Feature

When it’s too late to ‘say no’

Tackling drugs together, the white paper on drugs, begins to define a national strategy but ignores some fundamental questions, argues Chris Ford

The apparently inexorable rise in drug use among young people has prompted a review of British policy towards drug users. The current approach, often referred to as the ‘British System’, relies on tolerance and has allowed considerable clinical freedom to doctors to prescribe for patients with drug-use problems.¹ This is in stark contrast to other European countries, which have strict protocols covering doses, delivery and nature of the programme.

The advent of HIV focused attention on the need to stop the infection spreading among users, and harm minimisation became the buzz phrase. The pros and cons of the ‘British System’ - maintenance as an acceptable alternative to cessation-continue to be the subject of fierce debate as does its importance in relation to the much lower rate of HIV infection in British drug-users compared with other countries.

In the slipstream of harm minimisation many projects were set up, usually with special HIV money. Although some were not well thought through others were effective, looking at different ways of working. These have generated a rapid development of community involvement and began a shift away from a medically-dominated model of drug services.

The debate as to whether drugs should or could be legalised, or at least decriminalised, is increasing in some quarters. In contrast government policy remains firmly against legalisation and Claire Short’s recent intervention in the debate made clear, anyone who raises the question of legalisation, even in opposition, is likely to be silenced.

The government’s position was put forward in the white paper Tackling drugs together, published in May 1995,² which set out the government’s strategy for tackling drug misuse in England over the next three years. The focus of the strategy is on three areas: increasing the protection of communities against drug-related crime; reducing the acceptability and availability of drugs to young people; and reducing the health risks and other damage which result from drug misuse. As pointed out by Alan Beith MP, when discussing the equivalent Scottish report, it does not address any of the underlying causes of the drug problem, such as deprivation, alienation and lack of hope.

The white paper confirmed the shift in emphasis away from the harm minimisation model, which had been initiated by the most recent report from the Advisory Council on the Misuse of Drugs.³ Perhaps those responsible believe, falsely, that the HIV threat to drug-users has gone away (and have also forgotten the potential time-bomb of hepatitis C-80 per cent of injecting drug-users in London are positive for hepatitis C) and are going for abstinence through education and primary and secondary prevention.

Most people would agree that abstinence is the ultimate and proper goal (although the lack of outcome studies does not necessary confirm this). But abstinence is not always achievable and other options should also be available. Services using the harm minimisation model may now have to justify themselves in terms of crime reduction rather than other ‘less tangible’ benefits like improvements in the health of users.

Tackling drugs together does not contain any radical solutions, but at least it does begin to articulate a national strategy with clear aims and a plan for how to achieve them at local level. It centres around prevention and multiagency co-ordination. This is not new, but there are now definite structures so that all agencies and areas can work to the same agenda.

All areas are to establish ‘drug action teams’ (DATs) who will look at local priorities within the overall strategy. The DATs will consist of senior staff from health and social services, police and probation. Although they will have lot of power, they may have little knowledge, particularly of treatment services. This has been addressed partly by the establishment of ‘drug reference groups’ which consist of representatives from all local statutory and voluntary drug agencies, education, police and social services, who will provide local expertise and feed information and suggestions to the DAT. It is unclear whether there will be any new money to set these groups up (or indeed whether the whole strategy is being resourced properly).

Much emphasis is being placed on protecting communities from drug-related crime, to reduce the public’s fear of such crime and to ensure that the law on dealing in or supplying illegal drugs is enforced. The strategy fails to notice the fact that drug-users are part of the community. One study of 15-year-olds showed that 47 per cent had tried at least one drug.⁴

A major plank of the government’s new strategy was the creation, in April 1994, of a task force which was to review the effectiveness of all drug treatment services. Outcome measures would include abstinence from drugs, harm reduction, improvement in physical and mental health, reduction in drug-related crime and improved social functioning. A similar review of the effectiveness of enforcement and prevention was called for after the task force for treatment services was mentioned in the green paper-but shows no signs of appearing. If enforcement turned out to be less effective it might be useful for treatment to be subsided by criminal justice sources but as Roger Howard, director of the Standing Conference on Drug Abuse, suggests, there is no mechanism for this to occur.

The task force report, which was due in January 1996, will form the basis on which the Department of Health will issue guidance to purchasers and providers of services for drug-users and may have a significant influence on the type of service that commissioners will want to purchase. It is odd that this review was not undertaken before the publication of the white paper so that conclusions from the evidence could have helped in developing the strategy. Will the government want to hear results which may contradict the stated policy?

There other questions that need to be asked about the task force. How independent is it? Why are no comparisons between different treatment services being made? (And who would be hurt if comparisons were made?) Is it broad-based enough, and if it isn’t is this because of financial constraints? Compliance also has to be raised - are projects going to speak out if their funding is under review?

The widespread use of methadone as an oral heroin substitute has never been evaluated in this country. We have always relied on American and Australian studies and so the fact that the task force has set up methadone evaluation studies is to be applauded. We can only hope that this will give us clear results and not simply be used to reduce the large prescription bill for methadone.

One other consequence of the white paper is that all health authorities are being asked to review local ‘shared care arrangements’ between specialist drug services and general practitioners. Preliminary reports were to be in by November 1995 and full reports by February 1996. This will certainly add to the debate from both the statutory and general practice sides. Exciting examples of general practice involvement and shared care are developing around the country, but the review of shared care arrangements must not degenerate into just another way to push more secondary care into the community.

The doctors’ General Medical Services Committee has already expressed concern at that possibility and agreed at its last conference that the treatment of drug problems should not be part of core medical services. It believes most drug-users should be treated by specialists, arguing that if drug-users are to be treated in general practice, GPs must be willing, supported and trained and that a fee should be paid.

All this leaves me asking why we aren’t looking at the reasons for the increase in drug-taking. Are we thinking clearly enough about what causes the crime/drugs cycle and its meaning to youth? It seems that simply ‘saying no’ to drugs is no longer adequate-either for the punters or the policymakers.