line, as incorporated in to the Criminal Justice Act 2002 simply makes unlawful possession of Class C drugs an arrestable offence:

9 Power of arrest for possession of Class C drugs

In Schedule 1A to the Police and Criminal Evidence Act 1984 (c. 60) (specific offences which are arrestable offences), after paragraph 6 there is inserted—
“Misuse of Drugs Act 1971
6A An offence under section 5(2) of the Misuse of Drugs Act 1971 (c. 38) (having possession of a controlled drug) in respect of a Class C drug (within the meaning of that Act).”

No reference to aggravated possession, no reference just to cannabis. The Government proposal is to issue guidance, agreed with ACPO, on when and where people should be arrested but this will only be guidance. Ultimately, local forces and ultimately individual officers will have personal discretion as to when they choose to arrest.

Effectively, the reclassification of cannabis, in practice, simply means that the maximum penalties for possession have been reduced; it will remain an arrestable offence and the penalties for supply will remain the same as they were for Class B drugs - 14 years.

To make matters worse, unable to reach decision about how to implement the revised strategy, it is now being proposed that the reclassification of cannabis be delayed until autumn at the earliest. Young people, already labouring under the misaprehension that cannabis is either now legal or will be from July, are going to be further confused.

This mess is entirely of Blunkett's making. It stems from a premature announcement of the decision to reclassify, before the details had been worked out, followed by a craven retreat from the decision as he came under pressure from the police and the media.

Use on premises:
A series of leaks and reports in the papers caused a flurry of concern that the Home Office wanted to widen the proposed powers incorporated into the Anti-social Behaviour Bill 2003. The legislation proposes creating new powers to close premises where premises are associated with the use or supply of class A drugs and also with nuisance or serious disorder.

It was widely reported that the Home Secretary wanted to extend this power to cover Class B and C drugs too. This is something we were concerned would happen when the legislation was first proposed, and it was a relief to see no such amendment was made when the Bill was discussed at committee stage. Again, the driving force behind this seems to have been the Home Secretary, being advised and pressured by unknown sources.

Further confusion is being caused by the current state of play regarding the status of Section 8(d) of the MDA; it is not clear either to the field or to the Home Office, whether organisations still have an obligation to prevent the smoking of cannabis on premises that they manage.

Under changes to the sentencing for class C drugs offences, organisations who allow cannabis smoking post reclassification (or indeed supply of Valium!) will face a maximum of fourteen years in prison. But first clarification is needed as to whether or not 8(d) is still enforceable at all.

Time for Blunkett to get off drugs!
Given the importance of drugs policy and strategy, it is essential that drug strategy is taken out of Blunkett's inept hands. Since he has taken over primary control over drugs strategy, it has been wholly subsumed by his crime and anti-social behaviour agenda.

Rather than listening to his advisors and those from other departments, he has leant to much of an ear to the police and too little to those who understand the field. It is time for a change in this process and the brief for managing drugs should no longer be left with Mr. Blunkett.

19 June 2003

New guidance on injectable heroin and injectable methadone treatment for opiate misusers

The NTA released the long-awaited guidance on the prescribing of injectable diamorphine and methadone on Friday 13th June 2003. Such an inauspicious publication date was matched with an equally inauspicious publication. While recognising that diamorphine and methadone prescribing has a limited role in substitute prescribing, the guidelines bind such restrictions around the prescribing of diamorphine as to make it more difficult, rather than less difficult to achieve than it is at present.

So, rather than extending the prescribing of diamorphine, the NTA has effectively done the reverse. Responses from the field have, to date, been muted. Discussions on the UKHRA boards have been vocal and critical of the guidance, asking how "how can the NTA have got it so wrong?"

Roger Howard, the soon-to-depart head of Drugscope, provided a quote of stunningly anodyne quality, even by his own standards. Presumably, in anticipation of a move to Crime Concern, he has no wish to upset Blunkett or AInsworth. Anyway, his comment on the guidelines was: "We welcome the NTA guidelines on heroin prescription and hope that they will lead to the situation found in other countries where, when other treatments have failed, there is an increase in users potentially being prescribed heroin."

How the report was developed:
The Guidance describes itself as a "majority consensus approach" which presumably means that there was some dissent from the expert groups, but this was the consensus of the majority, and the views and concerns of the minority have not gone on record.

Our understanding was that, in the final document, the views of the medical consultants, were given higher prominence and the report reflects their views rather than all the experts consulted.

The Eight "key principles."
The report outlines 8 key principles that underpin prescribing of injectables, as follows:
1. Drug treatment comprises a range of treatment modalities which should be woven together to form integrated packages of care for individual patients.

2. Substitute prescribing alone does not constitute drug treatment. Substitute prescribing requires
assessment and planned care, usually with other interventions such as psycho-social interventions. It should be seen as one element or pathway within wider packages of planned and integrated drug treatment.

3. Within the substitute prescribing modality, a range of prescribing options are required for heroin misusers requiring opioid maintenance. Some options may carry more inherent risks than others (e.g. injectable versus oral options). Patients who do not respond to oral maintenance drug treatment should be offered other options in a series of steps. This would normally include:
• oral methadone and buprenorphine maintenance, specifically optimised higher dose
oral methadone or buprenorphine maintenance treatment, then
• injectable methadone or injectable heroin maintenance treatment (perhaps in combination with oral preparations)

4. Injectable maintenance options should be offered in a local area that can offer optimised oral methadone maintenance treatment including adequate doses, supervised consumption and psycho-social interventions.
This is essential to ensure oral drug treatment options have been fully explored prior to a trial of injectable maintenance treatment and to ensure smooth transition back to oral treatment if required.

This is an interesting clause and appears to be an interesting piece of sleight of hand. On the one hand it places a level of obligation on providers to make options other than oral methadone available to people who do not respond to oral methadone. This would appear to suggest that local areas would be expected to make such resources available. However, subsequent clauses provide a number of limitations on this.

The requirement to provide "optimised higher dose oral methadone" is an interesting development. It suggests a tacit acknowledgement that methadone is still being prescribed at insufficiently high levels, and without necessary support in place. So before local agencies can explore any other options such as injectables, increases in levels of methadone and additional support will need to be explored.

Given that a number of regions still have ridiculously low caps on methadone, increasing this will require substantial movement from local prescribers.

5. Injectable and oral substitute prescribing must be supported by locally commissioned and provided mechanisms for supervised consumption. Injectable drugs may present more risk of overdose than oral preparations and have a greater value on illicit markets and hence may require greater levels of supervision.

6. Injectable maintenance treatment is likely to be long-term treatment with long-term resource implications. Clinicians should consider the move from oral to a trial of injectable preparations carefully, including long-term implications for the patient and drug treatment systems and involvement of services.

7. Specialist levels of clinical competence are required to prescribe injectable substitute drugs.
Heroin prescribing also requires a Home Office licence.

So despite Blunkett's assertion that an aim was to increase access to diamorphine prescribing, no changes to the archaic licensing system.

In the main body of the report, there is a proposal that all injectable opioids would require Home Office licence if being used for the treatment of addiction which could, in turn, have an impact on people currently prescribed injectable methadone.

8. The skills of the clinician should be matched with good local systems of clinical governance, supervised consumption and access to a range of other drug treatment modalities.

The detail and key areas of concern:

The requirements around supervised consumption are the most odious aspects of the guidance, and the aspect that will reduce stability and make the guidelines unworkable. Provision of supervised consumption - even for a short initial period, will dramatically increase the cost of the intervention. While diamorphine is already a more expensive option compared to methadone, the cost of twenty-plus supervised injections per week, at an average of 10+ worker hours per week, will cost in excess of £150/client/week in terms of supervision, before the cost of converting suitable premises are bourne in mind.

Certainly, supervised consumption on pharmacy sites would be difficult: it is hard to envisage many pharmacies would want to undertake this task, and the same is probably true for GP surgeries. Which means that such consumption will need to take place in drug projects.

The guidance proposes "there was great potential in providing injectable drug treatment from highly centralised injectable clinics" which is fine in large inner-city areas but means that, in rural areas, such provision is not feasible.

While the report notes that supervised consumption will require multiple daily attendances, but perceives this to be a welcome development:

The requirement for daily or multiple daily attendance was also discussed as requiring a significant change in current British provision (particularly out-of-office hours). Whilst such requirements may encourage the patient to progress towards improved outcomes, they are also very restrictive of liberty and represent a significant, but positive, change from previous practice in England. (emphasis added).

But, as policy development work for the Soho Rapid Access Clinic highlighted, this brings with it some complications around storage of CDs on site. Daily doses of drugs have to be delivered to the clinic and CD cabinets installed. Staff authorised under the MD regulations will need to be on site to dispense, and medically trained staff on site for emergencies. Three times a day. For maybe one or two clients who have to travel in three times a day.

Although this guidance says that local provision will need to be commissioned, there is no additional money to make such provision available. Again, the NTA will be able to blame the local providers for their failure to provide rather than looking at their own responsibility.

Eligibility Criteria:
The guidance provides strict limits as to eligibility, as follows:
Inclusion criteria for injectable opioid maintenance:
Clients should meet all of the following inclusion criteria in order to be eligible for injectable
opioid maintenance:
• The client should have a protracted history (> 3 years) of heroin dependence and regular daily injecting.

This was to be expected but also means that some clients for whom injectable methadone or heroin may be appropriate will be excluded. For example, amongst homeless drug users in central London, a high proportion had rapidly escalated habits over a short period of time, but had built up substantial injecting habits over less than three years.

• The client should be aged 18 or over.
• The client should be able to provide informed consent. This includes no active medical or psychiatric condition impairing the patient’s capacity to provide informed consent
• The client should be willing to comply with the conditions of injectable opiate treatment, including:
  •  a treatment plan
  • regular supervision and monitoring
  • avoidance of persistent injecting in high risk areas (e.g. neck or groin veins)
This is a big concern and excludes long-term femoral injectors. Again, looking at Central London homeless populations, the extent of femoral injecting is as high as 80%. This group would be excluded from such treatment, even where it may be an effective intervention.

• continuation of injectable treatment being conditional upon positive healthy response to treatment (which includes other treatment elements in a package of planned, co-ordinated care)
• diversion of the prescribed injectable drugs and “double scripting” being grounds for discontinuation of injectable treatment.
• The client should first have received optimised oral maintenance treatment - an adequate period (normally at least six months and for some this could be significantly longer) of optimised conventional substitution maintenance treatment and associated package of care.
• There should be a persistence of poor treatment outcomes despite a current optimised oral maintenance treatment episode. Indicators of poor outcomes may include:
• continued frequent (daily or almost daily) injecting of illicit heroin or other opioids
• patients at continuing high risk of the transmission of HIV, HBV or HCV to themselves or others
• continuing injecting-related health problems (e.g. abscesses, cellulitis, systemic infections), poor general health, poor psychosocial functioning and drug-related criminality.

This is a catch 22 and a nasty one at that. In order to get on to a diamorphine prescription, a patient would have to engage with optimised oral methadone for at least six months. Failure to adhere to such a programme (e.g. use on top, missed appointments) is likely to result in being dropped from treatment. But if someone does adhere to the optimised methadone treatment, then it seems likely that the clinician will adjedge the methadone as being effective and, as such, there would be no need to switch to injectable diamorphine.

This is the drugs equivalent of the ducking stool; if you sink and drown, you weren't a witch; if you float you are and get burned.

If the inclusion criteria are met injectable opioid maintenance treatment may then legitimately be considered by the clinician, in consultation with the patient, key carers and the relevant multidisciplinary team.

The guidance seems to be a work in progress. It restricts and hampers the work of prescribing injectables without exploring how to overcome these barriers. The document offers no guidance on how supervised consumption can be practically achieved and creates substantial new obligations before injectables can be considered.

There is a failure to explore potential other routes of administration, including heroin reefers or other strategies for administration, or proposals for weekend take-home doses.

The model of thrice-daily supervision is hugely unworkable, and the exclusion of the most ill, those with impaired liver function and habitual femoral injectors excludes those most at need.

After a long period of waiting, there is no sign here of more treatment, better treatment or fairer treatment. This report sides heavily against those who wish to see diamorphine made available on prescription in a practical and accesible way.

This is a case of style not substance. The Government will claim credit for more flexible prescribing policy, and will blame practitioners for failing to deliver what they have, in fact, made impossible.

To view the complete guidance, follow this link:
Press Release: http://www.nta.nhs.uk/news/020115.htm

02 June 2003


The Home Office unveiled its new "Talk To Frank" campaign in May. The linked campaign includes a telephone helpline service, a website and a new advertising campaign to promote the site. The launch and publicity campaign will cost £3m this year.

Talk to Frank is put together by a large number of agencies.

The PHONE SERVICE: The rebranded "Talk to Frank" service is provided by the Scottish-based Essentia Group. (http://www.essentiagroup.com/).

Essentia describe themselves thus:
Rewriting the rules of an entire industry, the Essentia Group is the UK's leading contact centre specialising in health and social welfare - a technology-based provider of governmental and commercial organisations’ information and advice services in the area of health and lifestyle management.

Essentia do operate a number of smoking and mental health services and have a track-record in substance use; presumably therefore, soem staff have a history of working with substances and new staff are receiving a level of training to achieve this level of competence.

THE ADVERTISING CAMPAIGN: The "Talk to Frank" campaign was designed by Mother working in conjunction with PHD. Mother are big players in Adland, and their roster includes such health-inducing products as Coca-Cola and environmentally sound companies as Unilever. Unfortunately they do not have a website but you can send them feedback on the FRANK campaign by clicking here: mother@mother.ltd.uk.

PR for the launch was handled by Fishburn Hedges, a London based PR company who also provided PR for Connexions.

The website and email interface was put together by EURO RSCG CIRCLE (aka Circle), a global digital marketing agency. Their website is at http://www.circle.com/contact/index.html

Reviewing FRANK
So is "Talk to Frank" any good. Reception from the mainstream drugs field was mixed. Roger Howard, was warmly receptive of the site and offered the following uncritical comments to the Guardian:

"Frank has been extensively trialed in the community where young people and their parents seem to be receptive to the campaign.

"Frank will hopefully provide better and more accurate information for young people and their parents to encourage them to talk to each other about this topic and we look forward to seeing the evaluation on the effectiveness of this in the future."

Much has been made by the Government and the media that the "Talk to Frank" campaign represented a step change away from "Just say no" approaches and a new, more honest and credible approach.

In reality however, the National Drugs Helpline had never promoted itself in this way; previous publicity campaigns for the Helpline had concentrated on the line as a source of factual information, such as the long-runnning ads about cocaine and ecstasy that were often on XFM in London.

Release welcomed the rebranding too, describing the new "Talk to Frank" approach as "more friendly" than the NDH.

There were a number of criticisisms of the NDH; the most important of these was the ridiculously short time window target for callers. Many callers were simply referred on to a local service, and call-handlers assiduously bundled potentially long callers - especially distressed parents - on to other services as quickly as possible. If "Frank" is really providing a better service, it will be interesting to see if there is a greater "depth" to the work, or it restricts itself to simple advice and referal on.

The Campaign:
The idea of "talk to Frank" was clearly intended to promote the idea of speaking to an informed friend: but the advertising company decided that the informed friend should be someone who sounds like he is white and male. Despite the fact that the campaign was trialled, this seems like a strage choice: why Frank? Why a male? How does this fit in with any sense of cultural diversity? Some organisations have disapproved of the way that the police have been portrayed in the adverts too.

Content: KFx has refered a number of errors on the Website to relevant bodies and is satisfied that they are being dealt with at the time of writing.

Talk To Frank http://www.talktofrank.com/
Guardian Web review: Frank has no cred: http://politics.guardian.co.uk/homeaffairs/story/0,11026,962418,00.html

Drug advice campaign is a wasted opportunity, say charities: Guardian: 23.5.03

13 May 2003

The Home Office posts "official" position on Section 8(d)

The Home Office has written to people who responded to the consulation to Section 8(d) of the Misuse of Drugs ACt 1971, confirming the current Government position. The letter confirms that the Government does not intend to implement 8(d) at this time, prefering to explore alternative powers under the Anti-social Bhevaiour Bill.

The letter says that the postponement of the amended 8(d) will be for a period of 2 years to allow for evaluation, but that the potential to extend 8(d) "will remain on the statute book" pending evaluation.

13 March 2003

Section 8 and "Crack Dens:" What the Home Office did next...

Section 8 Amendment: Government adopts new approach?

The launch of the Government's white paper "Respect and Responsibility - Taking a Stand Against Anti-Social Behaviour" suggests that the Home Office may be adopting a new approach to addressing the use and supply of drugs on premises, following their ill-conceived amendment to Section 8 of the Misuse of Drugs Act 1971.

There is a great deal in the White Paper that has already prompted controversy, including measures to address with begging. However, the measure of most interest - tempered with some concern - is that regarding premises where the use or supply of drugs is taking place.

This clause has been trailed in the media as being a measure to clamp down on "crack dens." This was the same rationale for the amendment to Section 8(d) of the Misuse of Drugs Act 1971 by Section 38 of the Police and Criminal Justice Act 2001.

The proposal in the White Paper is a very mixed and needs to be approached with cautious optimism. Firstly, and most importantly, it leaves its scope very wide, and is not focused either on premises where crack is the drug in question, nor, more worryingly, on situations where the concern is about supply, rather than use.

The paper says:
For sometime local authorities, the police and local communities have been frustrated by their lack of powers to close down premises - rented, owner occupied or otherwise - where Class A drugs are being sold and used. We are determined to ensure that the ruin they can cause in communities is stopped.

Rather than the current approach, to pursue criminal proceedings under the Misuse of Drugs Act against the occupiers or managers of such premises, the White Paper proposes a more streamlined approach, which would probably require a lower standard of evidence.

The new powers will give police the power, after consulting the local authority, to issue notice of impending closure, ratified by a court, which will enable the property to be closed within 48 hours and sealed for a fixed period of up to six months. Drug dealers will be dealt with through the courts and the property will be recovered by the landlord.

Effectively, such a piece of legislation would give the police and local authorities the power to evict people from a property within 48 hours, without going through normal channels such as a landlord seeking possession, provided that the police could demonstrate that the use (or supply) of Class A drugs was taking place on the premises.

While the Government is proposing that this legislation be used to address properties where the use or supply of drugs creates a nuisance to communities, the scope of it is such that it could also be used against night-clubs, private citizens, squatters, treatment or housing providers or any other body.

Without seeing more detail as to the nature and scope of the proposed legislation, it is probably premature to condemn the proposal out of hand. Ideally, it would be a well-constrained piece of legislation that would require the police and local authority to demonstrate that nuisance was being caused and that such enforcement was the only solution

Such a piece of legislation would mean that there would be no need to proceed with the commencement of Section 8(d) of the Misuse of Drugs Act 1971 as amended by section 38 of the Police and Criminal Justice act 2001.

We would like to be able to welcome this proposal in the White Paper, and are glad to see that the Home Office has listened to the very real concerns of the field on this subject.

It would be churlish to criticise the twenty-two months of uncertainty ad confusion that stemmed from the original vote-grabbing decision to amend the law.

However, even though this is still only in the form of a White Paper, there is still substantial cause for concern, and it is far too soon for jubilation. In its loosest form, the proposal would represent a massive extension of police powers, with serious implications for civil liberties. In a constrained form, and as a replacement for Section 8(d) it would be a useful and appropriate measure.

In the meantime, the amended Section 8(d) remains on the statute book, awaiting commencement. The risk is that, in a frenzy to address the perceived drug problem, this piece of legislation is also enacted.

The Home Office should, without further delay, announce that such a commencement order will not be issued. Section 8(d) should then be repealed without any more prevarication, to allow the development of desperately needed harm reduction and housing provision.

In place, a carefully drafted piece of legislation, developed in full consultation with relevant fields, should be introduced in its place. Then, perhaps we can focus on the very necessary work in hand.

11 February 2003

Government Launches Prospects:

The Government launched its "Prospects" scheme with a low key announcement on the Number 10 website and a verbatim regurgitation of the news on the BBC website. The scheme is intended to address the long--identified gap in services for offenders who missed the CARAT boat by virtue of their shorter senteces but still needed support.

Unfortunately, the briefing from Number 10 was long on rhetoric but short on detail: salient points were:

"The scheme will be available to offenders who:
  • are sentenced to less than 12 months
  • are persistent offenders, but who do not have a history of serious offences
  • have a history of drug misuse
  • have tested negative for drug use in prison and who demonstrate a real motivation to be drug free
  • may have housing problems
  • have a local connection to the catchment area of the premises
After release from prison participants will stay for 12 weeks at the approved premises in the five local communities and undergo a strict but supportive regime.

This seems a bit scetchy; it is not clear if it means that people will be tested; at a guess it means that they will be evicted/breached if use is suspected. In addition, housing would of course be threatened thanks to restrictions under Section 8.

At the end of this period, they will be provided with a further six months tenancy in longer-term accommodation, and will continue to benefit from a support network run by the supplier.

And again, the same problems that dog TST work or Supporting People with Section 8.

The pilot will be tested in Exeter, Preston, Merseyside and the wider Bristol area. Contracts to run the projects have been awarded to UK Detention Services (UKDS), Stonham Housing Association and the National Association for the Care and Resettlement of Offenders (NACRO).

While Stonham Housing Group and NACRO are familiar names, UKDS was a new one to us; research reveals that they are part of the multinational "Sodexho Alliance" primarily known for supplying food in a multitude of arenas. Sodexho moved in to the provision of "correctional facilities" . Prisoners working in Sodexho-run facilities (UK, Sodexho run Forest Bank) are paid £14 per week, for jobs such as refurbishing sun-beds for local businesses. Sodexhoe's correctional wing earns in 91million euros in revenue per year.

The website talks about the detail of their drugs provision, in all its sketchy glory:
How are you combating drug use in your facilities?
Each time the government of the country we are operating involves us in this process, we have a program based on education and detoxification.

The following list enlarges upon that statement:
  • Detoxification offered to all requiring it.
  • Video about drugs shown to all inmates.
  • Extensive community involvement.
  • Director is a member of Community Drug Action Team.
  • Drug-free accommodation area.
  • 250 inmates engaged in voluntary drug testing program.
  • Processes to prevent overdosing risk on discharge.
  • Measures to prevent smuggling. 
  • Use of drug dogs.

 One would hope for counsellors and trained staff, especially as they move in to this specialized area of work...Sodexho recently extracted itself from its American correctional facilties, and has adopted a policy of not working in regimes which practice the death penalty or where they would be required to carry weapons. This hasn't stopped growing pressure on Sodexho to pull out of this arena altogether.

Sodexho was also the company that had responsibility for running the much criticised "voucher scheme" for asylum seekers in the UK.

A trawl on the internet reveals seething disquiet at the role that Sodexho play in the provision of prison services;

 "According to the most recent Prison Service Annual Report and Accounts (England & Wales, 2000-2001), Sodexho’s "model" prison at Forest Bank has the highest rate of rate of assaults and the sixth highest rate of positive drug tests among all 40 prisons in its class (Male Local Prisons) http://www.hmprisonservice.gov.uk/corporate/dynpage.asp?Page=516. Meanwhile, the company is also making money locking up refugees, including children, in its new Harmondsworth Detention "


If their drugs work is anything like their catering....