Home Affairs Committee - Drugs: Breaking the CycleWritten evidence submitted by Caroline Lucas, MP for Brighton Pavilion (DP173)

1. Executive Summary

1.1 My constituency is based in a city that regularly has more drug related deaths than anywhere else in the UK.

1.2 Since being elected I have met with many people across the city who work with drug users, are users themselves or whose families are affected by drug use. There is widespread consensus that current and previous national drug strategies are flawed, in that they are not based on evidence about how to best reduce drug related harms and are based on deterrence and criminalisation rather than public health. Brighton and Hove is currently exploring ways to develop its commitment to an evidence and health based approach and has recently undertaken a number of new initiatives to this end. I would recommend that the Government allow local authorities to develop a locally designed and evidence based model in order to reduce drug related social, individual, economic and environmental harms, even if this is at odds with national strategy and as a way of informing best practice nationally in the future. It should be for local authorities to determine what such a model might look like and to decide whether the anticipated benefits outweigh any downsides.

2. Brighton and Hove

2.1 Since 1999 Brighton and Hove has regularly appeared within the top three jurisdictions with the highest rates of drug related deaths, as measured by St Georges Hospital.1 The annual rate of drug related deaths in the city has varied between 38 and 51 over the last five years and peaked in 2000 with 67 deaths.

2.2 Young people’s drug use in Brighton and Hove is slightly higher than the national average, according to data from the Tellus3 Study, as is alcohol consumption in the group studied—young people in years six, eight and 10 of secondary school. The latest survey results show that 13.7% of young people who participated locally had either been drunk or taken solvents/drugs at least twice in the previous four weeks, or had been drunk and experimented with drugs at least once in their lives. These findings place the city in the top quartile nationally, ranking 26 out of 150 local authorities. Drug related deaths are only recorded nationally for over 16s.

2.3 Adult drug users in the city seem to be predominantly men—approximately 70% of the local treatment population are male and 78% of drug related deaths were male in 2007, for example. The 45–54 age group is the group with the highest number of drug related deaths. Alcohol, heroin, opiates and benzos feature heavily in drug related deaths in the city.

2.4 Anecdotally, staff working with drug users report that they are seeing more young people using legal highs in combination with cannabis and alcohol, leading them to conclude that the demographics around drug use in the city are changing. This presents new challenges for the city, especially as reliable and regular data about young people’s drug use is in short supply.

3. An Evidence Based Approach

3.1 Brighton and Hove last year undertook a ground breaking intelligent commissioning exercise in order to develop commissioning outcomes for preventing and reducing drug related deaths. In part this is an attempt to ensure the city maintains its reputation as a high performing cutting edge authority, and in part an attempt to develop a better understanding of the current and future needs of local residents and communities of interest, the demand for services, what works and what needs to change. Intelligent commissioning is, above all, a response to the fact that drug related deaths in the city have remained consistently high and agreement that evidence based work is the only way to change this situation.

3.2 At present, services reflect the priority being given to heroin users in the city. The evidence on drug related deaths and drug related harms indicates this is appropriate. However, as drug use patterns change, the city is concerned that services are flexible enough to respond, whilst drug prevention work takes account of changing habits and is evidence based.

3.3 Brighton and Hove’s commitment to an evidence based approach can currently only take it so far in reducing drug related harms and deaths. The city has to operate within a national drugs strategy that does not include any assessment of the effectiveness of policies such as criminalisation. Nor does the national framework take full account of the evidence from abroad that suggests decriminalisation can reduce harms and drug related deaths, as has happened in Portugal, for example, or that an approach based on public health rather than legality can lead to a reduction in demand for heroin and in levels of crime, as has happened in Switzerland.

3.4 Moreover, there is a woeful lack of evidence about what kind of education programmes work with young people—although plenty to suggest that just telling young people not to take drugs and helping them to identify different substances has virtually no impact.

3.5 Perhaps most surprising, in these days of austerity and value for money, there has been no cost benefit assessment of the 1971 Misuse of Drugs Act even though the economic costs of Class A drugs are estimated at more than £15.4 billion per year. Nor has there been any attempt to compare the Act’s effectiveness in reducing the societal, economic or health costs of drug misuse with alternative approaches based on treating drug addiction as a health issue not a criminal one, for example, or based on regulation rather than prohibition. This oversight is especially worrying given that, far from being neutral, in many instances the current model can push users towards more harmful products, behaviours and environments.2

3.6 Despite the restrictions imposed nationally, Brighton and Hove has done its utmost to develop a local strategy that is based on evidence. The city has also done as much as possible within existing laws to respond to drug use as a public health issue.

4. Randomised Injecting Opiate Treatment Trial (RIOTT)

4.1 Brighton and Hove is home to one pilot of the groundbreaking randomised injecting opiate treatment trial (RIOTT) which has shown that patients who were previously dependent on heroin, but did not respond to conventional oral methadone substitution treatment, can achieve major reductions in their use of street heroin. The trial also examined the effectiveness and cost-effectiveness of treatment with injected and oral opioids (methadone and heroin).The main measure of effectiveness on the trial was the proportion of participants who stopped using illicit heroin. Participants on the trial told me that it had saved their lives. It has given them back control of their lives, allowed them to kick crime, find their families and, over time, reduce their drug use.

4.2 I have met with Professor Strang from Kings College London who is the Chief Investigator for RIOTT, and he describes the outcomes as follows:

The RIOTT study shows that previously unresponsive patients can achieve major reductions in their use of street heroin and, impressively, these outcomes were seen within six weeks. Our work offers government robust evidence to support the expansion of this treatment, so that more patients can benefit.

4.3 RIOTT is also an example of regulated use of a drug that is otherwise prohibited. It provides a useful, albeit limited, example of how regulation can enable users to become prescribed rather than street users, thereby illustrating some of the benefits of regularising the supply route and decriminalising drug use.

4.4 For example, RIOTT’s users have a safe and dependable supply of both drug and related paraphernalia. This reduces their risk of contracting the blood borne diseases usually associated with injecting—a tangible health benefit. Crucially, they also have one to one support and counselling.

4.5 Programmes like RIOTT do require an upfront financial investment but the savings to be made in terms of less police time following up drug related crime, for example, or costs to the NHS more than compensate. Those cost savings theoretically more than compensate, but one of the problems is the “compartmentalism” of current Government thinking, whereby the department making the savings isn’t the one to benefit from them—this is a major barrier to progress.

5. A Local Model

5.1 RIOTT is just one example of Brighton and Hove pursuing a health and evidence based approach to drug use.

5.2 Last year I organised a round table in the city that brought together around 40 people concerned about the high level of drug related deaths, including professional experts, service commissioners, and service users. A number of important points were raised, some of which have been progressed already.

5.3 Naloxone: Provision of Naloxone Hydrochloride has the potential to save lives in overdose situations.3 Given that identified sectors of the population are most at risk I was keen to ensure that Naloxone packs were targeted appropriately and pleased to learn that significant work was already underway in Brighton and Hove to this end. Naloxone is now widely distributed to high risk cohorts of service users specifically:

5.3.1Offenders leaving HMP Lewes—alongside appropriate training.

5.3.2Parents and Carers—evidence shows that most people who overdose are either with or discovered by someone they know.

5.3.3All homeless people living in Hostels within the City. Training (or in some cases re-training) is also provided so that all hostel staff can recognise the signs of overdose and know how to administer Naloxone.

5.4 The city proposes to extend the provision of Naloxone further in order to ensure that all staff/staff teams working with people at risk of overdose can have immediate access to it.

5.5 Benzodiazepine use: Brighton and Hove has one of the highest rates of benzodiazepine (benzo) prescribing in the UK and benzos feature in over 50% of drug related deaths within the city. The vast majority of benzo prescribing happens via GPs and there is also the problem of benzos being widely available illicitly and over the internet.

5.6 NHS Brighton and Hove have part-funded a specialist Benzo Liaison Nurse within Sussex Partnership NHS Foundation Trust since 2009 and in 2010–11 the NHS Plan included a target to reduce benzodiazepine prescribing by 20%. Following the drugs roundtable, and clear indications from all involved that there needed to be further concrete action in this area, a special meeting was convened by Sussex Partnership NHS Foundation Trust. Among other actions, it was agreed to:

5.6.1Issue explicit guidance to all GPs about how to reduce low level/sub-therapeutic benzodiazepine prescribing—linking the existing prescribing incentive scheme with benzo reductions.

5.6.2Move responsibility for benzo prescribing for all service users in treatment to the treatment services.

5.6.3Produce promotional material for all community pharmacists.

5.6.4Try and develop peer lead support groups via MIND, as well as extend the support for benzo users within primary care through increasing the complement of support workers and existing volunteer counsellor/peer lead support.

5.7 Replacement programmes to recovery: The roundtable participants also discussed whether there was a tendency to leave users on replacement programmes without sufficient support and incentive to become drug free. Some present noted that there is a very real risk that individuals with a drug dependency will disengage from the treatment system if abstinence is the only option available to them, resulting in an increase in illicit use. It was agreed that as a city we need to be more ambitious on behalf of service users and look at the evidence surrounding drug free recovery, especially given the Government’s focus on abstinence.

5.8 Although not yet published the official drug death figures for 2010 are likely to show a dramatic reduction to less than 35 in Brighton and Hove. The Director of CRI, a major provider of drug services in the city says: “The speed of access to treatment, reduction in the rate of ‘unplanned discharge’ from services and wider availability of Naloxone would seem to have already had an impact. The well publicised heroin drought following the failed crop in Afghanistan in 2010 will similarly have had an impact.”

5.9 Brighton and Hove’s health and evidenced based model is supported on a personal level by Chief Superintendent Graham Bartlett of Brighton and Hove Police who says: “the use of drugs is not well addressed through punitive measures. Providing people with treatment not only resolves their addiction—thereby minimising risk of overdose, drug related health issues, anti social behaviour and dependence on the state, for example—but cuts the cost to the community by reduced offending.”

5.10 Brighton and Hove Police’s Operation Reduction initiative, first set up in 2005, also puts an emphasis on treatment. Through a coordinated response involving treatment and enforcement agencies, it looks to get more drug users into treatment as well as increasing the level of drug seizures and the number of individuals being charged for the supply of drugs. An assessment conducted in 2008 indicated that encouraging users into treatment had resulted in a 69% reduction in total offending between the two year pre and two year post period. For those targeted by the supply side interventions a 62% reduction in total offending had been observed. The scheme has contributed significantly to a decrease in offending across the city, specifically in terms of a reduction in the acquisitive offences associated with funding a drugs habit. Operation Reduction has received national recognition and in 2006 was commended at the annual Tackling Drugs Supply Awards.

6. Alcohol and Mental Health

6.1 Alcohol is a feature in a majority of drug related deaths—in 2009 alcohol was present in 60%.

6.2 Brighton and Hove has the second highest rate of suicides in England and in 2009 13% of drug related deaths were recorded as also having suicidal intent.

6.3 The city is keen to explore these links further, as well as those between levels of drug use and inequality, for example, to further inform its approach.

7. Recommendations

7.1 I would like to urge the Select Committee to make the following recommendations to the Government:

7.1.1That the national drugs strategy should give local authorities like Brighton and Hove far greater scope to pursue policies that are evidence based, which are shown to work locally to reduce drug related deaths and harms, and the benefits of which they have determined will outweigh any disadvantages. This should be granted even if local priorities are at odds with national policy or legislation. Government should also fund local authorities to this end. This would be in keeping with the advice from the Global Commission on Drugs who have recommended that national governments allow local initiatives to experiment with locally designed models that are, as they put it, “designed to undermine the power of organised crime and safeguard the health and security of their citizens.”

7.1.2To transfer the lead for drug policy from the Home Office to the Department for Health.

7.1.3To conduct an impact assessment of the Misuse of Drugs Act 1971, in order to compare the economic, environmental and social costs and benefits of existing policies with a range of alternatives. Ongoing evaluation should be made a formal requirement of all drugs policies and legislation.

7.1.4To ensure that St George’s Hospital’s national programme on substance abuse deaths continues and that a coherent national programme of collecting data about drug use and attitudes towards drug use, including young people, is introduced.

7.1.5To extend the RIOTT programme to other cities where there is an identified need.

February 2012

1 www.sgul.ac.uk/research/projects/icdp/our-work-programmes/substance-abuse-deaths/

2 For example see McSweeney, T, Turnbull, P J and Hough, M (2008). Tackling Drug Markets & Distribution Networks in the UK London: UK Drug Policy Commission
www.ukdpc.org.uk/resources/Drug_Markets_Full_Report.pdf Accessed 04.19.11

3 www.nta.nhs.uk/news-2011-naloxone-report.aspx

Prepared 8th December 2012