Feature

The real point now is prevention

The recent commons select committee report on drugs is a good start – but could go further, says Geof Rayner

As Oscar Wilde once observed: ‘Work is the curse of the drinking classes.’ And as usual he was right on target: cheap alcohol was the drug of choice for most poor Victorians, a powerful – if dangerous – anaesthetic for the harsh rigours of urban capitalism. But alcohol abuse had been even greater in the previous century. In the 1730s Britain was flooded with cheap, often poisonous, illicit gin. In London alone there were an estimated 7000 unlicensed gin shops, and the 11 million gallons of gin produced in one year sufficient for 14 gallons for each adult male.

Today we hear rather less about the perils of alcohol – indeed we would think it odd not to hear end of match comments by football commentators on the likelihood of a ‘good celebration’ (read ‘getting blitzed’). But while alcohol binging is now seen as normal behaviour, heroin or crack use is endlessly stigmatised. It’s a point of which the home affairs committee of the House of Commons seems fully aware. ‘At the outset’, they say in the introduction to their recent report, ‘it is important to keep a sense of proportion. Legal drugs, such as tobacco and alcohol, are responsible for far greater damage both to individual health and to the social fabric in general than illegal ones. It should also be borne in mind that not all drugs are equally harmful. While the inquiry has not specifically considered the social problems caused by alcohol or tobacco, our work has proceeded with these comparisons in mind.’¹

But what they missed in the process was an opportunity to understand not just the interaction between legal and illicit drugs and the link between substance use and poverty, but also a much longer history of attempts by legislators to solve the problems of substance use which have plagued Britain for at least 300 years.

While the use of drink and drugs extends to the highest reaches of society, as the tabloids constantly reveal, the health impact of both alcohol and drugs falls mainly on poorer communities. The hue and cry over the damage done by cheap gin in the eighteenth century resulted in a spate of legislation, culminating in the Gin Act of 1751, which increased taxation and banned spirit retailing by distillers and shopkeepers. The system for licensing alcohol sales today remains essentially that of the eighteenth century.

Today, illicit drugs continue to pose dilemmas for public health and criminal justice policymakers, as a variety of reports have showed, most recently the Police Foundation’s Runciman Report.² Its key recommendation for cannabis decriminalisation was rejected by then home secretary Jack Straw.

The MPs’ recent report takes a wider sweep. The focus is on Britain’s estimated 250,000 problematic drug users, many engaged in crime to support their habit. Drugs policy and the law should primarily be geared to dealing with them rather than with recreational drug users. The MPs recommend the expansion of treatment, especially for crack and heroin users, better training of GPs, explicit targets for harm reduction and public health, some reclassification (though not decriminalisation) of drugs, and more heroin prescribing schemes. One recommendation – setting up safe injecting houses – seems distinctly old hat. There is generally little difficulty in obtaining clean works from pharmacists, and it would be far better to invest even more heavily in syringe exchange schemes and advice on avoiding hepatitis C.

On prevention they argue that ‘all drugs education material should be based on the premise that any drug use can be harmful, and should be discouraged’. That’s a good public health principle, but far more needs to be said about ‘what works’ in prevention. As much of the evidence to the committee showed, there is little good information on effectiveness.

It is important to get the balance of policies right, and the MPs argue that prevention and treatment and prevention have fallen behind, while most public spending goes on policing. But it is also important to ensure that the policies we do have are consistently implemented. Interviews with 43 people with chronic substance misuse (mostly heroin) in a south east London borough, many with multiple criminal records, found that none had been through the local arrest-referral scheme, none had received post-prison support and many had hepatitis C, despite a local syringe exchange scheme. It was clear that there was insufficient support to GPs from specialist agencies because the agencies themselves had so much work to do. Almost universally, those interviewed were poor and had been excluded from or failed at school. Their addiction was not just to drugs or alcohol but to the lifestyle, and their lack of educational or employment opportunities vastly reduced their chances of making any change.

Although there is little doubt that the quarter of a million people with severe dependency need concentrated help and supervision, the MPs give scant attention to prevention, apart from general comments on the need to consider all substances, the funding only of prevention activities known to work, and the need to focus on the most vulnerable. It’s a pity that the opportunity wasn’t taken to address the roots of substance misuse – including the role of the tobacco and alcohol industries in damaging health. Perhaps next time.