3A comprehensive response to drugs
Comprehensive education, prevention and social support
49.It is essential that treatment and harm reduction services for those currently using drugs are improved in order to save lives and reverse the shockingly high rates of drug deaths. However, effort should also be focused more widely on improving prevention, education and social support–both to prevent people from using drugs in the first place, and to help improve people’s life chances as they recover from drug use.
50.We heard compelling evidence from those involved in educating young people about drugs about the importance of education which is founded on open dialogue, honesty and trust.73 However, too often parents lack the confidence to speak to children about drugs, leaving them to seek information on the internet, which firstly may give them unhelpful information, and secondly, does not give them the opportunity to ask questions.74 Stigma can make children reluctant to ask questions about drugs, for fear of being thought to be a user.75 Teachers have an important role to play, but may not be able to do so effectively - recent research showed that less than a third of them feel that their school is providing drugs education well, and fewer than half of teachers even know their own school’s drug policy.76
51.In its 2015 report on Prevention of Drug and Alcohol Dependence, the ACMD found evidence of approaches that are not effective, including “information provision (standalone school-based curricula designed only to increase knowledge about illegal drugs), fear arousal approaches (including ‘scared straight’ approaches), and stand-alone mass media campaigns”. In contrast, promising prevention programmes include “pre-school family programmes; multi-sectoral programmes with multiple components (including the school and community) and some skills-development-based school programmes”. The ACMD found that these effective programmes were not being widely delivered. It recommended that policy makers and commissioners should be realistic about what prevention services can achieve (e.g. seeking reductions in drug use, or delaying its onset, rather than creating complete abstinence). However, even these more limited aims can be highly cost effective by reducing the long-term consequences of problematic substance use.77
52.Prevention requires a deeper consideration of the circumstances surrounding a person’s drug use, and what might be done to support that person, rather than treating it solely as a clinical issue. Kerrie Hudson, operational lead at addiction recovery support service the Well and a person with a history of problem drug use, told us that when she was first treated for drug addiction as a teenager, this did not happen at all:
My experience of coming into a service was that I left school a heroin addict; I had my first methadone script at 17 years old but not a single person ever asked me, “What’s happened?”78
53.This matters at the end of people’s recovery journeys as well as at the beginning. Peter Yarwood of Red Rose Recovery described a ‘disconnect’ between the services and the communities they serve:
The first thing they want to celebrate is the fact that they are coming down the table in their medication–they are getting off it. When I ask them, “Have you managed to secure decent accommodation yet?”, the answer is often, “No, I am still in supported accommodation.” When I ask, “Have you secured employment yet?”, the answer is, “No, I am not employed. I’m still claiming benefits.” Recovery and social capital is in no way aligned to this drive to exit treatment. Where it has worked well, some of the resources have been ploughed into bringing the service users and the community with us on this journey.79
54.Tim Millar, Professor of Substance Use and Addictions, University of Manchester, echoed the importance of looking at the wider circumstances of a person’s life to help them with recovery:
If you have been using heroin for 30 years and have, at best, a patchy employment record and probably quite a substantial criminal record, it is difficult to reintegrate yourself. If we can support people to get jobs, friends and houses … that is highly likely to be productive.80
55.We also heard from witnesses about the links between trauma and addiction. Addiction explain these in their written evidence:
People with multiple adverse childhood experiences (ACE) are more likely to develop substance issues, in part to manage the overwhelming emotional and somatic sensations associated with trauma. Children who experience four or more adversities are eleven times more likely to go on to use crack cocaine or heroin. The chances of developing a dependence on substances double if a child has also experienced sexual abuse or other forms of violence.81
56.In Portugal we visited an outreach project focused first and foremost on giving drug users their own homes–the Portuguese experience is that once they are well-housed, people are far more able to take steps to recover from drug addiction and then towards other goals such as employment.
57.The first priority in developing a comprehensive response to drugs must be to improve existing drug treatment services, and extend and develop harm reduction initiatives. The Government needs to develop and fund a comprehensive package of education, prevention and support measures focused on prevention of drug use amongst young people. A comprehensive response should also include a focus on improving the life chances of people who are recovering from drug use. To do this, the Government should actively consider the re-establishment of a central drugs policy agency, drawing on lessons from both the Drug Treatment Agency and the Portuguese experience of SICAD (the central Directorate-General for Intervention on Addictive Behaviours and Dependencies). As well as funding and directing drug treatment services, it could play an important role in co-ordinating the multiple strands of drug policy, including policing, social care, education, housing and employment, and developing a truly joined-up, cross Governmental approach to drugs.
Reframing the approach to drugs policy
58.The first steps in developing a comprehensive approach to drugs must be to improve the funding, quality and availability of drug treatment and harm reduction services to save the lives of vulnerable people addicted to drugs, who are dying unnecessarily in unacceptably high numbers. As we stated at the start of this report, every drug death is preventable, and both policy and services should acknowledge that fact.
59.Next, it is essential to make wider improvements in prevention, education and social support. These measures should be strengthened and underpinned by reframing drugs as a health rather than a criminal justice issue. There is strong evidence that this reduces stigma and increases access to treatment and recovery. Moving responsibility for drugs policy from the Home Office to the Department of Health and Social Care is supported by the evidence, including from police representatives. International evidence has shown harm reduction approaches not only save lives but reduce the cost and burden on criminal justice systems.82
60.In some parts of England, the police have already begun to take steps towards reframing drugs as a health rather than a criminal justice matter. DS Woijeck Spyt explained the reasons for this:
Irrespective of your views on how effective prohibition is, prohibition has failed for the people the police come into contact with. The deterrent effect has not worked, otherwise those people would not be in possession of drugs. For the people with drugs that we come across, we need an alternative policy or an alternative strategy to address their drug use. The police are not medical professionals, so we are not equipped to deal with that drug use.83
61.Under the Durham Checkpoint scheme, first introduced in 2015, people caught in possession of drugs or involved in low level drug dealing are offered a ‘suspended prosecution’, giving them the opportunity to address the underlying causes of their drug use by encouraging them to engage with services designed to address their problems instead of receiving a caution or going to court. Early indications from an evaluation currently under way are that it reduces reoffending rates.84 Under Thames Valley Police’s approach, individuals found in possession of drugs are offered a ‘community resolution outcome’, which includes referral to, attendance, and engagement with a drug service provider. Drawing on the small pilot, projected savings to Thames Valley Police over a year are nearly £27,000. 42% of people referred completed their treatment (an initial assessment and three follow up sessions) but this rose to 78% of children and young people referred under the scheme.85
62.Hardyal Dhindsa of the National Association of Police and Crime Commissioners felt that the only disadvantage of these schemes was that they were not yet more widely available:
Diversion schemes can help reduce harm because you get people into treatment and recovery, as opposed to the criminal justice route … The problem from a police and crime commissioner strategic perspective is that it is ad hoc. In some places it is happening and in others it is not. We need a mechanism by which we understand the good practice and the evidence, and have a framework that enables it to be done consistently right across the country.86
Case example 2 - decriminalisation of possession in Portugal
In Portugal, possession of small amounts of illicit drugs for personal use has been reclassified as an ‘administrative’ rather than a criminal offence, and offenders are dealt with by statutory bodies called Dissuasion Commissions rather than the police or courts. These statutory administrative bodies, which are found in every region of Portugal, have powers to offer advice, refer for treatment, or refer to courts where necessary. Drugs are still illegal, and supplying and trafficking drugs is still illegal–we were told by the Vice-President of a Dissuasion Commission that the changes have not made it any easier to obtain drugs. We were also told that, as a result of the establishment of this system, resources have shifted from the criminal justice system to the health system. The number of people arrested for drug-related offences more than halved between 2000 - 2012.
Since 2002, Portugal’s drug death rates and HIV rates have fallen dramatically. While there were fears of ‘drug tourism’, this has not materialised, and drug use rates have remained stable. Academics and drug service workers we spoke to felt that the stigma attached to drug use had fallen, and that treatment was able to be provided in a more holistic, non-judgemental way. All those we met in Portugal involved in this policy area were very positive about their model. On introduction, there had been significant opposition, but there is now political consensus and nobody would want to go back. Some of those we met were now of the view that the next step should be legalisation and regulation, to enable the generation of taxation revenue and quality control.
However, we heard repeatedly that decriminalisation alone has not been responsible for these positive outcomes and that legal reforms cannot be considered in isolation from the wider, holistic package of measures that was introduced at the same time, including sustained investment in treatment service–without this wider package the outcome would have been totally different.
Decriminalisation was in fact only one of 80 recommendations made by the Portuguese Commission on Drugs in 2002. Interestingly, the Commission also recommended DCRs and take-home naloxone provision, but these recommendations were highly controversial and were not implemented, although Lisbon has recently established a mobile DCR.
We heard that Portugal is still facing challenges, many of which are linked to under-funding. These included a lack of access to drug treatment and psychological support in areas–some people we met reported that users could have to wait up to 2–3 months for treatment in some cases; prolonged dependence on methadone, in some cases over 20 years; and persistent problems in prisons.
63.Release, an organisation that provides information and advice on drug use and to drug law and campaigns on these issues, argued that the current illegal status of drugs prevents people from accessing treatment, and that decriminalisation could also play a role in reducing stigma and encouraging more people to seek treatment.87 Release also pointed out that only one in ten people who use drugs do so problematically,88 a point also emphasised by Police and Crime Commissioner Ron Hogg.89 We heard from health professionals that people with entrenched drugs problems often become ‘completely inured’ to the illegal nature of their behaviour, but that the illegality additionally complicates the lives of already extremely disadvantaged, disfranchised and stigmatised people.90 Professionals working with young people reported anecdotal evidence that the illegal status of drugs is a barrier to honesty and openness about drugs amongst young people, which can put them in more vulnerable situations.91 The stigma associated with drug use because of its illegality can also be a block to people living the lives they want to after recovery, and has an impact on the families of those using drugs as well, who often suffer from ostracization and isolation.92
64.We did not specifically examine the evidence relating to the legalisation of currently illicit drugs (“legalisation” in this context referring to making currently illicit drugs legal to supply and purchase, and potentially subject to regulation and taxation). However, we did consider approaches that move away from the current criminal-justice led approach to drugs, including diversion schemes, as described above, and decriminalisation - where the possession of small quantities of drugs for personal use is reclassified as an ‘administrative’ offence rather than a criminal offence.
65.In Portugal we heard that the decriminalisation approach has had an impact on stigma. There has also been, as would be expected, a reduction in arrests for personal possession drug offences, saving resources. Every person arrested for drugs possession now has a full risk assessment carried out, and is provided with advice, education and a treatment referral where necessary. Figures show a dramatic drop in drug related deaths in Portugal in the times since their reforms were implemented, without significant increases in drug use.93 Research suggests that in the eleven years following introduction of their new strategy, the cost to society of drugs fell by 18%. Whilst the reduction of legal system costs was one of the main explanatory factors, a reduction in health-related costs has also played an important role.94
66.However, a message we have heard very clearly and repeatedly, both on our visit to Portugal and from commentators in this country, is that decriminalisation alone was not responsible for these outcomes, and that the a major investment in drug treatment services, together with a wider holistic package of measures including education, community support and Dissuasion Commissions, was needed to achieve this change. Marta Pinto, an academic from the University of Porto whom we met during our visit to Lisbon, was clear in her presentation to us that it would be a mistake to consider the Portuguese legal reforms in isolation from the full holistic model, and that the outcomes in Portugal would have been very different had decriminalisation been introduced without an enhanced treatment offer and other supporting measures.
67.We heard that, from a very low base, it took two years of sustained investment and development to get treatment services to the necessary level. And the services have to be in place to support the increased demand from increased referrals, as the experience of English diversion schemes shows. Dr Wojkek Spyt of Thames Valley Police told us:
One of the biggest challenges in drugs diversion was to find the funding for the additional people we were referring. The local authority worked hard to alter the [key performance indicators] that had been set in the contract for the drug service provider, to enable them to deal with the additional demand we were sending their way. We are a gateway, so, if that gateway becomes bigger, the services we are referring to need more resources.95
68.Efforts to improve the unacceptably high rates of drug-related deaths would be strengthened by explicitly reframing drug use as a health rather than a criminal justice issue. Much of our evidence recommended that policy responsibility for drugs should move from the Home Office to the Department of Health and Social Care, and we strongly recommend this move. A health focused and harm reduction approach would not only benefit those who are using drugs but reduce harm to and the costs for their wider communities.
69.We support consultation on decriminalisation of drug possession for personal use, by changing it from a criminal offence to a civil matter. We recommend that the Government should look closely at how decriminalisation has been underpinned by a strong system of monitoring and referral for those who use illegal drugs through the Dissuasion Committees in Portugal, as well as the experience of police diversion schemes in England. Decriminalisation must only be introduced as one part of a full, comprehensive approach to drugs, the central plank of which is improving treatment and harm reduction services, underpinned by better education, prevention and social support. Any reforms should also be supported by rigorous evaluation which gathers longitudinal data on defined outcome measures.
77 ACMD, Prevention of Drug and Alcohol Dependence, 2015
82 The Lancet Commission on Public health and international drug policy, the Lancet, March 2016; Caitlin Hughes and Alex Stevens, What can we learn from the Portuguese decriminalisation of illicit drugs, British Journal of Criminology, July 2010; David Wilson et al, The cost effectiveness of harm reduction, International Journal of Drug Policy, February 2015; Ricardo Goncalves, A social cost perspective in the wake of the Portuguese strategy for the fight against drugs, International Journal of Drug Policy, February 2015
93 The Lancet Commission on Public health and international drug policy, the Lancet, March 2016
94 Ricardo Goncalves, A social cost perspective in the wake of the Portuguese strategy for the fight against drugs, International Journal of Drug Policy, February 2015
Published: 23 October 2019