59.4% United States  United States
8.7% United Kingdom  United Kingdom
5% Canada  Canada
4% Australia  Australia
3.5% Philippines  Philippines
2.6% Netherlands  Netherlands
2.4% India  India
1.6% Germany  Germany
1% France  France
0.7% Poland  Poland

Today: 240
Yesterday: 251
This Week: 240
Last Week: 2221
This Month: 4828
Last Month: 6796
Total: 129427
PDF Print Email
User Rating: / 0
PoorBest 
Addiction, Treatment
Written by Jacob Veale   
Wednesday, 22 June 1994 00:00

1994 VOL 5 NO 2 Copyright© IJDP Ltd.

HARM REDUCTION AND THE COMMUNITY

With the limited exception of HIV/ AIDS prevention, harm minimisation in the UK has focused on the harm that drug users may do to themselves. Jacob Veale examines how harm minimisation within Hammersmith and Fulham (part of inner London) has now begun to address wider issues.

INTRODUCTION

Hammersmith and Fulham Drugs and Crime Forum (the Forum) is a coalition of agencies from one area of London. The forum includes the Metropolitan Police, the Inner London Probation Service, Riverside Substance Misuse Service, the London Borough of Hammersmith and Fulham, the Family Health Services Authority, and Hammersmith and Fulham based voluntary sector drugs agencies. Appendix I shows the Terms of Reference of the Forum.

Its aim is the minimisation of drug-related harm. It focuses primarily on the harm that widespread drug use can do to the wider drug-free community. However, it does not disregard the needs of drug users them selves. Indeed, the Forum believes that the policies and practices that protect the wider community from drug related harm also protect drug users themselves from harm. The main drugs responsible for this wider harm in this area of London are opiates, cocaine and crack, amphetamines and benzodiazepines. Their use causes high levels of acquisitive or property crime (such as shoplifting, credit card and cheque fraud or burglary), rapid transmission to the drug free community of HIV infection, and a vicious circle of drug taking and trading that rapidly spreads drug taking to new users.

HAMMERSMITH AND FULHAM

Hammersmith and Fulham is a small, inner London Borough. It lies at the edge of London's 'West End' the capital's centre for theatre, the arts and night life. The population is 152 000. Just over half are between the ages of 15 and 44 years, and around 18% are members of various ethnic minority communities. Male unemployment was 15.4% in 1991 (Borough Profile, LBH&F, 1990), and is now considerably higher. It has the highest level of HIV infection of any local authority area in the UK. According to the Local Authority's Social Services Department, over 1% of all men between the ages of 18 and 54 years are known to be HIV positive, and of course the true proportion will be considerably higher ( 1992 ). The Forum estimates that there are between 2000 and 4000 injecting drug users resident in the area, and that between 5% and 14% (or from a minimum of 100 to a maximum of 560) of these are HIV positive.

Crime levels in Hammersmith and Fulham are typical of inner London. The most reliable local research findings on crime show that slightly over 50% of all households experience at least one serious crime each year, with 17% experiencing multiple victimisation (Painter et al.,1988). About 9000 people, or 6% of the population, experience street robbery each year, and about 8850 dwellings, or 12% of the total, are burgled (Painter et al., 1988). Police in Hammersmith and Fulham estimate that between 30% and 70% of all acquisitive crime in the area is committed by drug users seeking to finance drug purchases. Male and female prostitution are both present, and drug dealing at both retail and wholesale levels is widespread. People are known to come to the area from outside to buy or sell drugs.

THENATIONAL SCENE

This article will not provide a detailed history of the national picture with regard to drugs here. However, there are three very broad points that should be made (although in some respects these do not exactly reflect the picture in Hammersmith and Fulham). First, in the period since the late 1960s prescribing services have tended to be minimalist. They have generally offered rapid methadone detoxification for opiate users, some support to recently stopped users, and very little else. As a result, and predictably, they have only attracted two groups of users. Those who genuinely want to stop using drugs, and those who access the services to tide them over a difficult period, but have no genuine desire to stop using.

Secondly, we have relied almost exclusively on enforcement to control the illicit drug scene. Police and customs services have committed huge resources to the so-called 'war on drugs'. They have, by some measures, been very successful. Seizures have increased year on year in terms of quantity, and many traffickers have been caught. However, despite this effort and apparent success, the drug market seems to have been little affected. For example, over the last 10 years or so the retail price of street heroin has been stable even before taking account of inflation. Over the same period purity has tended to increase steadily. Demand for heroin has, meanwhile, been growing. We have falling real prices in a period of market expansion. To use the language of the market, we have a long term supply side glut. The picture with regard to cocaine is similar, although rapid expansion of the market is a slightly more recent phenomenon.

Thirdly, and in common with other countries, most notably the USA, we have consistently misinformed our communities about drugs. There are examples ranging from warnings that cannabis use leads to heroin addiction, to the persistent implicit message that addiction to heroin happens extremely rapidly after first use. These ideas persist in the public consciousness. Many people, and especially youth people, find out by first hand experience, or through the experience of friends, that these messages are inaccurate. As a result, they reject other messages on similar subjects from the same sources. Sadly, they reject the accurate information along with the nonsense. As a result, many who might have accepted the 'Just say No ! ' message are likely to say 'Yes ! ' to drugs . In the face of such a bleak picture, what can a small area like Hammersmith and Fulham do? There are two elements to the answer: shared understanding and shared policies and procedures.

SHARED UNDERSTANDING

We have pooled our knowledge of the drug scene to gain a reliable, if subjective, picture of its effects on the wider community, as well as on users themselves. The Forum, which brings together clinical and other drug professionals with criminal justice agencies and key public service providers, has produced a more coherent picture than those developed by clinicians or criminal justice agencies working in effective isolation.

The key elements of this picture are:

  • The great majority of drug users do not wish to stop. Of these 'committed users', most maintain supplies through drug dealing, acquisitive crime and prostitution, all of which harm the wider community.
  • Most of the harm drug users do to themselves is the result of injecting inappropriate preparations of drugs, injecting cut drugs, overdosing caused by unknown strengths of cut drugs, sharing injecting equipment, and of course the general deprivations involved in raising large amounts of money daily through crime or prostitution.
  • The illicit drug market is not significantly undermined by enforcement alone. Enforcement of the criminal law against simple possession also tends to increase crime levels. A user whose drugs are confiscated will seek to replace them immediately on release from custody, usually by first committing further crime to raise money. The sum effect of the enforcement action will have been to cause additional crime to be committed, and to increase the income of the supplier.
  • No prescribed drug is more harmful to the user, or the drug free community, than its illicit counterpart (although sometimes there is little difference).
  • Those who deal hard drugs at the retail and small wholesale levels, are almost always addicts dealing to supply their own habit.

SHARED POLICIES AND PROCEDURES

Having arrived at this picture, we tried to devise policy options that would alleviate the problems. In doing this we asked not only if the policy reduces the harm a user might be doing to her- or himself but also if it would reduce the harm that the drug user might be doing to the wider community? The main policy themes produced by this process are quite simple. They are:

  • That drug services must offer the option of stabilisation on prescribed drugs to users. To attract the maximum possible number of users into services, stabilisation regimes should include, and be seen to include, prescription of the user's primary drugs of use, to be administered by the user's usual method. So, heroin users might in some cases be prescribed heroin, at their genuine tolerance level, in injectable form. The same ca apply to users of more physically harmful drugs.
  • Criminal law enforcement must be linked into treatment services. There is little or no value in putting users through a 'revolving door" enforcement if they wish to continue their drug use. The desire for drugs almost always outweighs any fear of criminal sanction, and users know that the chances of getting caught on any one day are minimal. Indeed many users never get caught at all, for drugs or other related offences.
  • The services of local authorities, voluntary groups and criminal rehabilitation agencies must all be geared to helping the maintained user or ex-user to re-enter the wider, non-criminal community. This must include equal access to caring services, as well as to educational, work and vocational training opportunities

CONCLUSIONS

The Forum believes that we can turn these views into a practical programme on the ground. However, there are some problems. Although our views are both logical, and based on a considerable weight of experience, they are unproved. Furthermore, much of what might be called the 'drug services establishment' is firmly committed to the old enforcement and detoxification model. We have therefore decided that proceeding with our programme must be dependent on the establishment of high quality and long-term evaluation and monitoring . This is of course expensive and final agreements concerning resourcing have not yet been reached.

The drug services must prepare themselves to deal with many more clients. Although drug services in our area are already much more comprehensive and constructive than most in the UK, enhancing their existing services should rapidly increase their client numbers. They must be prepared and resourced to cope efficiently with this increase. The Forum has worked hard to develop a set of Prescribing Policy Guidelines, which will be used by clinicians to inform their prescribing practice and I underwrite the development of new prescribing protocols (Appendix l).

Police referral to drug services of people arrested in possession of any drug is in place, and has recently been widened to include people arrested for non drug crimes which are commonly connected with drug use, such as burglary, shoplifting or soliciting. Referral by the probation service is also in place.

The local authority, which is the local provider of schooling and adult education, housing, social and child care services, and leisure facilities such as libraries and sports grounds, has a major development task to undertake. Drug users, who currently have a largely criminal lifestyle, have tended not to use such services except where they can successfully conceal their drug use. But these services will be vital if users are to helped away from their illicit lifestyle by the provision of free prescribed drugs. A user, whose day is no longer filled by the imperatives of raising funds and buying drugs, needs good access to these services. They are what can fill a newly empty day, and perhaps also provide the beginnings of new interests. These in turn may result in eventual moves towards reduced drug taking or abstinence.

Local authority staff also need to develop the skills to recognise the effects of drug use, and be able confidently to refer clients into drug services. Family doctors, who have tended to refer drug users to the specialist clinics, and in some cases fail to provide even primary health care, must begin to take an active role in treating and supporting maintained users.

We need to move drug use out of the shadows Above all, we need to attack the illicit market by removing its customers. We know we cannot do this by gaoling them all because there are far too many. W could never catch enough at once to have any impact But how many users will buy low-quality street drugs a high prices if they can get high-quality pharmaceutical preparations for nothing?

Change on this scale is bound to take time to achieve. There is a heavy legacy of failed social policies of fear and suspicion on all sides, to overcome. But an illicit market without enough buyers or sellers must inevitably wither. We hope to demonstrate the visibility of the approach I have outlined, and I will not pretend that change in national policy is not also goal, albeit a distant one. It is our hope and belief that in the future, we will be able to report that we are achieving the re-socialisation of illicit drug users; and substantial reductions in drug-related crime, the size of the local illicit drug market, the numbers of new recruits to drug use and the spread of HIV, both with the drug-using community, and from there into the wider community.

APPENDIX I

  • Hammersmith and Fulham Drugs and Crime Forum Terms of Reference
  • To attract all illicit drug users in the London Borough of Hammersmith and Fulham, irrespective of race, gender, sexual orientation, disability, religious belief or criminal record, in to local drug services.
  • To have a full range of prescribing possibilities within clinical practice.
  • To provide services to illicit drug users irrespective of a client's drug of choice or method of administration of choice.
  • To reduce levels of acquisitive crime committed by illicit drug users to finance their drug use.
  • To reduce the availability of illicit drugs.
  • To educate the wider community, and particularly those who might begin to use drugs, regarding the potential consequences of, and risks associated with illicit drug use.
  • To develop drugs prevention strategies targeting the wider community and particulararly those who have never used drugs or who use them experimentally, so as to reduce the incidence of concious drug use.
  • To reduce as far as possible health-related problems associated with illicit drug use ( i.e. HIV/AIDS, hepatitis, limb loss through abscesses etc.).
  • To ensure a high degree of cooperation in drug service planning and delivery between Riverside Substance Misuse Service, the Metropolitan Police, the Inner London Probation Service, the I London Borough of Hammersmith and Fulham, and other organisations providing drug-related services.
  • To do all possible to ensure that prescribed drugs do not 'leak' onto the illicit drug market.
  • To provide and maintain scrupulous monitoring, assessment and evaluation of all drug-related services, and in particular of new and developing drug services.

APPENDIX II

  • Prescribing Policy Guidelines Principles
  • The Advisory Council on the Misuse of drugs concluded in 'Aids and drug use' (1988) that 'HIV is a greater threat to public health than drug use. The first goal of work with drug users must therefore be to prevent them acquiring or transmitting the virus'.
  • Services should aim to make contact with and provide services to the maximum possible number of drug users, irrespective of whether or not they wish to cease drug use, within available resources.
  • Prescribing practice should pursue the following hierarchy of goals:
  • - cessation of sharing of injecting equipment
  • - change from injectable to non-injectable drug use
  • - decrease in drug use abstinence.
  • The removal of a drug user from the illicit market (and the dangers inherent in that market) by prescribing over any period of time is likely to be of direct benefit to that user.
  • Treatment regimens which fail to provide a health gain should not be continued indefinitely.
  • The consequences of prescribing practice for the wider community are a legitimate consideration in the establishment of prescribing regimens for individual clients.
  • Clients must be given full access to their clinical records, provided with all information upon which treatment decisions are based, and be fully involved in decision-making processes regarding their treatment. Information allowing the identification of any individual client must not be interchanged without client consent.
  • Prescribing practice should remain open to change, and responsive to sound research. Such research should continue.
  • Information on service delivery should be readily available to the public, including:
  • details of prescribing policy

details of prescribing practice, including substances prescribed, proportions of patients receiving specific drugs, and periods of time spent on maintenance and detoxification regimens

  • average waiting times for new clients
  • client numbers for each main element of the service.

Practice

  • The risks and benefits of prescribing different drugs vary. However, use of pure pharmaceutical preparations of any drug is generally less harmful than use of illicit preparations of the same drug. Therefore no drug or preparation should be specifically excluded from prescribing policy or practice on the sole grounds that it is harmful, and decisions relating to prescribing to any individual should prioritise the complete removal of the client from reliance on the illicit market. It is accepted that in some cases this will require that clients be prescribed their drug of choice, to be administered by the route of their choice.
  • Prescribing practice should (with the client's agreement) seek to change clients drug use towards less harmful drugs and preparations. Clients should be encouraged to accept attempts to vary their drug regimen on the clear understanding that they may reject attempted regimens and revert to the preceding regimen after an agreed period should the experimental regimen prove unacceptable to the client.
  • Prescribing of drugs/preparations which are particularly open to administration by routes other than those for which they are intended (such as Diconal tablets) should be avoided in all but the most exceptional circumstances.

Jacob Veale, London Borough of Hammersmith and Fulham Community Safety Unit, Town Hall. King Street, London W6 9JU.

REFERENCES

Borough Profile (1990). Environment Department, London Borough of Hammersmith and Fulham.

Painter, K., Lea, J. Woodhouse, T. And Young, J. (1988). Hammersmith and Fulham Crime and Policing Survey. Centre for Criminology.

Social Services ( 1992) . HIV. A Local Authority Response. Middlesex Polytechnic, London Borough of Hammersmith and Fulham.


 

Show Other Articles Of This Author