10 December 2012

From Pay Day loans to the Pot-Trap

How poverty and pay-day loans are driving people to the cannabis cultivators.
As austerity bites, bills soar and Christmas hoves in to view, the legitimised high street “loan-sharks” – the pay-day loan companies, are minting it. But as CABs around the country will attest, more and more people are struggling to meet repayments or astronomic interest rates. People already in debt face losing more and more under a burden of crippling debt.Outside the same CABs, an offer of salvation is at hand - Cannabis cultivation.
As Police enforcement activity against large cannabis farms has become more and more effective, some cannabis cultivators have adopted a different strategy: instead of growing 500 plants in one house, why not grow 50 plants across ten houses? That way, it’s less likely that you lose the entire crop, and it requires ten times as much police research, ten warrants and ten raids. All of this needs to be executed in the limited germination-to-harvest time-frame.

Whereas previously, growers would have rented properties themselves for larger grow-houses and installed their own gardener, with smaller growing set-ups, there’s no need to rent a whole property. It’s easier to find someone who has a spare room and install the plants in there. For a while, people wanting a bit of extra money provided much of this space. But, of late reports from a number colleagues highlight that it is people falling deeper and deeper in to debt are being approached by growers. The offer is typically to have debts cleared in return for growing space. Significantly, some workers suggest that those in debt are being targeted with these offers; a colleague in the Midlands said that he knew of people being approached in the queue outside the CAB being approached with a view to housing a grow-room.

From the growers’ point of view, it’s a minimal risk, maximum return situation. They may get grow space for little outlay. The person who lives in the property, afraid of repercussions, is unlikely to share information with the Police. If there is enforcement action, the grower is insulated from risk of prosecution. The Occupier ends up running the risks, for minimum, if any reward.

For the people caught in this position, the situation is dire. On the one side, there is escalating interest if pay-day loans go unpaid. This could result in court action or loss of housing due to mounting debt. On the other hand, there is the risk of criminal proceedings and possible custodial sentences for cultivation of cannabis. If this wasn’t bad enough, there is the additional risk of reporting the growers or failing to cooperate in delivering the harvest.

Another worker working with a woman in this situation described her client’s intense fear as the plants grew bigger that someone would discover her harvest. But stuck in a triangle of debt, fear of police and fear of growers she felt utterly trapped and couldn’t see a resolution. Her only hope, as she saw it, was to get to harvest time, clear her debts and start over.

It seems likely that as more people are forced deeper in to debt and end up taking out loans that they can’t repay, there will be a growing pool of desperate people for the cannabis cultivators to draw on. For those facing this situation or already trapped in this position we need some responses. These could include:·        

  • Education and awareness raising within debt-advice services to highlight the perils of being drawn in to cannabis cultivation as a solution to unmanageable debt
  • A police amnesty so those who have been drawn in to allowing cannabis cultivation can get out of the situation without criminalisation and with regard for personal safety;  
  • Housing providers taking a supportive view of people coerced in to such cultivation so enforcement action doesn’t result in homelessness.

 At this stage it is hard to know the extent of debt is driving people to be unwilling hosts for cannabis growers. But anecdotal evidence says it is on the increase. It is important that those stuck in this situation are recognised not as villains but as victims.

17 October 2012

Anabolic Steroid Users, Needle Exchange and the Peril of Publicity

There have been a fair few media stories over the past few years about the increase in Needle Exchange usage by people using Performance Enhancing Drugs – especially anabolic androgenic steroids.
A classic of the genre is this one from the BBC: http://www.bbc.co.uk/news/uk-england-bristol-19650743. In truth through, the stories are highly interchangeable – usually some statistics about increased usage from a Needle Exchange, comments from drugs workers and experts, and some comment from a user about their use.

Inaccuracies and sensationalist reporting aside, the ongoing news stories originating from Needle Exchanges about steroid use is something or a double-edged sword.

On the one hand, needle exchanges and drug projects need to ensure that they retain the funds and resources that allow them to continue. As the welcome downward trend in heroin injecting continues, it is essential that funders and commissioners are aware that other populations need access to needle exchange. And so identifying and publicising the level of service usage – and the level of need is essential.

Indeed, some services, researchers, harm reduction advocates and academics are clearly of the mind that highlighting the level of use is one of the key tools for securing the funds required to develop and expand services to steroid users. Such expansion could include better specialist services – highly trained staff, opportunities to have blood analysis undertaken and better health care. To secure such funding, demonstrating a level of need is essential.
In order to do this, agencies need to record drug of choice. It also helps to identify and respond to trends, and also so that they can ensure staff are trained and resources. The agency needs the profile of their clients, funders demand it and resources hinge on it.

People who use Anabolic Androgenic Steroids often view the situation differently. They are acutely conscious that their drugs of choice occupy an unusual position within the Misuse of Drugs Act 1971. The drugs are currently legal to possess, even if not prescribed, putting them in a privileged position compared to most other Controlled Drugs. There have been changes to this in the past year – introducing a requirement to be in personal possession at the point of importation, but the removal or a requirement for the drugs to be “in medical form” to be lawful. These changes make it theoretically harder to purchase and import high quality “licensed” products on-line, whilst making the possession of counterfeit or underground products now wholly lawful.

As such some people using steroids think that they have a vested interest in keeping steroids “off the radar” and trying to reduce the extent to which it comes to wider public attention and certainly off the agenda of legislators. Even the argument that better evidence of need could result in better service provision cuts little ice here. Whilst we don’t know the exact figure, a fair proportion of people injecting steroids elect to purchase their elected equipment on-line rather than using needle exchanges. For some this is merely practical: not all needle exchanges give out the range or quantity of equipment that some users want. Others just don’t want to be seen using needle exchanges. A few argue that if they can afford it they should buy it rather than using a free service they view as being in greater need. But of the needle-exchange refuseniks, a fair few are making a very deliberate decision not to use needle exchanges to avoid contributing to statistics which could reveal the nature and extent of steroid use.

One of the recurring responses, from moderators on a leading UK body-building website makes the case thus:
Steroid users should never, EVER use an exchange.
Steroids are class C atm. They govt are always looking for the next "vote winner". Let's re-classify steroids to 'save the children' will be the call. How will they manipulate this change? From spurious data and figures that would be used to drive home a message to joe public that "the UK has a massive steroid problem". Look how many users there are compared to year xxxx etc etc. The more people using exchanges, the more convincing their argument, even when you and I both know relatively speaking it is no-where near problematic proportions.
As such, needle exchange discussion is not encouraged on [this bulletin board.]
Judging by the various threads and discussions this view is on the increase with more and more people electing to use on-line suppliers rather than needle exchanges.
In an (admittedly) small on-line poll less than one in four people using injectables said that they used pharmacy exchange all the time. A staggering 63% voted “I never have, and never will use an exchange.”

Given the track record of Government on drug prohibition, I can’t help feeling that some of the concerns of those who caution against needle exchange are well founded. One would hope that a rational Government would recognise that criminalising and driving a group underground would be counter productive. So far, in no small part due to careful presentation of evidence by leading lights in the UK, the ACMD has shied away from rescheduling steroids and the Government, despite the obvious temptation of the Olympics, has not seen an urgent need to do so. But against an ongoing drip-drip-drip of negative steroid media stories, I wonder how long until the status of steroids is renewed again.

Why, some will ask, does it matter if steroid injectors don’t use needle exchange? If this population can afford and are willing to purchase their own equipment, why should agencies be at all concerned?

Some workers (and indeed some commissioners) have endorsed this approach, saying that needle exchange isn’t really “for” steroid users and as such if they can afford their own equipment they should really buy it not use Needle Exchange.

Personally I have no truck with this analysis. I don’t remember a similar argument for means testing needle exchange being made for other drugs. Needle exchange is intended to be available to all who inject non-medical drugs, because of the public health need of such a service, irrespective of ability pay.

We want people to use services because that way we can ensure people get advice about injecting technique, access to advice, woundcare, BBV testing and vaccinations. Certainly many steroid injectors have a good understanding of what they are taking and how to use it. Others don’t and they need access to this information.

Not all steroid users are sourcing equipment on line; almost a quarter, for whatever reasons, needle exchange represents an essential source of equipment.

So here’s the catch 22.

In order to demonstrate need and to attract funding to provide great services agencies need steroid injectors to attend. But those same injectors are concerned about attending and being counted because, rather than seeing this resulting in better services, they fear that the aggregated statistics will be used to justify criminalising steroid use.

Agencies don’t help their case by stressing the confidential nature of their service and then ending up all over the front pages of the local press, highlighting how much steroid use has increased. If there were ever a way of reinforcing the fear that use of needle exchange puts steroids more firmly in the public eye and increases risk of prohibition, this is surely it.

So what’s the solution? In the short term, needle exchanges and other commentators need to think carefully about the pros and cons of highlighting increases in steroid use to the media. Not, I should stress, because this directly impacts on UK policy, but because the same steroid users who read the papers today are the ones who, tomorrow may be disinclined to use needle exchange.

More fundamentally, it highlights the importance of drugs policy being independent of political ideology. If users feel that they can’t trust how statistical data is being used, and they can’t believe in an evidence-based drugs policy it’s hardly surprising that they will seek to keep their use “off-radar.” Rather than viewing wider recognition of use as a way of garnering resources and better services, it is viewed with great fear.

People using anabolic androgenic steroids and discussing this issue on forums are deeply suspicious of the use of statistics and research by needle exchanges and how it impacts on the media and wider policy. Agencies need to recognise and respond to this suspicion and work to undo the damage.

23 April 2012

Changes to Steroid Legislation - swings and roundabouts

Changes come in to force today which affect steroids and other performance enhancing drugs and ancillary compounds.

The key changes are:
  • to remove the requirement that drugs are in a "medicinal form" making possession of non-pharma products lawful and 
  • to introduce a requirement of personal custody at time of importation, making purchasing on line unlawful.
 The changes which affect drugs in Schedule 4ii of the Misuse of Drugs Regulations can be found here: http://www.legislation.gov.uk/uksi/2012/973/contents/made and a more helpful Explanatory Note here: http://www.legislation.gov.uk/uksi/2012/973/pdfs/uksiem_20120973_en.pdf
The Explanatory Note explains:

Amendments relating to Schedule 4
7.7 At present the provisions specified in regulation 4(2) of the 2001 Regulations (the prohibition on importation and exportation of controlled drugs) are disapplied in relation to drugs listed in Part II of Schedule 4 to the 2001 Regulations in respect of the prohibition on importation and exportation when imported or exported “by any person for administration to himself” and when contained in a medicinal product.

7.8 The instrument will make clear that regulation 4(2) of the 2001 Regulations is limited to importation and exportation of drugs listed in Part II of Schedule 4 when carried out in person by the same person who then administers such drugs to himself. The instrument also removes the term “medicinal product” from the 2001 Regulations (including by omitting the definition of such term contained in regulation 2(1)) with the effect that the term “medicinal product” no longer applies to provisions under the 2001 Regulations in general.

The change made to remove the requirement for the products to be a "medicinal product" represent an interesting shift. The rationale for doing so when the ACMD advised the Government to remove this wording was that  
"The ACMD do not believe the term ‘medicinal product’ assists in the enforcement or legal framework for anabolic steroids under the Misuse of Drugs Act 1971. The ACMD consider that the term ‘medicinal product’ should be removed from the legislation as the term does not serve a recognised purpose"


This was clearly not a view shared by the Crown Prosecution Service or, for that matter the Court of Appeal who in R. v Foster upheld the conviction of Foster who was found to be in possession of Stanozolol in a non-pharmaceutical form (capsules branded "No Bull".) The case summary is here

Foster's case, and the later prosecution of Graham McAdams  whose guilty plea was largely influenced by the precedent set by Foster, seemed to indicate a willingness on the part of the CPS for possession of non-pharmaceutical steroids.

These two cases made it more likely that any compounds produced by Underground Labs (UG) would be held to be prohibited under UK law.

 The decision to remove the term "Medicinal" from the legislation means that henceforth, possession of UG lab-produced steroids will not be an offence in the UK if this possession is for personal use. This is a mixed blessing. On the one hand it means that prosecutions arising from legislative confusion such as Foster and McAdams should be a thing of the past. However, as such cases were rare, this has no huge implications.

More importantly, it means that there is no legal disincentive to possessing UG labs drugs, which may not be produced to the same standards as pharmaceutical products. The worry therefore is that this legislative change will increase the popularity of UG compounds, despite the increased risk.

The other key legislative change is to introduce a requirement that importation of Schedule 4ii drugs be undertaken by the person using the compound. Effectively this means that the user needs to have the drugs in their personal custody at the time of importation. This in theory makes it unlawful to import by post and restricts people being able to buy compounds on-line.

It will probably result in an increase in seizures of drugs being imported in to the UK, especially in bulk. But I suspect in terms of individuals ordering on line, the impact may not be so profound, especially where postage is taking place within the EU. Small quantities of packaged steroids, with a low odour, are not going to be massively easy to detect and so the quantity that slip through are likely to be significant. Those that are seized will be destroyed but it is unlikely to result in an upsurge in prosecutions for unlawful importation.

The bigger risk that concerns some commentators in the field, is that it will result in an increase in UK-based manufacture to avoid the issue of importation. This would mean more labs being set up in the UK either making steroids from scratch or packaging imported powder testosterone.

Only time will tell if these fears are well founded or not. But it is certainly a cause for concern that the legislative changes could see an increase in UG lab drugs whilst at the same time depenalising the use of such compounds.

Advocates of the legislation will probably argue that the previous legislative wording had resulted in a proliferation of steroid availability in the UK. However, with no effective research in to the current levels of steroid use in the UK, the incidence of complications arising from steroid use, and the current ratio of UG to Pharma products used, it will be well nigh impossible to demonstrate if the legislative changes have had a benign impact or not.

21 March 2012

drugs and radicalism: it was ever thus (part one)

The Occupy movement in London was the subject of significant negative publicity which related to drugs. While some of the allegations made were undoubtedly made by those with a vested interest in denigrating protesters http://www.guardian.co.uk/uk/2011/nov/21/occupy-london-camp-eviction-bid other, first-hand information confirms, to my satisfaction at least, that drug and alcohol problems were an issue amongst some of the people staying at the protest site.

This is not a new development. It's an old, old problem. It's probably a century old problem, but it's certainly one that has dogged radical politics in the past half century. And it's one that we have yet to engage with successfully. The creation of autonmous spaces - or what Hakim Bey termed Temporary Autonmous Zones - can be a time of positivity and constructive change. But the energy and creation of temporary autonomous space has, all too often, been negated by the arrival of significant drug problems, including problematic alcohol use.

This has been a very obvious issue for several decades. The issue for Occupy London is only the most recent manifestation of the same problem that dogged road protest sites, especially the M11 campaign, land-squats such as Pure Genius and squatted venues such as Kentish Town's "Rainbow Centre."

Here's the problem: create autonmous safe space outside society's normal rules, and a collection of people arrive to fill that space. Included in this rich mix are those for whom society's strictures are problematic, including those with prodigious levels of substance use. the TAZ may represent a safe space, free of judgement. It may also represent a place where there may be food, tolerance and opportunities to use a lot.

The presence of problematic substance use in TAZs is a problem, and one that has never been adequately resolved. As a manifestation of radical politics, those within the TAZ seldom want to involve forces of law and order to address their problem. But the issue left unaddressed almost invariably causes problems for the TAZ. At its most prosaic, it may be the draining of energy, where time and effort that should have been spent on radical action is instead spent trying to resolve internal problems. The tensions between the activists and the "lunch outs" at protest sites like the M11 were the stuff of legend and highlight the energy wasted over these issues.

The ability of substance use to undermine radical movements isn't limited to TAZs. We could look to at the way that amphetamine and barbiturates chewed through punk, or alcohol and smack through the 'new age' Traveller movement. We could probably look further back - wine and hashish during the Paris Communes, psychedelics during the Summer of Love? At each stage the fine edge between liberation and creativity in acts of rebellion grates uneasily against the way that radical movements are undermined and ultimately sunk by their proclivity for substances.

Those involved in TAZs have yet to develop a credible response. There is an understandable unwillingness to involve the Police. This is perfectly reasonable given that any embryonic radical movement needs to develop its own responses independent of the powers of the system Individuals may try and refer the person to support and treatment agencies but these often meet with limited success. The day centres and treatment agencies can offer some interventions but don't mean that they can resolve an issue rapidly or even successfully.

So what is the TAZ left with? Threats? Exclusion? Demanding the person leaves the site? Is all we are left with hand wringing on the one hand, or the time-honoured vigilante response of the boot and fist to that we cannot incorporate? All these things sit uncomfortably with the politics and morality of a Zone that declares itself outside the normal rules of the system. But the alternative - to accommodate and tolerate - doesn't always seem feasible.

This is a problem that those with an interest in radical politics have to engage with and resolve. A cohesive, practical and workable set of responses to problematic drug use are essential for a radical movement which seeks to carve out autonomous space. Do we tolerate? Treat? Or do we replicate the same responses that the state has followed - to exclude and criminalise.

I wish I had an answer to this. One solution - the utopian one - is that on the other side of the TAZ is a place where such problems just cease to be. This is an issue I want to come back to in a later blog. But on the journey to these sunny uplands, we still need to make the TAZ workable whilst addressing problematic substance use. And we haven't yet.

04 February 2012

Whose Duty - What Duty: Overdose, Naloxone and Acts of Omission

A recent piece I penned for DDN's "Soapbox" Column provoked a stream of angry responses. Some of these appeared in DDN's letter page the following issue.A few wrote to me directly. A few tweeted about it. I wrote to each of the respondents because I wanted to expand on the issue of acts of ommission and duty of care. This blog piece takes the gist of what I wrote and expands on it. As it draws on case law from the UK it is of limited relevance to other countries.

Let me be clear – I don’t think that a much-expanded use of naloxone per-se and an massive increase in take-home Naloxone is a bad idea. Quite the opposite. It has, can and will save lives. I also believe in the distribution of foil, crack-pipes, Water for Injection and the opening of Supervised Consumption Facilities. Each bring with them legal and ethical issues which need to be carefully explored. 

In the case of Naloxone, some of these could be concerned with the administering of Naloxone. But my concerns are not primarily to do with the administering of naloxone which I recognize is a very safe activity and when done properly, within the framework within which people are trained should not create significant problems.
So when one advocate of Naloxone states “the law protects those who administer naloxone from prosecution,” I largely agree - though would add that there could still be scope for litigation if an aspect of the administration were negligent. Others may disagree with this. It would be for a court to decide as there isn't a clear precedent for this. Where I think my views diverge is when the same advocate makes the assertion “it doesn’t punish those who fail to administer it.

I think this is an area that warrants further discussion and exploration, not least because of the case of sad and troubling cases of Evans and Townsend which I think has significant implications here. 
The cases of Evans and Townsend are deeply unfortunate.

The case dates back to the death in 2007 of Carly Townsend, in Wales, from a heroin overdose. Her mother, Andrea Townsend, and her half-sister Gemma Evans, were prosecuted, convicted and imprisoned for manslaughter on the grounds of gross negligence. Evans and Townsend is an important case because it potentially expands and certainly reinforces the concept of duty of care, especially  in overdose cases, what could constitute negligence.

Carly had taken heroin which her sister and been instrumental in procurring. In court it was reported that "[Townsend] said she was frightened after Carly's lips turned blue but this only lasted for seconds so she and Evans placed Carly on a bed and she "listened to her snoring from downstairs where she watched television.
She said repeatedly she thought her daughter would "sleep it off".

Although neither party had specific overdose training, they had placed the victim, Carly, in the recovery position but, critically had failed to call an ambulance. A duty of care was held to exist for both parties for differing reasons – for Townsend (the mother), a familial duty of care existed and for Evans (step-sister), because she had been involved in the supply – although not charged or convicted with supply of the drugs herself.  

I think this is a significant point. We accept and recognize the duty of care that can be applied to professionals, it also applies to familial duty of care, and based on Evans, it applies where there is some involvement in the supply (and by extension the administration.)

At the risk of speculating (which seems to be frowned on by some parties) the older case of Stone and Dobinson (1977) has a bearing here too, because it established that “a duty exists where a person assumes a responsibility for another…” I don't want to follow this line of reasoning too far - Stone and Dobinson is quite an old case and probably should not be relied upon. The idea that a duty of care can exist for bystanders who try to render help has not been supported elsewhere and so such an extension is probably not that useful.

Having accepted the duty of care owed by professionals, some family members, and those involved in the supply and administration to my mind it doesn’t seem to me unreasonable that a person, familial or otherwise, who has taken on the role of a “carer” (in the context of undertaking THN training with a view to administering to an opiate user) could be considered to have a duty of care in law. This would seem a logical extension of Stone and Dobinson, creating a category above that of mere bystander but withouth the established roles of professional or family members.

Based on this, the next question is this: could a failure to administer naloxone or the failure to call an ambulance after giving naloxone be considered a gross breach of duty of care if the person died of an overdose? Assume firstly that the person (professional or otherwise) has been trained, and that they are in a potential overdose situation. Naloxone is available. For whatever reason the person fails to administer naloxone. Why? Uncertainty, intoxication, fear, dissuaded by another. I don't know. It's a hypothetical. But anyway they don't administer and the person dies.

Based on existing case-law if we take naloxone out of the equation, and we simply leave it with the issue of calling an ambulance or not, then the failure to call an ambulance by a person held to have a duty of care, which resulted in the death of an overdose casualty has been held to be manslaughter on grounds of gross negligence. This is the legacy of Evans and Townsend.

By extension if a person with a duty of care administered naloxone but then failed to call an ambulance and the casualty then died, I can't see a reason why the same wouldn't apply. 

The remaining question relates then to the failure to administer naloxone.

So far, based on everything I have read and every analysis and discussion I have seen, the discussion has hinged on the risks and ethics of administering rather than not doing so.As I have said already, I have few concerns relating to administering, although I would still prefer to see a “good Samaritan-type law” to put the issue firmly beyond doubt.

My issue, and the one that stems from Evans and Townsend is the failure to administer and, so far, I am not satisfied that this has been adequately considered. While I acknowledge that legal action stemming from a failure to administer naloxone or  a failure to call an ambulance post-naloxone which resulted in fatality  is unlikely, I am not aware of any ruling, guidance or even a legal opinion which says it can’t happen. Based on current caselaw I think it can. So on that basis I don’t know that the statement “[the law] doesn’t punish those who fail to administer it…” has been demonstrated to be true.

In most settings this isn't a huge issue. It shouldn't preclude roll out of THN especially to family and friends of opiate users. It is simply to highlight that the very process of recruiting and training users, their families and peers to administer THN is a potential double edged sword albeit one with one side larger than the other. 

On the one hand it massively reduces the chances of a fatality – which is overwhelmingly important. But by virtue of the process of taking on a caring role and attending training, the extent to which a duty of care can be said to exist increases, and as such the resultant implications of any omissions – the failure to call and ambulance (or potentially the failure to administer naloxone) go up. It doesn’t mean it shouldn’t go ahead. It means for me that the legal issue should ideally be resolved or at the least those undertaking such a role being made aware of the risks of failing to act, in addition to risk of death.
All these issues take me full circle back to an area of concern which related to hostels, an area that has been of overwhelming interest to me for over ten years. In the small number of hostels that work from an “eyes wide open” basis and actively manage use on site, drug related fatalities have been reduced to zero (including in high-risk, heavy using populations). This has been as a result of careful assessment, trained staff, sensible policies and such factors. This has been a significant success.
My concern (and I recognize that it is a hypothetical) is the issue of Duty of Care (post Evans) is again important. Based on everything I have said so far, I think it is possible for a trained member of hostel staff to be prosecuted under criminal law (or sued by a victim’s estate) for a failure to call emergency services. I doubt you would disagree with this. By extension, if at some point hostels start to hold naloxone and receive training on its use, would a failure to use naloxone be a similar breach of duty? I think they would, hence the need for hostel staff to err on the side of caution and administer “to be on the safe side.” If a hostel is “over-zealous” does this mean people would go and use elsewhere? Maybe. I accept that this hasn’t happened yet – but then in the UK naloxone hasn’t been expanded in to hostel settings on the whole. When it does I hope that the issue is monitored very closely. I am aware that these same issue are now being explored very closely in terms of Police carrying and using naloxone. It will be interesting to see how these discussions resolve.
For a detailed analysis of Evans and Townsend, see the following