APPENDIX 26
Memorandum from the Standing Conference
on Drug Abuse prepared by Professor M. Hough
SUMMARY
The problem
— Illicit drug
use is widespread in the young population. For a small proportion—numbering
around 3 per cent—drug use is problematic. There may be
well over 100,000 problem users.
— These problematic
drug users spend large amounts of money on drugs—averaging
around £200 per week—and fund much of their use from
theft, fraud, dealing and other forms of crime.
— In the region
of a fifth of those passing through the criminal justice system
may be problem drug users who would benefit from treatment.
What works in dealing with this group?
— There is good
evidence that well-resourced and appropriately designed treatment
is effective in reducing drug use and in reducing drug-related
crime.
— Legally coerced
treatment appears to be no less effective than treatment entered
into voluntarily. The criminal justice system can thus serve as
a bridge to treatment.
— Community-based
treatment is substantially cheaper than imprisonment, with fewer
unintended side-effects.
Designing community based interventions
— Interventions
are needed at several points in the criminal process: arrest referral
schemes; diversion schemes; and court-ordered treatment programmes:
and after release from prison.
— These schemes
will only prove effective if they are properly resourced, and
if the right balance of "2 sticks and carrots" is found
to hold people in treatment.
— Money for treatment
services must be found by re-allocating existing resources; there
may be scope for increasing levels of asset seizure and using
the extra money on treatment programmes.
— The probation
service is the obvious agency to commission the necessary treatment
services.
— Any interventions
must be designed to reach groups which have, to date, been poorly
served by treatment services—women, those with children,
and black users, for example.
ALTERNATIVES TO PRISON SENTENCES
The Standing Conference on Drug Abuse (SCODA)
seeks to reduce the harmful effects of drug use through informed
debate, and promotion of best practice and effective, comprehensive
services. It is an independent organisation, providing a voice
for drug services and others concerned about the effects of drug
use on individuals and communities. This paper sets out SCODA's
response to the Home Affairs Committee of Inquiry. SCODA's membership
of over 450 bodies is drawn from drug treatment service providers
and local Drug Action Teams as well as education/prevention specialists,
police forces and others. The response was prepared for SCODA
by Professor Michael Hough, Director of the Criminal Policy Research
Unit at South Bank University and has been endorsed by SCODA.
It is concerned with alternatives to prison sentences as these
relate to criminally involved problem drug users. Following the
Advisory Council on the Misuse of Drugs (ACMD, 1982, 1988) we
define problem drug users as:
those who experience social, psychological, physical
or legal problems related to intoxification and/ or regular excessive
consumption and/or dependence as a consequence of their own use
of drugs or other chemical substances; and those whose drug use
involves, or could lead to, the sharing of injecting equipment.
Our memorandum discusses:
— links between
problem drug use and crime
— the costs imposed
on the victims and public services by problem users
— the research
about what works in reducing problematic drug use and related
crime
— developing community-based
ways of dealing with problem-using offenders
— strategies for
ensuring that "hard to reach" groups are not ignored.
On wider questions relating to alternatives
to imprisonment for offenders without drug problems, we endorse
the approach advocated by the Penal Affairs Consortium, of which
SCODA is a member.
BACKGROUND
In the five years since December 1992, the prison
population has grown by more that 50 per cent. The increase reflects
not a greater number of people passing through the criminal justice
system, but a change in the sentencing climate. Judges and magistrates
are now sending a greater proportion of convicted offenders to
prison, and those who go to prison serve longer sentences. In
aggregate, these sentencing decisions constitute a perverse sentencing
policy which is stifling more creative and cost-effective responses
to crime. The response to drug related crime provides one clear
example of this.
LINKS
BETWEEN
PROBLEM
DRUG
USE
AND
CRIME
Illicit drug use is widespread. Around half
of people between the ages of 16 and 30 have used drugs at some
stage in their lives (Ramsay and Spiller, 1997). Only a small
proportion develop serious problems associated with drug misuse,
however. Extrapolating from the Home Office Addicts Index and
the British Crime Survey our "best guestimate" is that
around 3 per cent of those who use drugs each year are problem
users who would benefit from treatment.[83]
This represents a total in excess of 100,000 problem users.
For the 97 per cent of people who engage in
casual or recreational drug use there is little evidence of clear
links between drug use and acquisitive crime. For the 3 per cent
of problem users, the evidence of a link is overwhelming—even
if the causal sequence is complex. Many studies have found that
problem users are now spending large sums on drugs, and that few
are able to support their use through entirely legal means. Figure
1 shows estimates from recent studies of the weekly spend or problem
drug users. The figure suggests that the statistics set out in
the Green Paper "Tackling Drugs Together" (Home Office,
1995) were an underestimate. If problems users' average expenditure
is around £200 per week per year their combined expenditure
in England and Wales alone would be at least £1 billion.
The probability is that more than half of this
sum is raised through shoplifting, burglary and other forms of
theft and fraud—£½ billion per year. Assuming
that stolen goods are fenced for a third or less of their replacement
value, losses to business and home owners will be in excess of
£1.5 billion. Dealing and prostitution are also common means
by which dependent users finance their use.
Various pieces of research offer pointers as
to the proportion of offenders passing through the criminal justice
system who are problem users. Probation research (eg ACMD, 1991;
NAPO, 1994) suggests that around a quarter of those on whom PSRs
have been completed are problem users, and that at least a fifth
of those under probation supervision have drug problems which
need assessing. Research carried out for the Home Office[84]
suggests that approaching a fifth of those passing through police
stations are problem users. And bearing in mind that there are
some 500,000[85] offenders
passing through the criminal justice system annually, our earlier
estimate of in excess of 100,000 problem users would represent,
again, a fifth of the total. Without wishing to claim any precision
for the estimate, therefore, we think it sensible to reckon that
around one in five of those passing through the criminal justice
system is a problem drug user. (It is also worth noting that problem
users are themselves at higher than average risk of becoming the
victim of both violent and acquisitive crime, and thus have contact
with the system in the role of victim as well as offender.)
There are estimates specifically of the proportion
of prison inmates who were drug-dependent on admission. Research
carried out in the late 1980s found that 11 per cent of male sentenced
prisoners and 23 per cent of female were drug-dependent in the
six months before their sentence (Maden et al, 1992); a more recent
survey of remand prisoners yielded estimates of 11 per cent for
both men and women (Maden et al, unpublished). These figures refer
to the prison population at any given time. The proportion
of those sentenced to prison who have drug problems may
be higher, given that problem users are likely to be over-represented
amongst short-sentence prisoners[86].
Approaching 10 per cent of the prison population may now have
had experience of injecting drug use before their sentence.
The programme of mandatory drug testing in prisons
has established that drug misuse within prisons is widespread;
around a third of tested prisoners had tested positive to any
drug by August 1996, and 6 per cent tested positive for heroin.
We note in passing that the cost of maintaining MDT is roughly
twice that of a credible prison-based drugs reduction and rehabilitation
programme, consuming a large proportion of prisons' healthcare
budgets (Gore and Bird, 1996). Anecdotal evidence suggests that
the introduction of MDT triggered a switch from (readily detectable)
cannabis to (less detectable) heroin use in prison—and it
is hard to see how empirical evidence to test this can now be
assembled.
We have already mentioned costs imposed on victims,
which may be in excess of £1.5 billion per year. Costs to
the system are also very significant. First there are costs to
the criminal justice system. Apportioning a fifth of the total
criminal justice costs to problem users would yield a figure of
£2 billion. This is probably an overestimate, because a large
proportion of police expenditure (the lion's share of the total)
is devoted to non-criminal issues. However, an estimate of £5,000
per year spent by the criminal justice system on a problem drug
user is reasonable[87].
This would yield an annual total of £½ billion. The
costs specifically to the Prison service may be a tenth of their
total budget of almost £2 billion-£200 million per year.
Social security spending is also large: excepting
time spent in pison, most problem users claim unemployment or
sickness benefit and housing benefit. If the average claim is
£100 per week again expenditure would be in the region of
£½ billion. There is, of course, no guarantee that cessation
of drug use would lead immediately to employment. Costs to health
and social services are much harder to estimate. Expenditure on
specialist drug services by health authorities and social services
departments is probably in the region of £100 million[88]
(substantially in excess of the £41.3 million per year notionally
allocated for England by the Department of Health). Figures for
generic health care are an unknown, but could be very high indeed.
Costs associated with treatment of HIV/AIDS will be very high
for a relatively small number of patients. Costs arising from
the treatment of Hepatitis B and C are likely to be substantially
higher, given the greater prevalence—but it remains to be
seen precisely how burdensome Hepatitis C turns out to be[89].
We have no basis on which to estimate generic social services
costs (eg in providing care facilities for the children of problem
users), except to say that these are significant.
WHAT
WORKS
IN
DEALING
WITH
CRIMINALLY
INVOLVED
PROBLEM
DRUG
USERS?
Whether the current balance of public expenditure
on this population is right turns on the research evidence about
the most effective—and the most cost-effective—ways
of dealing with this group. Other submissions will have covered
in detail the research evidence about the relative effectiveness
of prison and community penalties in dealing with the generality
of offenders. In summary, differences between reconviction rates
for those sentenced to prison, probation, or comunity services
orders are minimal, after differences in age and criminal history
have been taken into account (Lloyd et al, 1994). Whilst it is
clear that imprisonment offers some short term incapacitative
gains in keeping offenders out of circulation, it remains unclear
whether the crimes are simply deferred until release or whether
they are prevented altogether. Imprisonment is, of course, much
more costly than most forms of community intervention.
The findings described above refer to the generality
of offenders and the generality of court sentences. Research has
shown that specific types of rehabilitative programme—whether
community-based or in prison—can outperform this generality.
The emerging principles of good practice about effective programmes
for offenders are that they should:
— target high risk
offenders;
— focus on offending
behaviour and the factors underlying it;
— be clearly-structured
and properly implemented; and
— be staffed by
motivated and well-trained staff.
Many treatment programmes for problem users
meet these criteria, and many have emerged well from formal evaluation.
Most of the research evidence is American, and its applicability
to the British context cannot be guaranteed. Nevertheless, it
paints a coherent picture of what works and why (see Hough, 1996
for a review). The National Treatment Outcomes Research Study
is beginning to replicate these findings in Britain, showing that
a variety of different sorts of treatment reduce drug use (Task
Force, 1996; Department of Health, 1997). For our purposes, the
research evidence falls into three parts: there is a good body
of knowledge about what modalities of treatment are in general
effective. Secondly, there are rather more limited studies about
the scope for effective treatment within conditions of coercion—as
when treatment is ordered within the criminal justice system.
Finally there is limited information about drug treatment within
prisons.
Treatment for problem drug users in general
The overall picture is a positive one (cf Task
Force, 1996), suggesting that a variety of different forms of
treatment can help the problem users address their drug use:
— Methadone maintenance
programmes reduce both illegal heroin use and related crime
— Higher rates
of daily dosage (60 mg or more) of methadone seem to be more effective
than lower ones
— Structured, supervised
consumption of substitute drugs yields better outcomes than prescription
alone.
— Therapeutic communities
understandably have relatively higher drop-out rates than programmes
based on substitute prescribing, but those who stay full-term
do much better than comparison groups.
— Other types of
counselling and social skills training can be effective, provided
that they can retain clients in treatment.
The key elements of successful treatment—whether
or not delivered within the criminal justice system—appear
to be:
— getting misusers
with serious drug problems into treatment quickly;
— keeping them
there for as long as possible, and for a minimum of three months;
— providing incentives
to keep misusers in treatment, and delivering treatment within
a positive and supportive environment.
Treatment via criminal justice
The criminal justice system can be an important
conduit through which drug users with serious drug problems reach
treatment. Research findings specifically on the impact of community-based
treatment within the criminal justice system are:
— Legally coerced
treatment appears to be no less effective than treament entered
into "voluntarily".
— The criminal
justice system is well placed to direct people into treatment
and keep them there.
— Drug testing
can provide a means of responding to problems of disclosure in
identifying illegal drug use, and can help secure compliance with
treatment conditions.
— Drug testing
is better used as an integral part of treatment, rather than being
used simply as a form of surveillance.
Coerced treatment and drug-testing can obviously
raise ethical dilemmas. In resolving these, it is essential that
coerced treatment is not compulsory treatment, and
that treatment is no more restrictive of the liberty of offenders
than a conventional and proportionate punishment. Offenders should
retain the right to opt for the latter; and we welcome the Government's
decision that Treatment and Testing Orders should be made only
with the offender's consent. (In any case, treatment ordered as
part of a criminal sanction without the offender's informed consent
would not survive a challenge in the European Court of Human Rights.)
It is obviously essential to ensure that the coerced treatment
is appropriate to the individual in question.
These findings run counter to professional orthodoxy
at least as it stood until recently, which emphasised the pre-requisite
of client motivation to take part in treatment. We find them plausible
however, especially in view of the fact that apparently voluntary
participation is often underpinned by a degree of coercion from
family, partners, friends or employers. There is also anecdotal
evidence to the effect that problem users accept interventions
provided within a coercive framework and often find this approach
helpful.
Interventions in prisons
Though prisons may on the face of it seem to
offer unique opportunities for treatment, the availability of
drugs in prisons and the positive value sometimes placed by inmate
culture on drugs can subvert programmes. The research findings
on prison-based treatment are tentative:
— Prison-based
treatment programmes have rarely been evaluated.
— Prison-based
methadone maintenance programmes may be an effective "bridge"
to further treatment on release.
— The limited evidence
relating to prison-based therapeutic communities is promising,
and by implication "drug-free wings" may prove of value.
— Cognitive-behavioural
programmes and relapse prevention also seem promising.
The cost effectiveness of different approaches
The cost effectiveness, as opposed to the effectiveness,
of treatment services for problem drug users provided within the
criminal justice system is something of an unknown. The Effectiveness
Review (Task Force, 1996) found very little reliable information
on costs; the figures for drug interventions listed below draw
on the Review and other sources.
They should be regarded as tentative:
| six months' methadone programme
| £1,400 |
| two weeks' in-patient services
| £650-1,100 |
| 14 weeks' counselling |
£500 |
| six months in a therapeutic community
| £6,000-12,000 |
| six months in prison |
£6,500-12,500 (depending on category)
|
| a year's probation |
£1,200 |
What interventions yield the best return, and
in what combinations, is much harder to say. However, we believe
that the financial and non-financial costs of interventions built
round imprisonment are likely to substantially outweigh their
benefits, relative to community-based[90]
interventions.
On the positive side prisons can sometimes provide
problem users with an escape from their drug using environment,
and—given current waiting lists within community-based treatment
services—an opportunity to detox. Balanced against this
is the fact that skills and attitudes learnt in the artificial
setting of a prison may not be transferable to the home setting.
Secondly, only the naive would argue that prisons are drug-free,
and they can provide fairly intense pressures to use drugs. Thirdly,
the experience of imprisonment may deprive offenders of those
community supports—a home, a partner, possibly a job—which
might be pre-requisite to addressing drug problems and remaining
drug free. Finally, even before any treatment has been provided,
the cost of imprisonment is very high indeed.
COMMUNITY
INTERVENTIONS
FOR
CRIMINALLY
INVOLVED
PROBLEM
DRUG
USERS
The discussion so far points unequivocally to
the potential for dealing effectively and cost effectively with
criminally involved problem drug users using community rather
than custodial penalties. The weight of evidence, therefore, is
that offenders should be sent to prison for punishment and not
for treatment. Certainly the opportunities for treatment should
be exploited in the course of a prison sentence; but the former
can never justify the latter. This section considers how best
to develop community interventions.
In developing these interventions, two principles
must be respected. First it is of central importance that those
who reach treatment through a criminal justice route do not displace
those who seek help voluntarily. It would be a perverse system
which rewarded criminal behaviour by putting offenders at the
top of treatment queues. Given that waiting lists are widespread,
this principle has serious resource implications, discussed below.
Secondly, as the Effectiveness Review argued,
the chronic, relapsing nature of drug misuse needs to be recognised
in planning community interventions. Systems of "sticks
and carrots" to keep people in treatment must be designed
with enough pragmatism to accommodate a degree of failure before
eventual success.
In planning community interventions for criminally
involved problem users, it is essential to exploit the "window
of motivation" to seek treatment generated by the stress
of arrest and prosecution. There are four stages at which action
can be taken:
— problem users
can be identified, assessed and referred to treatment at the point
of arrest;
— after arrest
some can be diverted from the criminal process to appropriate
services;
— the courts can
order treatment to those who are prosecuted and convicted; and
— effective support
needs to be organised for offenders on release from prison.
Arrest referral
Large numbers of problem users pass through
the criminal justice system without being identified as such.
The most obvious point for identifying them and referring them
to treatment services is at arrest. Early experience of arrest
referral schemes was disappointing (c f Dorn, 1994), but it is
now emerging that proactive schemes with drug workers screening
arrestees in police station cells are cost-effective (Edmunds
et al, 1997b, 1997c).
Diversion schemes
For problem users who have committed less serious
offences, there is scope for diversion from the criminal process.
We see considerable promise in "caution plus" and "bail
support" schemes targeting those arrested for possession
of Class A drugs and those who have committed minor acquisitive
crimes. However, it is important that such schemes avoid offering
inducements to admit to crimes and operate within the provisions
of the Police and Criminal Evidence Act and the Bail Act. The
Crown Prosecution Service may have a role to play in making greater
use of case discontinuance, where good progress has been made
on a treatment programme. It is also worth exploring whether magistrates
should be given greater scope to adjourn hearings or to defer
sentence in less serious cases. This would provide sentencers
with a mechanism to encourage offenders to seek treatment, rewarding
success by passing a nominal sentence. In any form of diversion
from punishment, care must be taken to ensure that available treatment
resources are not swamped by trivial or inappropriate referrals.
Most of those arrested for the possession of cannabis will benefit
little from contact with drug agencies, for example.
Court-ordered treatment
Whilst we support the principle of diversion
to treatment services wherever possible, it is at the point of
sentence that there is most scope for ensuring that criminally
involved problem users get directed to treatment services. More
to the point for this paper, it is only at the point of sentence
that offenders currently being sent to prison for drug related
crimes could be diverted to community penalties. We see considerable
scope for strengthening the existing range of provision for community
penalties for this population.
We support the principle of treatment and testing
orders. The success of the Government's proposals will depend
on designing a pragmatic and realistic system of "sticks
and carrots" to hold offenders in treatment, and, crucially,
on proper resourcing.
It is important to recognise and be aware of
the implications that alternatives to prison may have for families
of drug using offenders.
It is often assumed that families want the drug
using offender to remain at home but the reality of coping with/living
with drug using and offending behaviour and its effects means
that, in some cases, this might not be the best option (certainly
for the family). Families may be pressurised to provide a bail
address when unwilling to do so, or when it may not be in the
best interests of other members of the family.
Additionally, leaving the family of the drug
using offender unsupported could actually undermine the success
of an individual's drug treatment. It is crucial that organisations
providing support to prisoners' families and other family support
initiatives are properly funded.
Resources
Delays in accessing treatment are commonplace
for problem users (Task Force 1996; SCODA, 1996). There are significant
bottlenecks in assessment, and in accessing prescribing services
and residential provision. Existing supply of drug services is
failing to keep pace with demand. Generating a significant flow
of clients from criminal justice agencies will make matters worse,
and will probably displace the existing clientele. Additional
resources must be found to pay for treatment accessed via criminal
justice.
Expenditure on these services will almost certainly
lead to large savings on police and prison budgets. We recognise
the difficulties in realising these savings, however. In the first
place, the savings do not accrue to the organisations which have
to find the additional resources for treatment services. As currently
organised, health authorities and social services departments
have to spend, and the criminal justice system stands to save.
Secondly, savings made at the margin tend not to be "easy
to bank"; for example, diverting problem users from prision
sentences would reduce overcrowding, rather than yield tangible
savings. Thirdly, for these savings to occur, investment in community-based
treatment services have to be made "up front". Fourthly,
even when savings are identified, the "fire-walls" between
departmental budgets are sufficiently impermeable as to prevent
the transfer of money from criminal justice, for example, to health
services. We also recognise that pressures on health and community
care budgets are intense. Strong arguments can be made for extra
spending on problem drug users; but equally strong cases can be
made for expenditure on politically more attractive projects—in
relation to paediatric care, for example, or care of the elderly.
For these reasons, we advocate a mix of four
strategies for resourcing drug treatment services for criminally
involved problem users. First, central government is well-placed
to provide guidance to criminal justice and health agencies
about the appropriate level of expenditure on drug services which
can be expected of different agencies in different types of area[91].
Secondly, there may be scope for transforming
such guidance into a requirement. For example, the Home
Office currently encourages probation areas to spend seven per
cent of their overall budgets commissioning services from partnership
agencies; financial sanctions are imposed on those who spend under
five per cent. The scope for specifying a probation sub-budget
for drug services should be examined. We think that this is the
best way of routing any new money to treatment for criminally
involved problem users. It should be recognised that this will
have a substantial impact over time on the nature of treatment
services.
Thirdly, we see some merit in Drug Action Teams
establishing joint budgets, with top-sliced contributions
from statutory agencies. There is limited scope for this; imposing
a requirement to topslice budgets may well tear DAT partnerships
apart. However, modest joint budgets would be of great value in
pump-priming and in funding innovation.
Finally, there is one under-exploited source
of new money: assets which can be seized from drug dealers and
other offenders. At present, the sums of money which are actually
seized are small[92].
However, there are few incentives on criminal justice agencies
to pursue asset seizure. With the right structure of incentives,
the total value of successful seizures could be substantially
increased, and used to provide additional (not alternative) support
for treatment services.
Whatever new provisions are put in place to
provide community-based treatment services for problem drug users,
it is essential that proper steps are taken to ensure that services
are provided equitably. It has been well established that white,
male opiate users predominate amongst agency caseloads. Despite
concerted efforts by many agencies, women, especially those with
young children, black users and crack users are under represented.
Those with complex problems—of drug dependency and mental
health problems, for example—tend to fall between two stools.
There are several reasons for these problems:
— there are tried
and tested interventions, notably methadone prescribing, for opiate
users;
— services for
stimulant users are less developed;
— women may believe
they risk losing their children if they expose their drug use
to authorities;
— there may be
a lack of culturally sensitive and appropriate services;
— services under
pressure tend to "pass the buck" rather than work together
when responsibility for clients is shared between specialisms
(as with dual diagnosis); and
— there may be
an unmet need for training and support in dealing with complex
cases.
The inequity in failing to each of these groups
becomes that much greater when services are provided via criminal
justice, diverting problem users from prison. Not only do they
fail to benefit from treatment, but they are differentially at
risk of imprisonment. We therefore place great emphasis on the
need to ensure that services are appropriately tailored to meet
the needs of the full range of problem users, and not just the
majority.
December 1997
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83 This estimate is based on the assumption that there
are three times the number of problem drug users as were notified
to the Home Office Addicts Index in 1996, implying some 130,000
problem users across Britain, and in excess of 100,000 in England
and Wales (Home Office, 1997). It also assumes that the 1996 British
Crime Survey can provide a broadly accurate estimate of the total
number of illicit drug users Ramsay and Spiller, 1997). The number
of problem drug users could well be higher, given that the Centre
for Research on Drugs and Health Behaviour estimated that there
are 125,000 injecting drug users alone. Back
84
An unpublished study by the Cambridge Institute of Criminology
has reportedly found one in five arrestees testing positive for
heroin use; whilst not all those who have recently used heroin
will be problem users, many will be-and this takes no account
of other types of drug. Edmunds et al (1997c) have estimated between
15 and 20 per cent of arrestees in various police stations may
be problem users. Back
85
Excluding motoring and summary offences. Back
86
Assuming that problem users are typically convicted of acquisitive
crimes of middling or low severity. Back
87
If a problem user acquired two criminal convictions a year, one
of which resulted in a probation order and the other in a short
prison sentence, expenditure would be well in excess of £5,000. Back
88
Extrapolated from expenditure in three large health authorities:-East
Sussex, Brighton and Hove; Lewisham, Lambeth and Southwark; and
Leicestershire. Back
89
Some 70 per cent of problem users are estimated to have Hepatitis
C (Strang and Farrell, 1996); if only a small proportion develops
severe liver problems, treatment costs will still be very significant.
The likely costs of Interferon/combination treatment could in
time be very high. Back
90
We use the term here to include residential rehabilitation, as
community rather than prison-based. Back
91
We recognise the complexity of identifying what proportion of
generic services are spent on problem drug users, but much more
could be done than happens at present. Back
92
Levi and Osofsky (1995) quote figures of seizure orders totalling
£62 million and recovered sums of £14 million."Hard
to Reach" Groups Back
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