Getting needled #1

How much needle exchange equipment is wasted? I don’t mean how much ends up not getting returned. That’s an issue I want to return to at a later date. But how much of it gets discarded unused?

This has been an issue since the early days of pre-packaged equipment. I remember when, long ago in the West End of London we moved from pick-and mix equipment to prepacked bags of 10 needles/syringes one of the big discards wasn’t used equipment but large amounts of unused equipment. People wanted one or two needles, we insisted on giving them ten needles and so, predictably, most of the equipment was chucked away, unused.

Anecdotal information suggests that this situation has not get better and, in some areas, has got much worse. Discussions and training sessions with housing organisations and community wardens has, in some areas, raised the issue of larger quantities of unused equipment being discarded. This has included virtually complete needle exchange packs, suggesting users only wanted one or two syringes and on other occasions discarded spoons.

As the range of needle exchange equipment has increased, with the advent of (for example, sterile spoons) and more distribution takes place with prepackaged equipment from pharmacies so, the risk is more equipment gets discarded unused.

The rationale for such bundling is to reduce cost – bulk purchasing reduces costs and prepackaging makes distribution faster. In theory giving out more equipment in bigger bundles should be a winning situation: less episodes of exchange reduces the burden on pharmacies, should mean each episode can be more intensive, and by giving more equipment out should reduce episodes of sharing or reuse. But has this happened in practice?

In one area for example the package size is 20 syringes per bundle with associated paraphernalia. It makes for a fairly large and obvious package – not discrete. And anecdotal feedback suggests that it is not uncommon for significant amounts of these packs to be discarded unused.

We don’t know how much equipment is discarded unused. It might be things that the person simply never wanted – such a person who didn’t want to use the provided sterile spoons. It might excess be excess syringes when the person, for whatever reasons, didn’t want all twenty, just one or two for use today. Or it could be the “other” needles – the twenty orange 25G needles that the person didn’t need because they were using the 23G blue needles in the same pack. They had to be provided together as a compromise necessitated by prepackaging equipment, in the knowledge that one lot of needles will be surplus and discarded unused.

Without knowing how much equipment is being discarded unused, we can’t start to put a price on it. This is bad enough. Worse, without a clear picture of how much equipment is distributed but not used, we risk working under the false impression that we are getting more equipment out to injectors and that it is being used. So we may end up looking at the headline figures – how much equipment is going out – where this figure has gone up, assume that our injectors are getting more clean equipment.

In the statistics for one area that I was looking at, the quantity of injecting equipment distributed almost doubled in the period from last year to this. We know in the same period that the number of injectors hadn’t gone up. In fact it had gone down. So the doubling in quantity of injecting equipment distributed should mean that the reuse or sharing of equipment would halve, which would be a great outcome. The fear though should be that a significant proportion of this additional equipment distributed is not being used, but discarded.

Perhaps the reason for the doubling of the distribution is in part because of large pre-packaged bags.

Across the same time frame in South Wales, pack sizes reduced instead of increasing (from ten needles per pack to three.) And while the number of packs distributed increased by around 30% the net result was an overall reduction of the number of needles distributed. Did this mean that the level of sharing and reduce increased? Or did it result in a reduction in wasted equipment?

We need to know the answers for two key reasons:

• We can’t start to accurately assess the extent to which distribution meets need, if we can’t say with any confidence what proportion of distributed equipment is actually being used;
• We could be wasting significant resources if we are distributing equipment which is being discarded unused.

There are several things we can do to try and better understand and address this issue.

The first requires some detailed research. There is a huge information gap that needs to be overcome. In many needle exchange areas the return rate is low, coming in below 50%. But at the same time the level of public discards is (mercifully) very low. This makes it very difficult to assess whether non-returned equipment is being discarded used or unused. We don’t know where it is going. Domestic waste? Building up at home? Public bins? Not known. And this isn’t the key question to be honest. It just means that it makes it harder to assess how much equipment is being discarded unused.

The only reliable way of eliciting this information will be research with needle exchange customers to assess what proportion of collected equipment is used, and what proportion is discarded, unused. Such research should ideally be cross-correlated against model of needle exchange, and type of equipment. Does large pre-packaging, for example increase the amount of unused equipment discarded. Is there less discarding with pick and mix?

A less reliable, but useful interim measure will be more accurate monitoring of drug litter and discards to ensure that all such monitoring differentiates between used and unused equipment. While some areas do this it is not universal, and to do so would help monitor trends over time and the impact that changes in provision have on discards.

If research shows up high levels of equipment is discarded unused, it will highlight the need for changes in practice and policy to reduce this senseless waste. But in the meantime some measures can be taken to maximize the chances that equipment taken from exchanges is used, and not discarded unused:

•  Maximizing pick and mix distribution to ensure people can take as little equipment (or as much) as they want
•  Avoiding prepackaged equipment exclusively in large quantities
• Ensuring that local policing policy and practice does not discourage people carrying quantities of clean equipment
• Ensuring that policies in hostels and supported housing is supportive of injectors storing clean injecting equipment on site
•  Provision of suitable bags to carry injecting equipment discretely (such as backpacks) rather than pharmacy carrier bags
•  Provision for homeless injectors and those for whom carrying large quantities is impractical – including distribution of small quantities of equipment with suitable means of disposal.
•  Raising awareness amongst injectors of the cost of equipment distribution with a view to reducing avoidable waste.

dope hyper inflation

Just over a year ago, I wrote about the wide variance in the value ascribed to cannabis plants during court proceedings. In the article the range of cited values was from £150 - 800 a plant.

So a piece in the Sheffield Star caught my eye as it highlighted that the values ascribed to cannabis had increased massively - with a meagre haul of five plants valued at £9050 - a staggering value of more than £1800 being ascribed to each plant.
 
It's just as well that the values placed on cannabis aren't included in the RPI because we'd then see inflation heading towards the 10% mark in no time.

Publish Post

Is your Drugs Policy fit for purpose?

I've been doing a lot of work lately reviewing organisation drugs policies. Some of these have been big organisations, some small. But a clear issue to emerge is the difficulty organisations still seem to be having in writing their Drugs Policies and the accompanying procedures.
The problems seem to fall in to three main groups:

1: No policy: I remain astonished that so many organisations still don't have drugs policies at all. It's almost fifteen years now since the Wintercomfort trial which saw senior Day Centre staff in Cambridge prosecuted for offences under the Misuse of Drugs Act, and this case should have ensured that every organisation engaging with people who use controlled drugs would have a workable policy in place. But this isn't the case. And the worst offenders? Local Authorities! On numerous training sessions, the social housing providers and day centres tend to have a drugs policy, but the Local Authority staff don't. All too often, the explanation is that the Local Authority has a "zero tolerance" approach to drugs and this is meant to form the basis of the drugs policy. Which leads on to...

2: Unworkable policy: where policy is in place, all too often it is so keen to demonstrate its anti-drug credentials, that it introduces unworkable clauses that are wholly unrealistic. These policies, if implemented, would see Police being called out for any suspicion of drug activity, and empty buildings where transgressors had been evicted. In truth such policies are never adhered to, leaving a void of confusion where staff, managers and residents interpret their policies as they see fit.

3: Mismatched Policies: sometimes, the policy itself is fine - but is at odds with the organisation's stated aims. All too often an organisation which should be working in an accessible and flexible way with homeless drug users has a robsutly zero tolerance policy which drives drug use underground or sees people being evicted - the very people the organisation is seeking to house.

The problems organisations have with their drugs policies are going to be compounded at present by the financial climate and funding cuts. To provide safe, supportive housing in an average sized hostel with people with significant drug related need, higer staffing levels are essential. Realistically three members of staff should be on shift at all times - less than this makes it hard to manage a crisis safely. One member of staff to tend casualty, one to go and summon help and admit emergency services and one to ensure that the rest of the building and residents are safe. Less than this is an accident waiting to happen. And "less than this" will increasingly become the norm.

Low staffing levels are likely to be worsened by under-trained staff. As budgets are slashed,. so is staff training and so organisations are likely to reduce the amount and quality of staff training which leaves both staff and residents at risk.

This is all happening at a time where, as part of the BS (Big Society, but interpret as you see fit), we are likely to see more wholly-volunteer run provision for the growing homeless population - including drop-in provision and nightshelters. While such provision my represent a much-needed response in areas of high need and low provision it brings its own risks. The well-meaning, but undertrained and under-resourced provision can become unsafe. Again, it is imperative that such provisionhas suitable training and policy in place so that it can run both safely and lawfully. The spectre of Wintercomfort hangs over provision that fails to do so.

There is one more factor that may drive some organisations towards ill-considered and mismatched policies. This is the increasingly common elision of "recovery" and "abstinence" and the proposal in the new Government drug strategy that housing provision for drug users should, along with treatment providers, increasingly receive payment by results.

The need for suitable and stable housing, with appropriate support, represents a critical aspect of the recovery journey. A lack of housing, or the wrong housing can make it much harder for people to start and sustain the process of change. BUT, and it's a big but, refusing housing to people who are not yet abstinent, or returning people to homelessness when they lapse is not beneficial.

Let's be clear: there is a need for housing which is wholly drug free and has minimal tolerance to drugs. This housing is urgently needed for people who are in recovery and abstinent and are striving to remain so. In such cases a minimal tolerance drugs policy would be wholly in accordance with the organisations aims. But where the primary aim is to provide housing to people who are homeless, and who may also use drugs, such a policy is misplaced. Organisations can and should support and nurture and aspire to the prospect of change and as this happens move people in to appropriate housing. But to use the threat of eviction to stimulate the process of changed hasn't been demonstrated to work. It just drives use underground, increases overdoses and hampers honest dialogue regarding use.

Given all these challenges and problems besetting housing providers working with drug users, it seems an opportune moment for us to relaunch the Sample Drugs Policy - a document that was originally written after the Wintercomfort Trial and has been revised regularly since then. This version - the seventh - is substantially rewritten with a longer introduction about how to develop a drugs policy. There are some more extensive procedures and flowcharts to help understand how to implement policy.

This version of the Policy is unashamedly a "high tolerance" model, aimed at organisations working with ongoing users. It will shortly be joined by other models - a moderate tolerance, low tolerance, and minimal tolerance version for use in different settings.

The development of this version has been much assisted by Homeless Link, and by Stoke On Trent Supporting People, without whom this revision wouldn't have seen the light of day.

The Sample Drugs Policy 2011 can be downloaded here

Give me your tired, your poor, your huddled masses: just not in Westminster

Throughout mythology and folk tales, a tried and tested method for Gods and Kings to test the state of their kingdom was to don the rags of a beggar and walk the streets to see if the great and the good were indeed so great or good.

Were a latter-day deity or monarch to pitch up in Westminster, then far from hoping to get fed and tended, they may well in the future fall foul of a Council by-law which would make it an offence to give food to the hungry or for the tired or sick to lie down.

Similarly, if the sermon on the mount were relocated outside Westminster Cathedral, the redistribution of fishes and bread would be a fine on conviction.

It would be hard to miss the proposals from Westminster City Council to criminalise the distribution of food and lieing down or sleeping in an area of Westminster.

The Council's website describes this as a move "backed by Homeless Charities" and the text on the website focusses on the issue of Soup Runs, asserting that the soup runs turn the area "into a no-go area for many residents and businesses with issues around litter, urination, violence and disorder."

Few people would disagree that there has been a long-standing need to ensure that any agencies distributing free food are well co-ordinated and take responsibility for ensuring that mess is cleared up afterwards. This concern is nothing new and the same discussions were taking place back as far as the early 90s when Homeless Network attempted to provide some coordination amongst the soup-run providers.

But the proposals from Westminster Council go far beyond criminalising the distribution of food. They prohibit lieing down or sleeping in the public places covered by the order - making it an offence to "lie down or sleep in or on any public place."

If the legislation is passed - and at present it is only the subject of consultation - anyone distributing refreshment or lieing down in the designated area would comit an offence and could be fined.


When the Council asserts that this move is "backed by Homeless Charities" it is hard to find a queue of them supporting the measure. St Mungos for example fall far short of backing the measure and instead state that they do not support the proposed ban on rough sleeping.

The main cheerleader for the measure in the voluntary sector seems to be Thamesreach whose Chief Executive Jeremy Swain is quoted on the Westminster Council website as saying: 
"The Westminster cathedral piazza and surrounding area has been the focus for soup run activity and rough sleeping for many years and this has inevitably had a detrimental impact on the lives of people living and working in the immediate vicinity.
“It is reasonable that the council should seek to introduce a bye-law covering this specific area whilst at the same time continuing to commit resources towards ending rough sleeping in the borough."

It is not clear from this statement if Mr. Swain is endorsing both the criminalisation of soup runs and the further criminalisation of rough sleeping. So far he has not deigned to cover the issue in his Blog. In the Guardian he is quoted as defending the proposal, but with the caveat "This is not a borough-wide ban, which I would oppose." We look forward to Mr Swain joining the protests when such a borough-wide extension takes place as it surely will if this initial bye-law is passed.

Nor is it entirely clear how fining people who sleep rough helps anyone. Unable to pay fines, people will be required to beg more or face short prison sentences for unpaid fines - which will simply eat in to Police and court time and increase the isolation and stigma faced by people who are homeless or vulnerably housed.

But in truth there are others whose stated stance (or lack thereof)  in relation to this legislation is more craven. Of these the most notable must be Westminster Cathedral. The deafening silence from this quarter, other than to lament:
"Of those homeless people who congregate in the area, there is a minority of hard drinkers and drug takers who cause residents and visitors distress, which I have witnessed and been told about," a Westminster cathedral representative told the council. "During the day they can often be seen in groups of up to 15, and this can dramatically increase in the evenings with the soup runs."

Given such an abandonment of the poor and huddled masses of South Westminster, it is hard to read the Westminster Cathedral website without astonishment at the hypocrisy therein.

In the news section, Father Witon happily burbles: 
"CAFOD believes that all human beings have a right to dignity and respect, and that the world's resources are a gift to be shared equally by all men and women, whatever their race, nationality or religion”.
One of the saints said: “the best place to keep your money safe is in the stomachs of the poor”. It is in this spirit that we are all invited to be generous with those who can never say that they have too much on their plate ."

Clearly this sentiment doesn't extend to the poor of South Westminster.

This is perhaps where localism and the Big Society have their first head-on clash: the Big Society expects people to give their time and their energy to take on rolls which the state is increasingly unable or unwilling to fund - like care of the poor and the homeless. But on a local basis residents and businesses want to see action against the same poor and the homeless. And it seems that when it comes to South Westminster, localism trumps Big Society.

In truth the legislation as it currently stands is probably unworkable - and certainly would end up being enforced in a partial and selective manner. There are some exemptions proposed in the legislation: so for example sporting events would be exempt, which will be a relief to marathon runners. And while it will be an offence to give people who are starving food, it will remain acceptable to give out promotional nibbles to encourage people to eat in local premises. Heaven's forbid local businesses should be further inconvenienced! But in the event of a Police kettling operation, they wouldn't be able to give out water to people. And as an aside, the right to peaceful protest would be curtailed by this legislation as lieing down - as a form of protest for example - would be illegal under this legislation. 

But beyond these legal concerns and the attitudes of Jeremy Swain and The Westminster Cathedral there is a bigger issue here - and that is the ongoing and accelerated cleansing of the poor and homeless from the streets of the Capital. A process that has included the introduction of ASBOs, the hosing down of rough sleepers and sleeping spots by Council street cleaners, the deliberate under-counting strategies endorsed by the Rough Sleepers Unit and now culminating in a proposal to make such the act of sleeping rough an offence.

The idea that this will be restricted to one area of Westminster seems naive. Should this piece of legislation be successful, then a rapid extension across Westminster is inevitable. And then, in the run up to the Olympics, seeing am extension to other London Boroughs as the City is cleansed for the marketing jamboree of the Olympics. Westminster proposes, Boris disposes and streets cleared of "huddled masses" for a tourist-friendly Olympics.

Consultation on the proposed legislation closes on the 25th March 2011.

Bulletins from the front: deep cuts, unplanned cuts, malicious cuts?

Services being cut…the vulnerable becoming yet more vulnerable…..those who work in public services nervously eyeing the post for the ‘your job is at risk’ notification. Oh, and one public toilet in Manchester. We live in times of concern, worry and uncertainty – well, we do if we are concerned with the welfare of others.

But we knew this was coming; the swing away from investing in the population was going to come at some point (I still haven’t made my mind up if all that spending was ok, being as it came at the apparent cost of letting the City do whatever it pretty much fancied for over a decade). 

The decisions and beliefs lieing behind the reductions in public spending are surely more ideological than practical, despite the protestations to the contrary. I can live with that. Some of us have seen the swing from investment in the population, via increases in spend on hospitals, schools, housing – well, social housing services if not bricks and mortar – and the swing back to cuts, cuts, cuts. What does appall me is the subsequent response from the public sector itself. 

Working in the world of Supporting People I’ve seen the budget swell larger each year – until this year, with massive cuts apparently required, a series of reductions now have to be made. From the apparent top to bottom of the local government I can see in action the rationale behind what goes and what stays is  and, ….well, frankly, the playground can see more sophisticated decision making processes. 

We have a reduction in the number of staff in the team – but is this based on any kind of reasoned approach, a setting of priorities for the programme that needs a particular set of individuals with the right skills, expertise and knowledge to make the best use of limited resources? 

Guessing you know the answer to that. No, of course not. The whole element of measuring service quality, the staff that actually have contact with the people who use services and those who work every day in those services – looks like its going to be gone baby, gone. 

We’ll still be counting numbers though. We’ll be able to tell you how many,and where. Just not what’s actually going on for people, whether the service is actually making a difference or, worse, whether the service is safe or not. 

It just gets better. In my naïve reasonings (hah!), I had considered that a thoughtful and planned approach to cutting Housing Support Services would be adopted, with thought about which service for which individuals would have the most consequences if they were reduced – or, in many floating support services in our County, gone altogether. 

But again – no. Actually cuts are being made with no rationale and reason. Except that sometimes it seems to take the form of malice. A sense of old scores being settled prevails at times. And I am all too aware that any discussion about the people living in these services, those who are being supported in situations where there is no other support available – there is no thought for them, none that I have seen. I just see a ruthlessness by some to keep their own jobs intact, at any cost. This isn’t what I came in for.

Reporting in - News from the South West

I have maintained radio silence for the last couple of months watching how things unravel, but now it is time to break cover.

Between now and the end of February councils will be setting their budgets for next year and then we will have a much better idea of the fate in store for some of the most vulnerable members of our society.

It seems that unitary authorities are being as short sighted as the executive councils when it comes to removing the funding for a whole swathe of services which currently provide a safety net for those people with multiple vulnerabilities, none of which hit a threshold for a statutory service. Admittedly a lot of the statutory services are being cut too probably by setting the priority criteria even higher.

A colleague of mine who works for a district housing department bemoaned that it is as if this government have decided on a full on attack on housing;

The grant given to Housing Associations to build new social and affordable housing has been completely cut, but they are still supposed to deliver new housing stock, how? by taking out loans - but how will they repay the loan I hear you ask - through the rent they charge. "affordable" rent = 80% of the market rent, social rent can be whatever (interestingly, I saw a bedsit for rent from a housing association for £103. per week today how affordable is that!!).

The bottom line is with loans to repay the Housing Associations are going to take less risks on who they give a tenancy to; the young and upwardly mobile for "affordable" housing or those on 100% benefit (social housing).

Already the place of last resort social housing will become the sole residence for the sick, unemployable and the dispossessed with that social calamity of the sink estate making an unwelcome reappearance.

Changes to housing benefit will shut yet another escape route for those trying to dig themselves out of the poverty hole. Changes to the Local Housing Allowance will mean that those receiving Housing benefit will only be able to afford property with a market rent that falls in to the lowest 30% (so that will be all the crap accommodation then). but if you are under 35 and single then you will only qualify for the rent for a single room in a shared house.

All is not doom and gloom. If there is a will there is a way.

In the face of cuts to the Supporting People budget Exeter City Council are looking at innovative and cost effective ways to maintain some housing in the city for non priority homeless. The STAR scheme which has been running for 2 years can offer a temporary flat to someone rough sleeping giving them among other things a reference for a rent deposit scheme. This scheme uses part of the housing act which says a council can house someone without accepting a duty toward them, it counts as temporary accommodation so the council can claim top rate housing benefit and the excess is then used to buy in a bit of floating support. Any local authority could do this even if they don't own their housing stock.

I guess what I am trying to say is things are bad, the outlook for the year ahead is grim, but there are ways to keep on ensuring that there is some support available for those people who traditionally slip through the net and we have to keep trying.
The time for moaning is over, the time for action is now

Over and out.

Omissions, Contradictions, and Confusion: The 2010 Government Drug Strategy reviewed

“Gone are the days,” reads the introduction of the new drug strategy “when central Government tells communities and the public what to do.” (p2). Yet a mere seven pages later the Government does exactly that, saying “People should not start taking drugs and those who do should stop.” (p9).

Such contradictions are a recurring theme within the 2010 Government Drug Strategy. Given such contradictions and the serious omissions within the Strategy, it’s a shame that the Strategy received such an uncritical response from the drugs field. The sense of agencies keen in a time of austerity to make nice rather than challenging the Strategy was palpable.

Vanishing Harm Reduction:  In a Stalinesque linguistic purge, the terms “harm reduction,” “risk reduction” or “reducing harm” have been wholly expunged from the Strategy. I wonder to what extent this wanton abandonment of the term “harm reduction” is as much a rejection of the terminology of the previous drug strategies as an ideological rejection of harm reduction by the current Government. But whatever the rationale there is precious little space within the Strategy for pragmatic harm reduction with on-going users. The approaches are supply and demand reduction to prevent use, and abstinence-focussed treatment to end dependent use. But between these two poles there is a gaping void where effective harm reduction measures would have sat.

The sole reference to harm minimization is on page 29 where, in somewhat garbled terms the strategy says:
“We will achieve better outcomes for those entering treatment by:…continuing to promote harm minimization measures including needle exchange and drug-assisted treatments that encourage drug users to enter treatment, in order to reduce the risk of overdose for drug users and the risk of infection for the wider community…”

It’s not entirely clear from this wording if “drug assisted treatment” has now been demoted to an intervention “that encourages drug users to enter treatment” rather than being a treatment in its own right. But the overwhelming sense I get from the amount of space and time given to NSP in the document is that it is not considered a priority within the Strategy. The fear must be that this reduction in priority will give commissioners and fund-holders the green light to cut spending on this area to the bone.

Recreational users: Whilst this (limited) acknowledgement of the role of needle exchange is welcome, and the implied retention of overdose-prevention strategies is also welcome, this still leaves a substantial population with their needs wholly unmet: non-problematic, non-dependent users. This group, the largest proportion of people within the drug using population don’t seem to be effectively considered within the drug strategy – certainly not from a harm-reduction point of view.

The Government drugs information service “FRANK,” is presented in the strategy less as a way of making people “aware of the consequences of their actions” and as a way of providing “accurate and reliable information on the effects and harms of drugs…” Whilst it will be a welcome development of Frank succeeds in providing “accurate and reliable information” it seems likely that Frank will be required to become much more partisan – promoting behavior change and stressing risks much more than providing any harm reduction information in literature or on the phone.

This development is certainly in keeping with the expectations of the Centre for Social Justice who demanded reform of Frank saying that this was "imperative if we are to prevent young people from engaging in drug and alcohol abuse so we urgently call for wholesale reform of Talk To Frank and the messaging within it."  (ref)

With the Release drugs helpline facing closure, and Frank heading more firmly in a “drugs are dangerous, don’t do them” direction, it becomes harder to see where accurate, pragmatic harm reduction information for the vast majority of recreational users is going to come from.

Power of evidence – or just power? Given that the Conservatives now form part of the coalition Government, it’s interesting to see how the Government’s strategy on drugs has abandoned some of the measures that the Home Affairs Select Committee recommended in 2002. Back then, a more-radical, not-in-power-at-the-moment David Cameron advocated, with the committee, several things, including:

·         "We recommend that an evaluated pilot programme of safe injecting houses for heroin users is established without delay and that if...this is successful, the programme is extended across the country"

·         We recommend that a target is added to the National Strategy explicitly aimed at harm reduction and public health;

"·      We recommend that Section 8 of the Misuse of Drugs Act 1971 is amended to ensure that drugs agencies can conduct harm reduction work and provide safe injecting areas for users without fear of being prosecuted;" (ref)

It is a shame that none of these worthy interventions survived Cameron’s journey from opposition to Prime Minister and that have not featured in the new Strategy.

While these evidence-based interventions have not survived to see inclusion in the Strategy, some interventions which have no evidence base have been included. So for example the strategy exhorts a return to the days of ex-users going in to schools to do prevention work. It has been reframed as “Community Recovery Champions – people who are already in recovery…who will be encouraged to…contribute to prevention in communities and schools.” (p21)

This is a real retrograde step and one for which there is no evidence base of effectiveness.It is effectively a return to the old-days of ex-users telling young people "not to do what I did," but presupposes (I hope) that people in recovery will be slightly more subtle than some of the shock tactics that were used in the past. It was always a useful tool against those who were not going to use anyway, but short of simply rescreening "Better Off Dead" (which was the sum total of my own drugs education at school) the Strategy couldn't be much less use than those already using or inclined towards use.

Contradicted and Confused:

Behind the scenes, when the Strategy was being drafted, there must have been some serious horse-trading going on as various factions tried to get their perspectives incorporated. The Lib-Dems appear to have sacrificed any hope of liberalisation of the drug laws as the price of becoming “coalition prank monkey.” Certainly the Lib-Dem manifesto aim to “ensure that financial resources, and police and court time, are not wasted on the unnecessary prosecution and imprisonment of drug users and addicts” has vanished and instead the Strategy promises that this will be decided locally by Police and Crime Commissioners and that drug possession will appear on Crime Maps. “Drug dealing and drug possession,” the Strategy ominously (and ungrammatically) warns “is a crime.”

The other key area of tension that was played out behind the scenes was the turf war between Ian Duncan Smith who has had a longstanding interest in drugs and wanted to see the DWP take a leading role in drug strategy, and the Home Office with whom drug strategy has typically rested. Others lobbying hard to influence drug strategy was the Centre for Policy Studies the Conservative think-tank where Kathy Gyngell gave the Strategy the most luke-warm of receptions saying “Fair words about recovery are just not enough. Nor is hope of a ‘recovery contagion’ unless many, many more people are paid for to go into abstinence based therapeutic programmes like those run by The Providence Project and the Ley Community, unless methadone prescribing is capped.” (ref) 

The manifestation of these tensions is apparent within the strategy, and when the Drug Strategy is considered in context of the wider policy picture, these contradictions and confusion become all the more apparent and concerning.

Contradiction 1: “commitment to an evidence-based approach.”
Page 9 of the strategy affirms that the Government “values the work and the independent advice of the ACMD, which has experts from fields that include science, medicine, law enforcement and social policy. We are committed to both maintaining this expertise and ensuring the ACMD’s membership has the flexibility to respond to the accelerating pace of change.”

These are fine words, but the stated commitment rings hollow when considered alongside clause 150 of the Police Reform Bill (ref)  which would remove the obligation to maintain those representatives from medicine from the ACMD.

Contradiction 2: “vulnerable young people”
The strategy highlights that “vulnerable groups – such as those who are truanting or excluded from school” face increased risks in relation to drugs. Reducing school exclusion should therefore be a critical aim of any intervention to support vulnerable young people.

It will be interesting to see how the needs of vulnerable children and the need to reduce school exclusion sits alongside proposed powers discussed on Page 10 of the strategy to “tackle problem behaviour in schools, with wider powers of search and confiscation. We will make it easier for head teachers to take action against pupils who are found to be dealing in drugs…”

The proposed White Paper on Schools, The Importance of Teaching  proposes increasing the authority of Heads to exclude, but at the same time increasing their obligation to take responsibility for excluded pupils.

Contradiction 3: “rehabilitiation in a Payback Jacket.”

On the one hand, there is a clear desire stated within the strategy to use community interventions such as Drug Rehabilitation Requirements, to help move people away from dependency and offending. However, this desire is at odds with the Government’s desire to ensure that justice is seen to be done – and so the Strategy proposes “combining drug and alcohol requirements with other sentencing options, such as Community Payback, to make sentences more robust and ensure that punishment is visible to the community.”

Whilst some form of reparation and payback is clearly essential, the priority surely must be to address drug dependency first and foremost. And it is hard to see how a day of highly visible “community payback” in a fluorescent jacket will represent a contribution towards recovery capital.

Contradiction 4: “forensics”

As part of its response to ‘legal highs’ the Strategy says the Government will “improve the forensic analytical capability for new psychoactive substances and will establish an effective forensic early warning system.” (p15)

Such a system would be very welcome indeed – and would be better still if it would also provide early warning of contaminants in heroin and such like. Unfortunately, however, since the Drug Strategy was published, the BBC reported   that the UK Forensic Science Service would be wound up from 2012. It is not clear, therefore where a forensic early warning system of the type proposed in the Strategy would come from, and if indeed it can ever happen now. With Forensic analysis shifted to either cash-strapped police forces or private enterprises it is hard to see where the money for such a scheme would come from.

Contradiction 5: “housing need”

The recognition of housing need from page 22 of the Strategy is very welcome, and the report stresses  “the importance of providing accommodation for these people.”  The importance of Supporting People in this context is noted and the strategy mentions that the Programme will have £6.5  billion investment over the next four years.

What the strategy doesn’t mention is that this money represents a 11.5% reduction in SP money, is not drug-specific and is not ringfenced (ref). So in some areas of the UK we have already seen swingeing cuts to SP funding and provision with budget cuts of 40-50% being announced in some areas and entire services being culled. So the proposal in the strategy and the reality on the ground are substantially at odds.

The Great Unresolved Issue:
At the heart of the Strategy is a commitment to “recovery.” The strategy title includes “building recovery.” But within the addiction field the term “recovery” is argued over and defined in various ways, so within the Strategy too the term “recovery” is subjected to various interpretations and indeed it is hard to find two consecutive sentences where “recovery” has the same meaning in both.

A clue to the Government’s interpretation of “recovery” is the subtitle to the strategy – “supporting people to live a drug free life.” So here the aim of recovery is equated with abstinence.

But the Strategy seems unwilling to commit to this interpretation. On page 18 of the Strategy the ambition is for “individuals to leave treatment free of their drug or alcohol dependence so they can recover fully.” This would mean that the result of treatment is an end to dependence, but not necessarily abstinent. And “recover fully?” Well in the next paragraph this is expanded on with the words “into full recovery and off drugs and alcohol for good. It is only through this permanent change that individuals will cease offending, stop harming themselves and their communities and successfully contribute to society.” [emphasis added].

So within this interpretation, full abstinence is the only solution. Not managed use, controlled use, or substitution. Ironically this interpretation of “recovery” is at odds with many recovery advocates who would argue that abstinence alone does not equate – or even lead to full recovery and the sense of personal and spiritual wholeness is an essential component of true recovery, not mere abstinence.

 In the next paragraph, the Strategy offers a different interpretation: “wellbeing, citizenship and freedom from dependence.” So abstinence is not essential here. And a sentence later the definition has shifted again: “it is an individual, person-centred journey, as opposed to an end state, and one that will mean different things to different people.”

So in the space of six lines the Strategy has veered from a position that expounded that the only outcome should be “off drugs and alcohol for good,” and moved to a “person centred journey as opposed to an end state.”

A couple of sentences later the Strategy changes course again and defines an end-state saying “our ultimate goal is to to enable individuals to become free from their dependence.” All crystal clear then except that, a sentence later the ground has shifted again. “Supporting people to live a drug-free life is at the heart of our recovery ambition.”

Such confusion and ambiguity at the heart of the drug strategy should be a cause of huge concern. As we move towards payment by results, the interpretation of a successful result becomes more and more important. Is the successful result complete abstinence? Or is it an end to dependency? These are not the same and, if the past is anything to go by, can become the source of huge controversy.

Certainly in her ongoing battle against the NTA, Deirdre Boyd of Addiction Today has repeatedly argued for abstinence as a core feature of recovery and so is unlikely to settle for less as a “success” for the new strategy.

Recovered enough to work?           The definition applied to “recovery” is not, however, merely of ideological importance or for providers who will be paid by results.

It is also critically important in terms of eligibility to benefits and readiness for work. So, for example, on page 23 of the strategy, the document says “we will offer claimants who are dependent on drugs or alcohol a choice between rigorous enforcement of the normal conditions and sanctions where they are not engaged in structured recovery activity, or building appropriately tailored conditionality for those that are.” [emphasis added]

There are two phrases here to which are hard to decipher. “Structured recovery activity” is a loaded phrase. It hinges in part on what interpretation is being applied to “recovery.” And the idea of “structured activity” begs the question “what activity?” and “whose structure?” It suggests that someone who is starting to engage in recovery-oriented interventions (such as, for example, starting to attend a self-help group on a sporadic basis) would not be involved in “structured recovery activity” and so would be subject to “rigorous enforcement of normal…sanctions.” But if the definition of “recovery” is not defined, then how can job centre staff be clear if a claimant is involved in “structured activity?” Elsewhere it is accepted that substitute prescribing is both an aspect of recovery and structured. So would this measure mean that someone was engaged in “structured recovery activity?” Given that on such questions a person’s receipt of benefit and in turn things like housing may hinge, it is a critical question.

It seems inevitably that, without very explicit clarification for job-centre staff here, claimants will be exposed to local and arbitrary interpretation of what level of compliance is required – meaning that people engaged in the “wrong” kind of recovery, or taking too long to recover in the “right” way will be removed from the benefit system.

Challenge Now!

So that’s our muddled, contradictory, drugs strategy. Maybe it’s no bad thing. Maybe the fact that it is in a state of flux – even though it has now been published – means that it is more malleable and can be more easily challenged, refined, adjusted and improved. Because at the moment it is contradictory, muddled and confused. It is more of an optimistic wish list – where the Government wished to get to, rather than a map of how to get there. But it will require a great deal more critical analysis rather than the warm words of endorsement from the field if the Strategy is to resolve the issues that are currently unresolved.