Evidence submitted by The Faculty of Public Health and the Association of Directors of Public Health (DRU0096)

Home Affairs Committee – submission of evidence

The Faculty of Public Health and the Association of Directors of Public Health

1. This report is submitted on behalf of the Faculty of Public Health, a membership organisation for nearly 4,000 public health professionals across the UK and internationally, and the Association of Directors of Public Health, the membership body for Directors of Public Health in the UK. We are submitting this response in light of the clear imperative to adopt alternative approaches to the management of drug use and related harm in the UK to improve population health.

The UK drug framework

How effective is the UK drug framework in today’s society?

2. During the last decade drug related death rates have significantly increased in the UK (1-3), surpassing those of many countries (4). This has been described as both a public health crisis and emergency (5-6). As such, we believe it is apparent that current policy is failing to reduce drug related harm, in line with the conclusions of the 2019 Health and Social Care Committee on drugs policy (6).

3. Different drugs have distinct risk profiles, which are not appropriately reflected in their respective classifications under the Misuse of Drugs Act (7). Furthermore, the risks of drug use are not only related to the pharmacological properties of the substances, but to how and in what context they are used. Many people who use drugs do not suffer significant harm from doing so, whilst more problematic use and harm is often associated with upstream factors including socioeconomic deprivation (8) and adverse childhood experiences (9), which predispose to a range of health and social disadvantages. Law enforcement focused responses to drug use, which do not adequately consider the reasons why people use drugs, may exacerbate the underlying issues that predispose to more harmful use.

4. Since the introduction of the Misuse of Drugs Act over three million criminal records have been generated for drug offences, with significant costs for the criminal justice sector (10). In 2017, 60% of individuals prosecuted for drug offences were prosecuted for the possession of drugs, including 36% for the possession of cannabis (11). Contact with the criminal justice system is associated with many health and social disadvantages (12). The risk of arrest, and associated stigma may deter those who have problematic relationships with drugs from seeking support, healthcare, and harm reduction services (13-16); and may lead people to use drugs in more secretive and riskier ways (17).

5. Punitive drug policies are disproportionately applied to members of certain ethnic groups. People who are black are stopped and searched for drugs nearly nine times more often than people who are white, and they are more likely to be arrested, prosecuted, and sentenced to immediate custody (11).

6. Whilst drug enforcement negatively impacts people who use drugs there is unclear evidence of its impacts on drug use prevalence (18). Studies have demonstrated there is no clear relationship between drug laws and the prevalence of drug use (19-23). The Home Office, in 2012, concluded “levels of drug use are influenced by factors more complex and nuanced than legislation and enforcement alone” (24).

7. Historical efforts to prevent the supply of drugs have proven largely ineffective. Whilst there have been localised, temporary reductions in the availability of certain drugs (25-26), it is not clear how this was achieved, and the Drugs Strategy reports opium and cocaine production doubled between 1998 and 2017 (27). Available evidence suggests that arresting drug dealers or seizing drugs does not have a substantial impact on drug supply (28). At the same time, as Professor Dame Carol Black’s Review of Drugs highlighted (29), efforts to reduce the supply of drugs may have unintended consequences, as arresting suppliers can increase competition, thereby promoting innovation and leading to escalating violence (30-38).

8. Impacts of isolated reductions in the availability of certain drugs on other types of drug use and risk behaviours are poorly understood. For example, when not able to obtain heroin, people who use opioids have reported using drugs they know are likely to be adulterated, using other types of drugs, and resorting to poly-drug use (39-40). There is mixed evidence as to whether greater availability of cannabis in the USA has been associated with lower levels of opioid related deaths (41-42). And commentators have hypothesised that reductions in cocaine use and related harm in the UK in 2009 may have been related to the availability of mephedrone prior to it being controlled under the Misuse of Drugs Act (43).

9. Additionally, current legislation may create barriers to the provision of innovative, evidence-based harm reduction interventions. For example, the UK Government has repeatedly opposed the establishment of overdose prevention centres, arguing that providers would be committing a range of offences under the Misuse of Drugs Act (44).

Does the current framework, or a particular aspect of the framework, need to be reformed?

10. The highest coordination forum of the United Nations (UN) has called for drug policies to be reorientated towards a public health approach, putting “people, health and human rights at the centre” (45); and the Lancet Commission on Public Health and International Drug Policy highlighted that punitive drug policy approaches are often inconsistent with human rights norms (13).

11. The escalating level of drug related harm in the UK under the existing framework demonstrates a clear need for change. The question is not whether, but how to reform drug policy to improve population health and reduce health inequities.

12. Recognition of the harms caused by criminalisation, and the lack of evidence for its beneficial impacts, provide a strong justification for decriminalising the possession of drugs for personal use. Furthermore, it is necessary to adapt legislation to ensure it does not prevent the provision of evidence-based harm reduction interventions, including overdose prevention centres.

13. The decriminalisation of the possession of drugs for personal use has been recommended by amongst others: the UN Chief Executives Board for Coordination, comprising the Executive Heads of the UN system organisations, including the World Health Organisation and the UN Office on Drugs and Crime (45); the 2019 Health and Social Care Committee on drug policy (6); the Advisory Council on the Misuse of Drugs (ACMD) (46); and health bodies including the Royal Society for Public Health, the Royal College of Physicians and the Faculty of Public Health (47-48). The Government appeared to recognise the arguments for decriminalising the possession of drugs when instituting the Psychoactive Substances Act, which only criminalises the supply and production, and not the possession of the substances controlled under its auspices (49).

14. Ultimately, how to reduce drug related harm should not primarily be a question of whether the possession, production, or sale of drugs is illegal. First, it should be a question of how to minimise the factors which predispose people to use drugs in more harmful ways. And second, a question of how to limit the capacity of actors to profit from drugs, which drives innovation to produce new harmful substances and promote drug consumption.

15. Literature exploring the ‘commercial determinants of health’ demonstrates how the unbridled activity of commercial actors, serving to benefit from health damaging behaviours, has detrimental impacts on population health (50). This is apparent in both the legal and illegal markets for drugs, in which suppliers adopt marketing practices to promote behaviours which have detrimental impacts on consumers for want of profit (50-51). Whilst it is possible to oversee and modify suppliers’ behaviours in legal markets by, for example, instituting restrictions on how and where drugs are sold, there is no oversight of the practices of illegal drug suppliers. Nor is there oversight of how profits from the drug market are utilised, which provide funding for organised crime (52), and potentially, in some parts of the world, terrorism (53).

16. Clearly, drug policy reform is politically contentious, drawing emotive responses from policymakers and the public. To gain public support for policy change to reduce levels of drug related harm, and interventions to improve the health of people who use drugs, it is incumbent on the Government to ensure that messaging does not reinforce and propagate harmful attitudes towards people who use drugs, contributing to the stigma they experience. Despite campaigns being instituted to tackle the stigma faced by people who use drugs (54-55), and recognition of the importance of this in the recent Drug Strategy (27), the parliamentary debate following the Strategy’s introduction demonstrated mixed opinion as to whether this should be a priority (56).

17. The UN Drug Conventions were instituted to promote ‘the health and welfare of [hu]mankind’ (57); an aim which is inconsistent with the effects of historical and contemporary punitive drug policies. There is clearly latitude within the Conventions to adopt alternative approaches, demonstrated internationally as more than thirty countries have instituted some level of decriminalisation or regulation (23). The UN Chief Executives Board for Coordination has endorsed the decriminalisation of drug possession (45) and the International Narcotics Control Board (INCB) has explicitly stated this is possible under the auspices of the UN Conventions (58), the implementation of which it was established to oversee. In regard to overdose prevention centres, the INCB has stated that their provision is consistent with the Conventions, provided they are offered alongside other services with the intention of reducing drug related harm (59).

UK drug policy

What is your view on the UK Government’s 10-Year Drug Strategy published in December 2021?

18. Some elements of the recent Drug Strategy are welcome, particularly the much-needed increase in funding for drug treatment services. This is necessary for services to increase the availability of and retention in opioid substitution therapy, with convincing evidence this reduces a range of drug related harms (60-65). There will, however, be logistical challenges for the successful implementation of the Strategy, including how to recruit and retain skilled staff who are able to effectively provide care for a group with complex medical and social needs.

19. The Strategy’s endorsement of diversionary sentencing to divert people from the criminal justice system is also welcome, however, there are important questions related to how these schemes should be implemented. Particularly, it is necessary to consider whether coerced treatment for people who use drugs is consistent with accepted norms and guidelines in medical ethics (66).

20. Aside from legislative reform, there are other considerations which are notably absent from the Strategy. First, that of novel harm reduction interventions including overdose prevention centres, heroin assisted treatment and drug checking services, for which there is promising evidence they reduce riskier drug taking behaviours and drug related harm (67-69). Second, that of the human rights of people who use drugs, which the UN Chief Executives Board for Coordination, and guidelines from the UN Development Programme highlight should be of primary importance in the development of responses to drugs (45,70). And third, the close involvement of communities who use drugs in the development of the Strategy, who entreat there should be “nothing about us without us” (71).

21. Although the Strategy states that evidence is “at the heart” of its approach (27), this is not always the case. Research investment is focused on only two of its four pillars of drug policy: treatment and prevention, whilst drug law enforcement remains largely unevidenced (18), and legislation creates barriers to building the evidence base for innovative harm reduction approaches (72).

International comparisons

Are there laws, policies or approaches adopted in other countries that have been effective in reducing drug use, drug related deaths and/or drug related offending?

Innovative harm reduction interventions

22. Other countries in Europe, and wider afield have adopted the provision of evidence-based harm reduction interventions, which are not widely provided in the UK, including:

• Heroin assisted treatment: comprising the prescription of diamorphine for people with opioid dependence who did not respond to first line oral treatments (methadone and buprenorphine). Heroin assisted treatment is provided in various countries, notably including Switzerland, where the approach has been embraced since legislative change in 1998 (73). Studies in the UK and internationally have demonstrated the benefits of heroin assisted treatment, including reductions in illicit heroin use and increased retention in drug treatment (68). Provision of heroin assisted treatment remains limited in the UK, despite the successful implementation of pilot services (74). This may be related to its significant costs; however, evidence demonstrates these are compensated by savings for other services, including related to reductions in acquisitive crime (75).

• 23. Overdose prevention centres: where the most vulnerable can use drugs under the supervision of trained professionals who intervene in the event of an overdose. These services are currently provided in at least 15 other countries, and an unsanctioned service operated in Glasgow in 2020-2021 (76). Available evidence demonstrates various benefits of the sites, including reductions in drug related deaths where they were introduced and increased engagement with drug treatment services (77,67). In 2021, more than 80 eminent medical, public health, academic and third sector organisations, including the Association of Directors of Public Health, the Faculty of Public Health and 13 other Royal Colleges and Faculties called for pilot overdose prevention centres to be introduced in the UK (78), echoing calls from the ACMD (79) and the 2019 Health and Social Care Committee on drug policy (6). More research is needed to evaluate the impacts and cost-effectiveness of the sites, however assertions that providers would be committing offences under the Misuse of Drugs Act create a barrier to introducing pilots and conducting research in the UK (72).

• 24. Drug checking services: where people who use drugs can test their substances before consuming them, to ascertain whether they are adulterated or particularly dangerous. These services provide an opportunity to engage people not in contact with drug treatment services and provide harm reduction advice. Whilst limited drug checking services are provided in the UK, they are more widely available in other countries, notably including the Netherlands, where the nationally funded Drugs Information Monitoring System (DIMS) has operated across a network of sites since 1992 (80). Available evidence demonstrates drug checking services can influence the behaviour of people who use drugs to deter the use of more dangerous substances, whilst providing an opportunity to monitor the substances in circulation (69). Provision of public facing drug checking services has decreased in the UK since a Home Office licensed serviced briefly opened in 2019 (81).

Decriminalisation

25. Various countries have, to some degree, decriminalised or have never criminalised the possession of drugs (23). Notably, Portugal decriminalised the possession of all drugs for personal consumption in 2001. There, possession remains an administrative offence, whereby people who are found in the possession of drugs must attend a ‘Dissuasion Commission’ comprising psychologists, addiction specialists, mental health, and social workers. They may be issued with a warning, a fine, a suspended penalty, or, if they are dependent on the substance, they may be referred to drug treatment (82).

26. Following the reform, although the use of some drugs increased proportionately with increases in neighbouring countries, there were reductions in injecting drug use, HIV, hepatitis C and drug related deaths (83-84). It is not possible to disentangle the impacts of decriminalisation from the effects of contemporaneous social investment and changes to drug treatment and harm reduction services (83-84). Nonetheless, the experience of Portugal demonstrates that criminal sanctions, which have well recognised deleterious impacts on people who use drugs, are not required to reduce drug related harm.

27. It should be noted that the International Network of People who Use Drugs has highlighted that although decriminalisation approaches internationally have been a step in the right direction, it is necessary to consider the ongoing negative impacts of administrative sanctions and related stigmatising attitudes towards people who use drugs (85).

Looking towards regulation

28. Commentators, including the Global Commission on Drug Policy, comprising former Heads of State and Government, have highlighted the potential benefits of regulating currently illegal drug markets (86). This would require consideration of the distinct risk profiles of different drugs and how they are used, with closer regulation of the greatest importance for those drugs which are more likely to cause harm (86). Multiple countries, including the USA, Canada and Uruguay have established legal cannabis markets, with varying degrees of corporate involvement and commitment to promoting public health (87). In the UK, a fundamental re-orientation of responses to currently illegal drugs will need to be informed by international experiences and lessons learned from alcohol and tobacco regulation, to minimise the risk of commercial actors promoting consumption and more harmful use.

If so, could they reasonably be expected to work in the UK?

29. Emerging evidence from the UK and in comparable settings internationally has demonstrated the benefits of innovative harm reduction interventions. It would be possible to increase the provision of heroin assisted treatment and drug checking without changing existing legislation, whilst the provision of overdose prevention centres could be facilitated with minor changes to existing legislation or the institution of new legislation giving statutory protection to providers. In terms of decriminalising the possession of drugs or gaining greater control over their supply by regulating drug markets, the establishment of a non-partisan expert commission could be considered to develop recommendations drawing on international experiences and, in the case of regulation, evidence generated during efforts to effectively regulate alcohol and tobacco.

30. Clearly, there are many factors which may make different drug policy approaches more or less effective in different settings. Nonetheless, current policy responses in the UK have not been effective in reducing drug related harm, and it is imperative to consider alternative approaches.

April 2022

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