10 January 2011

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.


educari said...

Kevin, as usual your clear-sighted analysis cuts through the obfuscation, and raises both theoretical and practical questions that go to the heart of the contradictions in the Strategy.

The Pseudo-Impostor said...

You hit the nail on the head. Just like most other abstentionist nonsense, the new drug 'strategy' flip-flops like a stranded fish between preventing/curing 'drug dependence' and making people 'drug free'. So there is a long-term plan to stop people using any alcohol? Not when there is so much money to be made from selling and taxing our favourite and most dangerous drug. It's double-talk and utter hypocrisy as usual.
As for FRANK, this source of government propaganda about drugs has always been a bad joke to anyone who knows anything about drugs. Try contacting them and asking how you can use a drug more safely - makes you laugh more than cannabis.