DRP0047

Written evidence from Transform Drug Policy Foundation

1.  Transform works to reduce drug-related harm through evidence-based reforms to policy and practice. We are an independent charity working with a range of national and international partners, and we hold ECOSOC special consultative status at the United Nations. For more information on our work see www.transformdrugs.org, or contact info@transformdrugs.org 0117 325 0295.

2.  We are happy to submit additional analysis or evidence on request, and give oral evidence.

3.  Summary

Developing effective responses to drug-related health harms requires a public health approach. This means identifying the nature and scope of the problem, understanding the structural drivers that shape risk and vulnerability, and tailoring interventions to target risk and protective factors. Our submission identifies key drivers of harm and describes reforms that could mitigate them.

4.  What is the extent of health harms resulting from drug use?

In 2017, there were 3,573 deaths related to illegal drugs in the UK.[1]  The rate of heroin and morphine deaths in England and Wales increased dramatically between 2012 and 2016 doubling from 10 to 21 per million.[2] Cocaine-related deaths increased from 1.9 deaths per million in 2011 to 7.5 deaths per million last year.[3] We are also seeing an increase in the number of deaths associated with fentanyl.

5.  In Scotland, death rates are considerably higher. On average, between 2013 and 2017, around 140 deaths per million were linked to drugs other than alcohol.[4] If we take the 2017 figure alone (934 deaths), this rises to 263 deaths per million among 15-64 year-olds: the highest in Europe by a large margin.[5] The next highest in Europe in 2016 was Estonia (132 per million) then Sweden (88 per million).[6] Portugal’s rate was 3.86 deaths per million - just 27 people from a population almost twice the size of Scotland's.[7]

6.  Early data indicates a further 43% rise in drug overdose mortality in Glasgow from January to October last year, compared with the same period in 2017.[8]

7.  Overall, around a third of all drug deaths in Europe occur in the UK.[9] These figures are proportionately high in comparison to alcohol, despite the fact that on a wide range of measures alcohol ranks as one of the most harmful psychoactive substances.[10]

8.  In England and Wales there were also 7,258 hospital admissions in 2017/18 related to drug-related mental and behavioural disorders: 9% higher than 2008.[11]

9.  According to the National AIDS Trust, the mortality rate for men with HIV was more than four times higher if they injected drugs.[12] In Glasgow, there were 121 new HIV infections 2014-17 among people who inject drugs.[13] With many other UK urban centres having similar issues, there is a risk of further outbreaks.

10.  Underlying social drivers of problematic drug use and high risk behaviour

Problematic drug use is not the inevitable consequence of initiation. Most individuals who try illegal drugs use them occasionally, moderately, and do not suffer significant health harms as a result. The United Nations Office on Drugs and Crime (UNODC) estimates that around 11% of people who take illegal drugs globally suffer from drug use disorders.[14] However, there is a clear and well-evidenced link between problematic or high risk behaviours and a series of underlying environmental risk factors. These include social deprivation, inequality, parental neglect, emotional, physical or sexual abuse, histories of being in care, poverty, school exclusion, mental health problems, and changes in social/personal status such as unemployment, divorce or bereavement.[15]

11.  Currently, policy is too narrowly focused on punitive enforcement-led goals. For drug policy to effectively reduce harm, it needs to address the wide range of factors that drive problematic use.

12.  Punitive ‘tough on drugs’ politics, and criminalisation of people who use drugs

UK drug policy is based on two core assumptions. Firstly that supply-side enforcement can prevent or reduce drug use, and secondly that the criminalisation of people who use drugs is an effective deterrent. There is little evidence to support either assumption. 

13.  In 2003 the Prime Minister’s Strategy Unit estimated that removing organised criminals from the drug trade would require consistent seizure rates of 60-80%.[16] The Government has made no estimate of seizures as a proportion of the total drugs market.[17] However, research in Scotland estimated heroin seizures amounted to around 1% of the supply 2000-06.[18] Viewed in this context, seizures are an affordable cost of business for organised crime groups. Far less than tax rates paid by most legitimate businesses on trades with substantially lower profit margins, or even legal product loss rates (supermarkets waste around 2% of food, and fresh fish retailers waste 5% of products).[19]

14.  In reality, supply-side enforcement seizures target low hanging fruit, and advantage the most efficient and ruthless criminal operators. In a high-profit market criminal entrepreneurs will always find a way to meet demand, and supply disruptions have historically been temporary, localised and marginal. They can displace markets, but not eradicate them. The ‘County Lines’ phenomenon, for example, is partly a response by organised crime gangs to the successful disruption of previously dominant supply chains and networks.

15.  More than half a century of enforcing prohibition has failed in achieving its goal, recently re-stated by the Home Secretary, of a ‘society free of drugs’.[20] Indeed, the UK Government’s evaluation of its 2010-16 Drug Strategy acknowledges these failures, stating that ‘some enforcement activities can contribute to the disruption of drug markets...but the effects tend to be short-lived. Activity solely to remove drugs from the market, for example, drug seizures, has little impact on availability’, that ‘illicit drug markets are resilient and can quickly adapt to even significant drug and asset seizures.’[21] The latest authoritative analysis on this issue comes from the UN System Coordination Task Team of the UN Chief Executive Board (representing the directors of all 31 UN agencies, and chaired by the Secretary General) assessing the efficacy of the UN’s 2009-19 global drug strategy. In March 2019 it produced a highly critical report entitled “What have we learned in the last ten years?” concluding that; ‘The assumption that tougher law enforcement results in higher drug prices and therefore lowers the availability of drugs in the market is not supported by the empirical evidence.’[22]
 

16.  There is a similar lack of evidence for the user-level deterrent effect of punitive enforcement. In 2006 the Science and Technology Select Committee concluded that: ‘We have found no solid evidence to support the existence of a deterrent effect, despite the fact that it appears to underpin the Government’s policy on classification’.[23] The Government’s response was to say that it ‘believes’ there is such an effect, but ‘accepts that there is an absence of conclusive evidence’.[24] No such evidence has emerged in the subsequent 13 years, despite the Home Office’s commitment to ‘consider ways in which the evidence base in the context of the deterrent effect can be strengthened’.[25] In 2014 the Home Office stated that it failed to ‘observe any obvious relationship between the toughness of a country’s enforcement against drug possession, and levels of drug use in that country’.[26] The latest UK drugs strategy evaluation noted that ‘there is, in general, a lack of robust evidence as to whether capture and punishment serves as a deterrent for drug use’.[27]

17.  In a study of the relationship between policy and prevalence of use of cannabis in nine countries, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) found that ‘no simple association can be observed between legal changes and cannabis use prevalence’[28].  A World Health Organization study of 17 countries found that drug use ‘is not simply related to drug policy, since countries with stringent user-level illegal drug policies did not have lower levels of use than countries with liberal ones’[29]. The Advisory Council on the Misuse of Drugs has also noted that ‘peer-reviewed studies have not found that removing criminal penalties for possession is associated with higher rates of drug use.’[30] Most recently, a study of cannabis use among over 100,000 teenagers in 38 countries found no direct association between policy liberalisation and use.[31]

18.  Criminalisation of people who use drugs does, however, have a profoundly negative impact in terms of creating or exacerbating health harms. As the Royal Society for Public Health recently stated:

19.  Criminalisation [of people who use drugs] leads directly to long-term health and wellbeing harm, including greater exposure to drugs in prison, severing of family relationships, and barriers to education and employment. This harm falls disproportionately on disadvantaged ethnic and socio-economic groups – who are far more likely to be charged for drug possession despite similar levels of use – exacerbating existing health inequalities...criminalisation fails to address underlying substance misuse issues and discourages those with an addiction from coming forward for treatment.[32]

20.  Over 80% of all recorded drug offences are for possession, rather than supply. In 2017, 1,017 people in England and Wales were imprisoned for possession for personal use alone.[33] Health harms from drug use in prison include transmission of HIV and Hep C through injection drug use, and recent concerns with synthetic cannabinoids e.g. Spice.[34] As the Government’s own review of the Psychoactive Substances Act has noted, imposing a ban on substances such as Spice, while associated with an overall reduction in use, has led to much more acute harms among vulnerable users including the prison population.[35]

21.  The Government’s evaluation of its previous Drug Strategy accepts that:

22.  There are potential unintended consequences of enforcement activity such as violence related to drug markets and the negative impact of involvement with the criminal justice system...including unemployment and harm to families – parental imprisonment is a risk factor for child offending, mental health problems, drug abuse and unemployment amongst others.[36]

23.  The Director of the UN Office on Drugs and Crime (UNODC) has not only recognised that current drug policy creates ‘a huge criminal black market that thrives in order to get prohibited substances from producers to consumers’, but furthermore:

24.  What one might call policy displacement. Public health, which is clearly the first principle of drug control, also needs a lot of resources. Yet the funds were in many cases drawn away into public security and the law enforcement that underpins it. [37]

25.  Higher levels of enforcement are associated with hurried and higher-risk injecting.[38] Enforcement-related price inflation can also encourage high-risk injecting over safer forms of administration (e.g. snorting or smoking) to maximise ‘bangs for bucks’.[39]  Displacement from one drug to another can also follow enforcement efforts.[40] [41] The impacts are unpredictable, but as experience with amphetamine-type stimulants and NPS demonstrates, can lead to the use of novel drugs about which little is known (a risk factor in itself), creating challenges for police, forensics, harm reduction, treatment and emergency services.[42] Inadequate access to information can encourage high-risk behaviours such as poly-drug use and bingeing, and increase risks in crisis situations.

26.  Criminalisation can create political and practical obstacles for health professionals in doing their job addressing drug-related health problems and reducing harms, and how they are obliged to work within a legal and policy framework that is often in direct conflict with fundamental medical ethics – not least the commitment to ‘first, do no harm’.

27.  Authorities seeking to educate young people about drug risks are simultaneously seeking to arrest and punish them. The resulting alienation and stigma undermines outreach to those most in need. A recent EMCDDA report on systems approaches to prevention reiterated the case that punitive drug laws can hinder, not help, effective prevention measures.[43]

28.  Enforcement impacts disproportionately on some of the most vulnerable and marginalised populations – those from socially deprived or BAME communities, young people, people with mental health problems, people who are dependent on drugs, and people who inject drugs. Black people are stopped and searched for drugs at almost nine times the rate of whites, while Asian people and those in the ‘mixed’ group are stop-searched for drugs at almost three times the rate of white people.[44]

29.  Prohibition and unregulated supply

Criminal markets encourage the creation and use of more potent drugs that generate greater profits. This is comparable to how, under 1920s US alcohol prohibition, consumption of beer and wine gave way to sales of more concentrated, profitable and dangerous spirits. Under current prohibition, smoked opium has been replaced by injectable heroin, increasingly now being cut with fentanyl, and cocaine markets have evolved towards smoked or injected crack cocaine. More recently, the cannabis market has become increasingly saturated with more potent varieties, as well as synthetic cannabinoids such as Spice.

30.  Illegally produced drugs lack health and safety information, and are of unknown (and highly variable) strength and purity, creating a range of risks not associated with their counterparts in the legal market.[45] Risks of overdose are increased, particularly for people who inject drugs, when drugs are unexpectedly potent. There are infection and poisoning risks associated with the adulterants and bulking agents used by criminal suppliers to maximise profits.[46] A particularly alarming recent concern is the emergence of the potent synthetic opioid fentanyl (50 times more potent than morphine), and fentanyl analogues such as carfentanil (1000 times more potent than morphine) in supplies of street heroin. There were an estimated 75 fentanyl deaths in England and Wales in 2017, 29% higher than the previous year.[47] In the US there were 28,000 deaths involving synthetic opioids (other than Methadone) in 2017[48], with Canada also facing a rapidly escalating fentanyl-related death rate.[49] Although other issues are involved in North America, this highlights the potential future scale of this challenge.

31.  There is a particular infection risk amongst injecting drug users from biological contaminants. The UK for example, has witnessed clusters of infections associated with contaminated heroin, including 35 deaths in 2000 from Clostridium novyi bacterium,[50] and over 30 infections with Bacillus anthracis (anthrax) leading to ten deaths in 2009-10.[51]

32.  The 2019 UN System Coordination Task Team  review of global drug policy - mentioned previously - concluded:

33.  Punitive drug policies continue to be used in some communities, despite being ineffective in reducing drug trafficking or in addressing non-medical drug use and supply, and continue to undermine the human rights and well-being of persons who use drugs, as well as of their families and communities. [Our emphasis]

34.  Drug seizures themselves cannot generally be expected to disrupt drug markets unless they are extremely large since usually suppliers can easily replace the lost drugs at wholesale costs. ... once a market is established, there may be little return on an investment in intense law enforcement.[52]

35.  The evidence is clear - policies criminalising people who use drugs, and blanket prohibitions of widely used drugs are at best ineffective, but more often are actively harmful, particularly to the vulnerable and marginalised. Instead, examination of the structural drivers of drug-related health risks point towards a range of policy needs and different health-led solutions:

36.  Addressing longer term social inequality and deprivation

The limits of traditionally understood drug policy interventions need to be understood, and drug policy contextualised within the wider long term challenges of addressing shortcomings in a range of welfare, mental health, and social services, particularly for marginalised populations who are most vulnerable to problematic drug use and related harm, as well as wider challenges of inequality, multidimensional deprivation, and youth alienation.

37.  As the UN System Coordination Task Team notes: ‘Vulnerability factors are largely out of the control of the individual and are linked to a multitude of social, environmental and health conditions, requiring interventions that address not only drugs but also other risk factors’[53]. Addressing these underlying social drivers of drug related health harms, and protective factors, is clearly a far bigger challenge for policy makers (and beyond the scope of this short submission).

38.  Reverse cuts to public health and drug services and remove obstacles to evidence based innovations
 

We urgently need to reverse the cuts in drug treatment funding. Whilst all public services have borne cuts, reducing treatment services is a false economy, creating much greater downstream costs.

39.  Political obstacles to innovative harm-reduction interventions need to be removed. Transform has been closely involved in supporting a number of these innovations including:

• Police-led initiatives to divert people caught in possession of drugs into health services  rather than prosecution and custody
• The use of Heroin Assisted Treatment for people with long terms heroin dependency  who do not respond to standard opiate substitution approaches[54]
• Drug safety testing services, which help prevent use of adulterated or high-strength products[55]
• Safer drug consumption rooms (DCRs), which have engaged hard to reach populations in treatment, prevented overdose deaths and HIV infections across the world, are recommended by the ACMD,[56] but remained blocked by the UK Home Office[57]

40.  Decriminalisation and Diversion

The United Nations Chief Executives Board for Coordination - representing 31 UN agencies including the World Health Organisation, the UNODC, UNICEF and UHOHCHR recently stated its unanimous support for member states to ‘promote alternatives to conviction and punishment in appropriate cases, including the decriminalization of drug possession for personal use’ and to ‘call for changes in laws, policies and practices that threaten the health and human rights of people’.[58]

41.  Decriminalisation is now also the editorial position of the Lancet[59], and the British Medical Journal (which also supports legal regulation)[60] and the policy of the Royal Society for Public Health, the Royal College of Physicians[61], and the British Medical Association. Decriminalisation of some or all drugs is now established policy in more than 25 countries[62]. Useful guidance on best practice has been assembled by the Global Commission on Drug Policy.[63]
 

42.  Since decriminalising possession and use of drugs in 2001, Portugal has seen problematic use, drug-related deaths and HIV infections fall significantly.[64] Decriminalisation was the ‘critical enabler’ that released additional funding for treatment, and allowed a more integrated health based approach while removing the many negative impacts of criminalisation described above.

43.   

44.  Source: Portugal Country Report 2018 http://www.emcdda.europa.eu/countries/drug-reports/2018/portugal_en

and Drug Related Deaths in Scotland, NRS Scotland 2018 https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/deaths/drug-related-deaths-in-scotland

45.  UK Diversion Schemes

A growing number of police force areas are taking step towards this approach through the introduction of schemes to divert people caught in possession of drugs for their own use (or in some cases for minor supply or cultivation of cannabis offences) away from the criminal justice system, and instead refer them for an assessment, education, support or treatment.[65]

46.  Heroin Assisted Treatment (HAT)

HAT can help reduce overdose deaths, HIV infections, use of illicit heroin, acquisitive crime, street dealing, and street drug litter. It has also been credited with aiding a substantial fall in heroin use in Switzerland. UK HAT trials found acquisitive crimes per user fell from about 40 to 13 per month - a fall of around 13,000 crimes per year committed by the 40 people on the trial.[66]

47. 

48.  Source: Switzerland moved to a health based approach, including HAT and Drug Consumption Rooms in 1994. Addiction Monitoring in Switzerland, Federal Office of Public Health http://www.suchtmonitoring.ch/fr/3/7.html?opioides-mortalite ; Drug Related Deaths in Scotland, NRS 2018 https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/deaths/drug-related-deaths-in-scotland

49.  Drug Safety Testing

High and variable strength, and contaminants in illegally produced and sold drugs, are key drivers of drug related fatalities. Testing services for people who use drugs reduce the risk of overdose or poisoning, as does tailored expert harm reduction advice provided with test results. It also provides an opportunity to deliver targeted health advice to ‘hidden populations’ not normally engaged with drugs services, and to monitor drug content and trends.[67] Where exceptionally strong, contaminated or mis-sold drugs are found, medical and emergency services can be alerted, and public warnings issued.[68] Such services have been running successfully in a number of European countries for more than 20 years.

50.  After a number of informal UK projects in festivals and city centres since 2016[69], the Home Office has recently given approval for, and licensed a pilot drug safety testing facility in Weston-Super-Mare, delivered by the national treatment provider Addaction.

51.  Supervised Drug Consumption Rooms (DCRs)

The Home Office has acknowledged that DCRs have public health benefits, for example a letter to Glasgow City Council, which unanimously asked permission to open one,[70] says:

52.  The Government’s own report, Drugs: International Comparators (2014), acknowledges that there is some evidence for the effectiveness of drug consumption rooms in addressing the problems of public nuisance associated with open drug scenes, and in reducing health risks for drug users. The Government’s Advisory Council on the Misuse of Drugs (ACMD) has also provided additional evidence based on studies of the effectiveness of facilities in Vancouver and Sydney, noting that they reduce injecting risk behaviours and overdose fatalities. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) too finds that drug consumption facilities have the ability to reach and maintain contact with high-risk drug users who are not ready or willing to quit drug use.[71]

53.  The other concerns in the above Home Office letter rejecting Glasgow City Council’s request are dealt with in a letter to the Home Office minister Victoria Atkins, from three Police and Crime Commissioners, including:

54.  We can assure you that the police in the UK have similar experiences [to police in European countries] and would have the requisite knowledge and skills to manage law enforcement to tackle drug dealing and to tolerate drug possession offences to allow the DCR to operate properly – as we do with current harm reduction centres.[72]

55.  The Government’s current main argument for opposing DCRs is that by allowing illegal drug use, they support the illegal drug market. But the reverse is true. In the short term, without a DCR, people will still buy the same quantity of drugs - but they will often use them alone, and/or in the street instead. In the long term, DCRs can reduce the size of the illegal drugs market, as they help get people into treatment. According to the EMCDDA:

56.  There is no evidence to suggest that the availability of safer injecting facilities increases drug use or frequency of injecting. These services facilitate rather than delay treatment entry and do not result in higher rates of local drug-related crime.[73]

57.  Exploring options for regulation of drugs production and supply

Identifying illegal production and supply as a key driver of multiple health harms demands an exploration of options for legally regulated markets for certain widely used drugs. This is no longer a theoretical debate - with multiple jurisdictions now exploring or implementing legally regulated markets for cannabis (including Uruguay, Canada, Mexico, the Netherlands, New Zealand and 11 US states including California), and other drugs (Coca in Bolivia, NPS in New Zealand). Transform has produced a range of detailed analysis and proposals for how responsible regulation might happen for different drugs in different scenarios, as well as case studies of regulation in practice[74]. 

58.  We also note that in 2002, and again in 2012 the Home Affairs Select Committee recommended:

[T]hat the Government initiates a discussion within the Commission on Narcotic Drugs of alternative ways—including the possibility of legalisation and regulation—to tackle the global drugs dilemma[75]

59.  Recommendations

60.  Re-centre drug policy towards evidence based public health and harm reduction approaches, and away from failed punitive enforcement, repressive approaches and ‘war on drugs’ ideology.

61.  The lead on UK illegal drug policy should move from the Home Office to the Department of Health to help ensure that in future the UK has a joined up, health-led approach to all drug use - illegal and legal.

62.  Government should establish a more comprehensive monitoring and evaluation framework for all elements of drugs policy, specifically regarding health impacts - including indicators and targets for reducing key health harms - including drug related deaths.

63.  Government should urgently remove existing political, legal and practical obstacles to a range of evidence based harm reduction interventions - specifically:

64.  Government should ring-fence a minimum drug treatment budget as part of the public health grant to each local authority to prevent and reverse recent cuts.

65.  Government should devolve decision-making over opening supervised drug consumption rooms to local areas to allow them to meet local needs - as it has done for Drug Safety Testing. This would aim to allow the opening of pilots, with a view to amending the Misuse of Drugs Act 1971 when mandated evaluation demonstrates efficacy on key indicators.

66.  Government should support a wider roll-out of Drug Safety Testing, including in city centres, with increased research funding to properly evaluate impacts.

67.  Government should follow the ACMD advice by providing funding for national upscaling of HAT availability to meet need in key target populations. This can usefully begin with provision of research funding for a series of local pilots to establish UK best practice. This funding must be additional to existing resources for drug treatment services.

68.  Home Office and Department of Health to develop best practice guidelines on developing and delivering Diversion schemes to maximise the public health benefits - and begin a process of wider legislative reform to bring forward de jure decriminalisation of small scale non-violent drug offences including possession for personal use, and minor supply or cultivation of cannabis offences.

69.  Government to set up a  National Drug Policy Working Group to coordinate and support delivery of drugs service innovations and wider structural reforms at the local, regional and national level. The group would include key stakeholders from relevant Government departments and agencies, service providers, and groups representing people who use drugs and other impacted communities.

70.  Establish an independent expert parliamentary commission of inquiry to explore options for, and make recommendations, on the legal regulation of certain currently illegal drugs.

 

71.  Appendix A

73.                @glasgow.gov.uk

74.  Reference: TRO/0003293/18

75.  Dear              ,

76.  Thank you for your e-mail of 10 April addressed to the Home Secretary about drug consumption rooms (DCRs).  Your question has been dealt with by the Drugs Legislation Team at the Home Office.

77.  The Government, along with all of those involved in this area, recognise the need to reverse the recent trends that we have seen in drug-related deaths.  However, we disagree on several points in relation to the establishment of DCRs.  Whilst the Government is aware of the potential public health benefits of DCRs, there is no legal framework for their provision in the UK and we have no plans to introduce them.  A range of offences are likely to be committed in the operation of DCRs.  The UK's approach on drugs remains clear - we must prevent drug use in our communities and support people dependent on drugs through treatment and recovery.

78.  The Governments own report, Drugs: International Comparators (2014)[1], acknowledges that there is some evidence for the effectiveness of drug consumption rooms in addressing the problems of public nuisance associated with open drug scenes, and in reducing health risks for drug users.  The Government’s Advisory Council on the Misuse of Drugs (ACMD) has also provided additional evidence based on studies of the effectiveness of facilities in Vancouver and Sydney, noting that they reduce injecting risk behaviours and overdose fatalities.[2]  The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)[3] too finds that drug consumption facilities have the ability to reach and maintain contact with high-risk drug users who are not ready or willing to quit drug use.

79.  However, the Government is not prepared to sanction or condone activities that support the organised trade that facilitates the availability of drugs and causes harm to individuals and communities.[4]  It is important that the Government continues to send a clear message that drugs controlled under the Misuse of Drugs Act 1971, and their supply, present such harms that possessing them under any circumstances must be subject to a commensurately strict regime.

80.  There are also practical difficulties that the establishment of DCRs in the UK may pose.  The Home Office report noted that DCRs have been legally problematic, pose ethical issues for medical professionals and difficulties for enforcement agencies.  The report cited the example of one facility in Switzerland in which low-level dealing was permitted on the premises.  While the example in the report may be unique to the model in operation in the facility in question, it highlights the difficulties that the police in the UK may face in enforcing the law in the event a DCR was established.

81.  The report also finds that DCRs have the potential to attract users from wide distances.  For example, in a facility in Copenhagen, Denmark, some users come as far as the Jutland peninsula and from Sweden.[5]  It is therefore a concern that the creation of a DCR in one part of the UK may pose difficult law enforcement questions for police forces other than the one hosting the facility.

82.  Our broader approach: 2017 Drug Strategy

83.  The Government’s approach to reducing the harms caused by drugs is a balanced one.  In addition to recognising the need to restrict supply and reduce demand, the Government’s 2017 Drug Strategy sets out a continued commitment to supporting individuals to recover from their dependence and live a life free from drugs and dependence.

84.  In this regard, whilst the Government will not change the law to allow DCRs, we support a range of evidenced-base approaches to reduce the health-related harms associated with drug misuse.  For example we have maintained the availability of injecting equipment through needle and syringe exchange programmes to prevent blood borne infections.  We have also amended the Misuse of Drugs Regulations 2001 to permit needle exchange programmes to distribute foil for heroin smoking and we are committed to widening the availability of Naloxone to prevent drug-related deaths.

85.  We also recognise that, for many people who become dependent on heroin, opioid substitution therapy (OST) will be an important part of their pathway to recovery.  OST has a widely-recognised and evidenced effect in helping to reduce deaths from overdoses, and in reducing other harms caused by drug misuse.  For those where opioid substitutes have not been effective, Heroin Assisted Treatment (HAT) provides an alternative and effective way of treating individuals.  This is an option open to local areas under the existing legal framework and we fully support local areas that pursue this approach, including the Glasgow proposal.  Given that funding decisions on drug and alcohol treatment have been devolved, it is for local areas to decide whether to commission HAT services based on an assessment of local need.  As such we would be supportive of Glasgow’s initiative to provide HAT where it meets the needs of local service users.

86.  I hope that this reassures you the Government is committed to tackling the harms associated with the misuse of drugs whilst having no plans to introduce DCRs.

87.  Drugs Legislation Team

Drugs and Alcohol Unit

Home Office

Email: Public.Enquiries@homeoffice.gsi.gov.uk 

[1] https://www.gov.uk/government/publications/drugs-international-comparators

[2] Advisory Council on the Misuse of Drugs, Reducing Opioid Related Deaths in the UK, p.36

[3] http://www.emcdda.europa.eu/topics/pods/drug-consumption-rooms

[4] The Government’s concerns about the potential for the creation of such facilities condoning organised crime are also shared by the UN’s International Narcotics Control Board, as set out in its 2016 Annual Report: https://www.incb.org/documents/Publications/AnnualReports/AR2016/English/AR2016_E_ebook.pdf

[5] Drugs: International Comparators Report (2014), p14.

88.  Appendix B

89.  Victoria Atkins MP

Ref: AJ/HE/1713

Minister for Crime, Safeguarding and Vulnerability

Home Office

2 Marsham Street

London SW1P 4DF

04 May 2018

Dear Minister

90.  STATEMENT ON ‘REDUCING OPIOID-RELATED DEATHS IN THE UK REPORT – FURTHER RESPONSE REGARDING DRUG CONSUMPTION ROOMS’

91.  In your recent response to the ACMD’s recommendation, you expressed concerns about “the challenges that DCRs place on law enforcement agencies”i. As democratically elected Police and Crime Commissioners, responsible for the strategic direction of our respective police forces, we are well-placed to address the anticipated issues you raised. However, we are deeply concerned about the government’s continued opposition to the introduction of DCRs.

92.  Evidence, including reports you have cited, highlight the success of DCRs in other countries

93.  In your letter to the ACMD you state that The Home Office’s International Comparators report “concluded that DCRS have often been legally problematic, pose ethical issues for medical professionals and difficulties for law enforcement”. However the same report found that DCRs “increase access to social, health and drug treatment services”, “target difficult, hard-to-reach drug users”’, and “provide a safer injecting environment”.

94.  The International comparators report also states that “DCRs in other countries have most often been established as a response to the acute social and public health issues that arise when drug misuse is concentrated in a small area.” It is clear that “acute social and public health issues” are relevant to the current context in the UK, with drug related deaths at an all-time high and the added risk that fentanyl has the potential to be introduced into the heroin market. If the Home Office does not take action we could see a crisis developing as is the case in the USA and Canada.

95.  International evidence also shows that DCRs “do not result in higher rates of local drug-related crime” and instead can reduce “street disorder and encounters with the police” ii DCRs have been shown to reduce syringe sharing and litteriii which in turn reduces the risk of blood- borne virus infections, and they can reduce overdose fatalities and ambulance call-outs for overdoseiv, thereby reducing pressure on our emergency services. Evidence also suggests that DCRs “save more money than they cost”v, with evidence from Vancouver that the DCR there saved over $18 million in health costs over a 10 year period.vi

96.  In your letter you also state that the United Nations’ International Narcotics Control Board (INCB) shares your views that the creation of DCRs have the potential to condone organised crime. This in fact is not what the report says, the INCB Annual report of 2016 states: With respect to “drug consumption rooms”, the Board wishes to reiterate its frequently expressed concern that, in order for the operation of such facilities to be consistent with the international drug conventions, certain conditions must be fulfilled. Chief among those conditions is that the ultimate objective of these measures is to reduce the adverse consequences of drug abuse through treatment, rehabilitation and reintegration measures, without condoning or increasing drug abuse or encouraging drug trafficking. “Drug consumption rooms” must be operated within a framework that offers treatment and rehabilitation services as well as social reintegration measures, either directly or by active referral for access, and must not be a substitute for demand reduction programmes, in particular prevention and treatment activities.

97.  The position taken by the INCB was effectively a shift in its position to endorse DCRs subject to certain conditions. In its 2017 Annual report it stated:

“The Board reiterates that in order for the operation of “drug consumption rooms” to be consistent with the international drug control conventions, certain conditions must be fulfilled. First among those conditions is that the ultimate objective of such facilities should be to reduce the adverse consequences of drug abuse without condoning or encouraging drug use and trafficking. ” vii

98.  The position of the INCB is therefore not aligned to that of the UK Government’s.

99.  Also, the issue you raise of the Danish experience and the presence of Swedish people attending the DCR is unique to that country. People from Sweden who use drugs – in particular heroin - have a long history of accessing harm reduction services in Denmark. This is a direct result of Sweden’s punitive approach to drug use and lack of harm reduction interventions, such as needle syringe programmes and opiate substitute therapy. There is no reason to believe that the UK would experience anything similar considering the support for DCRs by the devolved governments and the fact Ireland will be establishing their own DCR this year and France has opened a number of these facilities in recent years.

100.  There are clearly many strong arguments in favour of introducing DCRs in areas of need, as the ACMD has rightly recommended.viii

101.  Clarification of some of the statistics and evidence contained in your letter

In your letter to the ACMD you state: “Over half of all organised crime groups operate in the UK are involved drug-related crime”ix

102.  These claims are accurate, but have little relevance to the subject at hand. While some European studies report “small-scale drug trafficking in the immediate vicinity of the [DCRs]”x, there is no evidence that this is a consequence of the DCR itself; rather, that DCRs are often opened in areas where drugs are sold. The reality is that those accessing the DCR are already purchasing and consuming drugs such as heroin, but rather than injecting in a safe space they are injecting in our town and city centres – these are our current drug consumption facilities.

103.  Arfon Jones, North Wales PCC and Ron Hogg, Durham PCC, recently visited Geneva, to see first-hand the delivery and the impact of a Drug Consumption Room, Quai 9, and received input from the police. Law enforcement cooperated with the centre, and senior police officers from the Criminal Investigation Department attended the steering committee. Police officers in Geneva said that in the last 2 years there was no serious crime amongst drug addicts who use such facilities. Safety and security measures were introduced around the centre and they operated targeted interventions and controls of the dealers near the centre. It has been estimated that the 10% of the heaviest users of heroin in Switzerland consumed around 50% of all the illicit heroin imported. As a result, getting these users engaged in harm reduction services via a Drug Consumption Room has the potential to reduce the consumption of illicit heroin, which could substantially reduce the scale of the illicit heroin market, depriving organised criminals of resources.

104.  “Around 45% of all acquisitive crime is committed by regular users of heroin and/or crack cocaine, and that these crimes cost society approximately £6 billion a year” xi

105.  Again, this is not relevant to DCRs, as there is no evidence that DCRs increase acquisitive crime.xii Evidence from Sydney found that the presence of the DCR had no reported effect on thefts or robberies around the facility.xiii Another study from Vancouver concluded that the presence of the DCR was not linked to an increase in drug trafficking, assaults or robbery.xiv

106.  However, the paper that you cite that estimates £6 billion lost due to acquisitive crime also shows that drug-related deaths and NHS treatment for people who inject drugs cost society approximately £4 billion a yearxv - a cost which could be significantly reduced by introducing DCRsxvi.

107.  “The Government spends an estimated £1.6 billion in 2014/15 on law enforcement activity aimed at tackling the criminal activity linked to the trade in illicit drugs”

108.  This figure is from the Home Office’s evaluation of the Drug Strategy 2010, which also notes that “activity solely to remove drugs from the market, for example, drug seizures, has little impact on availability”. This enforcement also has many “potential unintended consequences”, the report describes, including drug market violence, “health harms from varying purity of drugs”, and the “negative impact of involvement with the criminal justice system”.xvii Our call for new approaches such as Drug Consumption Rooms is a natural response to the Home Office’s own research, which recognises that the current approach is not working.

109.  Drug treatment services already manage many of the legal risks associated with a DCR

110.  In your letter you state that DCRS are ‘legally problematic’ however many of the activities that would be illegal under the Misuse of Drugs 1971 Act are already managed by drug services, especially needle syringe programmes (‘NSPs’). For example, it is widely accepted that people accessing NSPs for sterile equipment will be in possession of a controlled drug. Even the Crown Prosecution Service accepts this position, stating in its guidance for charging standards for drug offences:

111.  These schemes [NSPs] need police and CPS co-operation because those who run and use them will necessarily commit offences under the Act. It is therefore not normally in the public interest to prosecute:

• a drug user retaining used needles;
• a drug user possessing sterile needles;
• bona fide operators of schemes.

112.  Simple possession cases that are based on police surveillance at or near exchange centres should not normally be prosecuted. The need to prevent the spread of serious infections outweighs the normal requirement for prosecution.

113.  Furthermore, services ensure they have policies in place to limit section 8 MDA 1971 liability (activities related to premises). The International Comparators report highlights the risk of a potential offence under the Serious Crime Act 2007, by ‘encouraging or assisting’ a crime, however some harm reduction advice provided at NSPs may be considered to fall within this offence, especially in the absence of significant case law for this specific provision where the aim is in the public interest i.e. to reduce drug related deaths, blood b0orne viruses and public nuisance.

114.  The international evidence shows that DCRs are not problematic for police, who will have historically had to manage potential drug specific crimes in relation to the provision of harm reduction services, such as NSPs. This learning is applied to the location and surrounding area of the DCR, where, like NSPs, drug dealing is not permitted. We can assure you that the police in the UK have similar experiences and would have the requisite knowledge and skills to manage law enforcement to tackle drug dealing and to tolerate drug possession offences to allow the DCR to operate properly – as we do with current harm reduction centres.

115.  We therefore ask that you review your decision to prevent the introduction of DCRs as an example of the government’s commitment to “exploring alternative options available, within [the] legislative framework”. If the Government was to allow a pilot site, based on a local needs assessment, to operate in the UK, we would be able to demonstrate what works locally. We are sure, like us, you want to see a reduction in drug related deaths, a reduction in health risks, fewer open drug scenes, improved cleanliness, reduced public insecurity related to drug use and an increase in services that support some of the most marginalised and vulnerable in society.

116.  Kind Regards

Arfon Jones North Wales Police and Crime Commissioner

David Jamieson West Midlands Police and Crime Commissioner

Ron Hogg Durham Police and Crime Commissioner

117.  Victoria Atkins Response References

i Victoria Atkins MP (13 April 2018) ‘Reducing opioid-related deaths in the UK report – further response regarding drug consumption rooms’, Ministerial response to the Advisory Council on the Misuse of Drugs, Available online at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/699825/ Letter_from_Victoria_Atkins_MP_to_OBJ.pdf

ii European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (2017) Drug consumption rooms: an overview of provision and evidence, Available online at: http://www.emcdda.europa.eu/system/files/publications/2734/POD_Drug%20consumption%20rooms.pdf

iii European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (2017) Drug consumption rooms: an overview of provision and evidence, Available online at: http://www.emcdda.europa.eu/system/files/publications/2734/POD_Drug%20consumption%20rooms.pdf; Potier C. et al. (2014) ‘Supervised injection services: What has been demonstrated? A systematic literature review, Drug and Alcohol Dependence, 145, 48-68.

iv Ibid v Advisory Council on the Misuse of Drugs (ACMD) (December 2016) Reducing Opioid-Related Deaths in the UK, Available online at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/576560/ ACMD-Drug-Related-Deaths-Report-161212.pdf

vi Bayoumi, A, and Zaric, G, 'The cost-effectiveness of Vancouver's supervised injection facility' CMAJ. http://www.cmaj.ca/content/179/11/1143

vii International Narcotics Control Board (INCB) (2018) Report of the International Narcotics Control Board for 2017, United Nations: New York, 36-37, 118, Available online at: https://www.incb.org/documents/Publications/AnnualReports/AR2017/Annual_Report/E_2017_AR_ebook.pdf

viii Advisory Council on the Misuse of Drugs (ACMD) (December 2016) Reducing Opioid-Related Deaths in the UK, Available online at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/576560/ ACMD-Drug-Related-Deaths-Report-161212.pdf.

ix HM Government, Serious and Organised Crime Strategy, 2013 x Hedrich D. (2004) European Report on Drug Consumption Rooms, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon; Potier C. et al. (2014) ‘Supervised injection services: What has been demonstrated? A systematic literature review, Drug and Alcohol Dependence, 145, 48-68. xi Home Office, Understanding Organised Crime: estimate the scale and the social and economic costs, 2013

xii Home Office (2014) Drugs: International Comparators ̧ Available online at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/368489/ DrugsInternationalComparators.pdf ; Available online at: http://www.issdp.org/conference- papers/2007/papers/issdp%20stevens%20paper.pdf

xiii European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (2017) Drug consumption rooms: an overview of provision and evidence, Available online at: http://www.emcdda.europa.eu/system/files/publications/2734/POD_Drug%20consumption%20rooms.pdf

xiv Ibid

xv Because of the significant increase in drug-related deaths across the UK, the cost to society of drug-related deaths is likely much higher than it was estimated to be in 2010/11. According to the method used in this report, drug misuse deaths (registered in 2016 across the UK) alone cost society approximately £5.4 billion a year. The costs of NHS treatment will also be underestimated because these estimates exclude the cost of treatment for Hepatitis B, C and bacterial infections from injection.

xvi Andresen M.A and Boyd N. (2010) ‘A cost-benefit and cost-effectiveness analysis of Vancouver’s supervised injection facility’, International Journal of Drug Policy ̧21:1, 70.76; Bayoumi A.M. and Zaric G.S. (2008) ‘The cost-effectiveness of Vancouver’s supervised injection facility’, Canadian Medical Association Journal, 179:11, 1143-1151; Pinkerton S.D. (2010) ‘Is Vancouver Canada’s supervised injection facility cost-saving?’, Addiction, 105:8, 1429-1436.

xvii Home Office (2017) An evaluation of the Government’s Drug Strategy 2010, 10, 79-80

March 2019