Evidence and Policy: Crime and public health in UK drug policy

1. Evidence and Policy: Crime and public health in UK drug policy Alex Stevens

2. Evidence and policy British drug policy: an argument between crime and health Rolleston committee, 1926 Care won over criminalisation Produced the �British system� of �benevolent neglect� But doctors still accountable to the Home Office. Response to increased drug use in 1960s Tighter controls on doctors Regulation of drug treatment Misuse of Drugs Act 1971 Response to �heroin epidemic� of the 1980s Tougher penalties for drug dealers Central Funding Initiative - �18 million Drug strategy 1985 focuses on enforcement and prevention. Response to HIV epidemic of the late 80s Relatively quick implementation of harm reduction Which was supposed to include abstinence as a goal.

3. Evidence and policy A theory of policy formation The �discourse coalition� approach (Hajer) Discourse A set of ideas and symbols that share common concepts. Coalition A loosely formed group of individuals and organisations who form around a discourse. Discourse structuration The attempt to make a discourse the dominant way of thinking about an issue. Discourse institutionalisation The translation of a discourse into laws, practices and policies which express it.

4. Evidence and policy This presentation Use the discourse coalition approach to look at use of evidence in British drug policy. The available evidence on: Drug use Drug-related health problems Drug-related crime Uses of evidence The Drugs Act 2005 Cannabis classification The new harm reduction An excluded discourse? Drug use as non-deviant

5. Evidence and policy Drug Use

6. Evidence and policy Problematic drug use

7. Evidence and policy Drug-related death: Trend 2006 � 421 in Scotland 1,366 in England and Wales 2006 � 421 in Scotland 1,366 in England and Wales

8. Evidence and policy Drug-related death: European comparison

9. Evidence and policy Blood-borne viruses: Trend in HIV

10. Evidence and policy HIV: International Comparison

11. Evidence and policy Blood-borne viruses: Hepatitis C 41% of injectors in E, W & NI estimated be HCV+ 44-62% in Glasgow.41% of injectors in E, W & NI estimated be HCV+ 44-62% in Glasgow.

12. Evidence and policy Health inequality Drug use is spread throughout society Class A use higher among affluent groups (BCS). Dependence and related health problems concentrated in deprived areas and groups. Unemployed people 3.75 times more likely to report drug dependence (SPM data). 42% of drug-related deaths in Scotland in 2003 took place in the most deprived neighbourhoods, comprising only 19% of the population (Zador et al. 2005.) Criminal victimisation also concentrated in deprived areas. Over half of all household property crime is found in the poorest one fifth of communities in England and Wales (Hope 2001).

13. Evidence and policy Summary on drugs and health Drug-related death is high (and rising in Scotland) HIV is (internationally) low (but rising) Hepatitis C is high (and rising) Drug dependence contributes to health inequality.

14. Evidence and policy Crime (in general)

15. Evidence and policy Drugs as crime

16. Evidence and policy �Drugs cause crime� Estimates of the proportion of crime that is caused/driven/motivated by crime in policy debates: Vary from 20% to 70% Have settled at about a half. Estimated cost of �drug-related crime� �13.9 billion per year (Gordon et al 2006). Based on misinterpretation of �pathologising studies� of arrestees and drug users in treatment. For example, the recent consultation document for the new Welsh substance misuse strategy claimed that �It has been estimated that drug motivated crime accounts for half of all crime�.For example, the recent consultation document for the new Welsh substance misuse strategy claimed that �It has been estimated that drug motivated crime accounts for half of all crime�.

17. Evidence and policy Overestimating proportions from arrestees Note source of the estimated proportions in the New_ADAM stduy and its arrestee survey successor. New-ADAM was, as its authors repeatedly warned the Home Office, not generalisable. It included purposively selected research sites and had a relatively low response rate (around 30% of interviewees who passed through these sites). The Arrestee survey has more representative sampling of sites, but has an even lower response rate. An even bigger obstacle to the use of arrestee surveys in estimating the proportion of crime that is drug-related comes from the assumption that arestees form a random sample of offenders � that the police are operating from a complete sampling frame of all offenders, rather than choosing to arrest offenders in the ways that make most sense to them.Note source of the estimated proportions in the New_ADAM stduy and its arrestee survey successor. New-ADAM was, as its authors repeatedly warned the Home Office, not generalisable. It included purposively selected research sites and had a relatively low response rate (around 30% of interviewees who passed through these sites). The Arrestee survey has more representative sampling of sites, but has an even lower response rate. An even bigger obstacle to the use of arrestee surveys in estimating the proportion of crime that is drug-related comes from the assumption that arestees form a random sample of offenders � that the police are operating from a complete sampling frame of all offenders, rather than choosing to arrest offenders in the ways that make most sense to them.

18. Evidence and policy Drug users over-represented in arrestee samples

19. Evidence and policy Drug user reports of police supervision Rhodes et al 2007: qualitative study of drug injecting in South Wales �Homeless injectors spoke of police being �on your case everyday, even if you�ve done nothing wrong�, of being �constantly hassled�, of police who �won�t leave you alone��. �They [the police] know every smackhead in Merthyr. That's why they are always on our cases, searching us and this and that.� Also indicates extra likelihood of police arresting drug users when they offend.

20. Evidence and policy Overestimating costs from drug users in treatment The estimate of �13.9 billion in annual crime costs from problematic drug users rests on the National Treatment Outcome Research Study Asked questions of 1,075 drug users at entry to treatment about offending in previous three months extrapolates from them to estimated 327,466 problematic drug users. Assumes that: Offending is accurately reported. Offending is the same in the entire year as the three months previous to treatment. PDUs in treatment offend at the same rate as all PDUs. Coincidentally, �13.9 billion is also the estimate given for the annual cost of fraud by Levi and Burrows in an article in this month�s BJC. But we do not (yet) have a national fraud strategy, or a programme of �tough choices� for fraudsters.Coincidentally, �13.9 billion is also the estimate given for the annual cost of fraud by Levi and Burrows in an article in this month�s BJC. But we do not (yet) have a national fraud strategy, or a programme of �tough choices� for fraudsters.

21. Evidence and policy Offending peaks before treatment entry N.B. 90% of NTORS sample were heroin users. Their mean duration of heroin use at treatment entry was nine years (Gossop et al 1998). This suggests that they were offending at much lower levels than those reported in the NTORS study even while they were heroin users. So it is not appropriate to extrapolate frm the high levels reportedf by the NTORS sample to all heroin users.N.B. 90% of NTORS sample were heroin users. Their mean duration of heroin use at treatment entry was nine years (Gossop et al 1998). This suggests that they were offending at much lower levels than those reported in the NTORS study even while they were heroin users. So it is not appropriate to extrapolate frm the high levels reportedf by the NTORS sample to all heroin users.

22. Evidence and policy Summary on drugs and crime Crime is falling. Proportion of crime by drug users likely to be less than estimated. Value of crime by drug users likely to be less than estimated. Plus, doubts that the relationship between drug use and crime is causal Search for the �third variable�.

23. Evidence and policy The use of evidence in drug policy:2. The Drugs Act 2005 Available evidence on drug problems: Drug use high in UK, despite prohibition. Strong correlation of drug use and crime. High rates of drug-related death. High and increasing rates of hepatitis C Emerging concern over neglect and abuse of children of problematic drug users Evidence then filtered through the Prime Minister�s Strategy Unit

24. Evidence and policy Example 1: Drugs Act 2005 A piece of �pre-election window dressing�, or� An attempt to use some of the evidence on drug problems. Following work of John Birt and the Prime Minister�s Strategy Unit.

25. Evidence and policy PMSU report on drug problems (2003)

26. Evidence and policy PMSU 2003 policy suggestions �Grip� and treat �high harm causing users�. Move the funding and accountability for drug treatment from the Department of Health to the Home Office. Make heroin use an offence and introduce a compulsory registration scheme for those found guilty of it. Users would be identified by compulsory testing on arrest. Provide a case manager from the National Drugs Service for every registered heroin user to manage and purchase services for the user.

27. Evidence and policy Policy responses in Drugs Act 2005 Repeal previous provision which criminalised hostel workers. Creation of ISO to run alongside ASBO Creation of new crimes: Possession and supply of unprocessed psilocin mushrooms Presumption of supply for certain amounts Dealing near schools Refusing intimate searches and X-rays Using under 18�s as couriers Refusing a drug test at arrest Refusing to be assessed for treatment

28. Evidence and policy Ex�2: The UK cannabis kerfuffle, 2004-2008 2004: In response to various reports (including ACMD 2002), govt� reclassifies to class C. Max� sentence for supply of class C increased to 14 years. Police in England & Wales introduce presumption of non-arrest of adult cannabis possessors. 2005: In run-up to election, Charles Clarke refers decision back to ACMD. 2006: ACMD reaffirms class C and is accepted. 2007: Brown refers decision back again to ACMD 2008: ACMD re-reaffirms class C, but cannabis re-reclassified to class B. Police continue presumption of non-arrest for first offences. Meanwhile, cannabis use continues to fall in England & Wales, while rising in Scotland.

29. Evidence and policy Cannabis: The evidence No risk of fatal overdose Cannabis (even skunk) is not �lethal�. Significant association with schizophrenia Ongoing debate on causality Some evidence of association with cancer and heart disease. English market becoming dominated by stronger forms of domestically cultivated skunk 10% average THC content, compared to 6% THC in cannabis resin. No evidence that legal changes affect patterns of use. Risk of dependence to users: 9% of lifetime users (NCS study in USA in 1992)? 16% of adolescent users 33-50% of daily usersRisk of dependence to users: 9% of lifetime users (NCS study in USA in 1992)? 16% of adolescent users 33-50% of daily users

30. Evidence and policy Cannabis: the debate Cannabis is dangerous because it�s stronger Than when �we� took it. Cannabis causes mental illness The criminal law �sends out signals� to young people So � �ignore the experts� and further criminalise cannabis users.

31. Evidence and policy Ex� 3: The new harm reduction Rises in deaths, HIV and HCV suggest we need to reinforce efforts to reduce risky injecting, fatal overdoses and the spread of blood-borne viruses. Especially for vulnerable groups: Young injectors. Heroin users who have not engaged, or who have dropped out of treatment. Prisoners. Methods Outreach, peer & carer interventions. Drug consumption rooms. Heroin assisted treatment. Prison needle exchange. Peer intervention � e.g. working with �seasoned� injectors to support them in not initiating new people into injecting. e.g. Training drug users and carers of injecting drug users in the use of emergency naloxone.Peer intervention � e.g. working with �seasoned� injectors to support them in not initiating new people into injecting. e.g. Training drug users and carers of injecting drug users in the use of emergency naloxone.

32. Evidence and policy Drug consumption rooms (Hunt & Lloyd 2008) �Protected places for the hygienic consumption of preobtained drugs in a non-judgemental environment and under the supervision of trained staff.� (Akzept) Available in Germany, Switzerland, the Netherlands, Spain, Norway, Luxembourg, Australia and Canada. Evaluation results: Effective in reaching homeless & public injectors Statistically significant reductions in drug-related death, despite one death (from anaphylaxis) in German DCR. Reductions in risk behaviour and public nuisance.

33. Evidence and policy Heroin assisted treatment (Uchtenhagen 2008) Has been evaluated in Switzerland, Germany, the Netherlands and Spain (English pilots under way). Provides heroin for on-site injection and psycho-social support to people who have not stabilised in methadone treatment Results: Reduced illicit heroin use Improved health Reduced crime More employment Switzerland - Reductions in heroin initiation and many participants move on to abstinence (Nordt)

34. Evidence and policy Prison needle exchange Available in Switzerland, Germany, Spain, Portugal (soon). At least six evaluations (Dolan et al 2003): All favourable results. Reduction in sharing of injecting equipment Drug use decreased or stable No new cases of HIV or HCV reported No use of needles as weapons No reports of new initiations into injecting

35. Evidence and policy Political response Interesting bifurcation between DCRs and HAT Drug consumption rooms rejected: Localised dealing Anti-social behaviour Increase in acquisitive crime Heroin assisted treatment Cautiously accepted, depending on pilot Explaining the difference HAT seen as reducing crime HAT consistent with the supervisory element of the health discourse coalition DCRs too close to accepting drug use as �normal�

36. Evidence and policy Drug use as non-deviant �Normalisation� mistakenly taken to mean: That a majority of people use illicit drugs. That people should take illicit drugs. Drug use as non-deviant because: Using substances to change brain functioning is a �human universal�. Drug use is not always a sign of illness or criminality The idea of drug use as non-deviant is ignored by both crime and health coalitions Which share �discursive affinity� around the idea of drug use as deviation from the norm � either criminal or pathological If drug use is non-deviant and it can be damaging, we need: Ways to regulate drug use and availability. Systems to prevent and reduce drug-related harm. Support for people who want to stop using drugs If drug use is non-deviant and it can be damaging, we need: Ways to regulate drug use and availability. Systems to prevent and reduce drug-related harm. Support for people who want to stop using drugs

37. Evidence and policy Conclusions British drug policy is the result of ongoing, long-running arguments between crime and health discourse coalitions. In recent years, evidence has been used selectively to support the criminalisation of drug users and drug services. The dissident idea that drug use is non-deviant has had little effect on policy.