Evidence and Policy: Crime and public health in UK drug policy

1
Evidence and Policy Crime and public health in
UK drug policy

• Alex Stevens

2
British drug policy an argument between crime
and health

• Rolleston committee, 1926
• Care won over criminalisation
• Produced the British system of benevolent
  neglect
• But doctors still accountable to the Home Office.
• Response to increased drug use in 1960s
• Tighter controls on doctors
• Regulation of drug treatment
• Misuse of Drugs Act 1971
• Response to heroin epidemic of the 1980s
• Tougher penalties for drug dealers
• Central Funding Initiative - 18 million
• Drug strategy 1985 focuses on enforcement and
  prevention.
• Response to HIV epidemic of the late 80s
• Relatively quick implementation of harm reduction
• Which was supposed to include abstinence as a
  goal.

3
A theory of policy formation

• The discourse coalition approach (Hajer)
• Discourse
• A set of ideas and symbols that share common
  concepts.
• Coalition
• A loosely formed group of individuals and
  organisations who form around a discourse.
• Discourse structuration
• The attempt to make a discourse the dominant way
  of thinking about an issue.
• Discourse institutionalisation
• The translation of a discourse into laws,
  practices and policies which express it.

4
This presentation

• Use the discourse coalition approach to look at
  use of evidence in British drug policy.
• The available evidence on
• Drug use
• Drug-related health problems
• Drug-related crime
• Uses of evidence
• The Drugs Act 2005
• Cannabis classification
• The new harm reduction
• An excluded discourse?
• Drug use as non-deviant

5
Drug Use
6
Problematic drug use
7
Drug-related death Trend
8
Drug-related death European comparison
Source EMCDDA Annual Report 2005
9
Blood-borne viruses Trend in HIV
Source Health Protection Agency
10
HIV International Comparison
11
Blood-borne viruses Hepatitis C
Source Health Protection Agency
12
Health inequality

• Drug use is spread throughout society
• Class A use higher among affluent groups (BCS).
• Dependence and related health problems
  concentrated in deprived areas and groups.
• Unemployed people 3.75 times more likely to
  report drug dependence (SPM data).
• 42 of drug-related deaths in Scotland in 2003
  took place in the most deprived neighbourhoods,
  comprising only 19 of the population (Zador et
  al. 2005.)
• Criminal victimisation also concentrated in
  deprived areas.
• Over half of all household property crime is
  found in the poorest one fifth of communities in
  England and Wales (Hope 2001).

13
Summary on drugs and health

• Drug-related death is high (and rising in
  Scotland)
• HIV is (internationally) low (but rising)
• Hepatitis C is high (and rising)
• Drug dependence contributes to health inequality.

14
Crime (in general)
15
Drugs as crime
16
Drugs cause crime

• Estimates of the proportion of crime that is
  caused/driven/motivated by crime in policy
  debates
• Vary from 20 to 70
• Have settled at about a half.
• Estimated cost of drug-related crime
• 13.9 billion per year (Gordon et al 2006).
• Based on misinterpretation of pathologising
  studies of arrestees and drug users in treatment.

17
Overestimating proportions from arrestees
18
Drug users over-represented in arrestee samples
Logistic regression of data from Offending, Crime
and Justice Survey showing predictors of reported
arrest among self-reported offenders, aged 10-25
(n1,370).
19
Drug user reports of police supervision

• Rhodes et al 2007 qualitative study of drug
  injecting in South Wales
• Homeless injectors spoke of police being on
  your case everyday, even if youve done nothing
  wrong, of being constantly hassled, of police
  who wont leave you alone.
• They the police know every smackhead in
  Merthyr. That's why they are always on our cases,
  searching us and this and that.
• Also indicates extra likelihood of police
  arresting drug users when they offend.

20
Overestimating costs from drug users in treatment

• The estimate of 13.9 billion in annual crime
  costs from problematic drug users rests on the
  National Treatment Outcome Research Study
• Asked questions of 1,075 drug users at entry to
  treatment about offending in previous three
  months
• extrapolates from them to estimated 327,466
  problematic drug users.
• Assumes that
• Offending is accurately reported.
• Offending is the same in the entire year as the
  three months previous to treatment.
• PDUs in treatment offend at the same rate as all
  PDUs.

21
Offending peaks before treatment entry
Source adapted from Gossop et al 2006
22
Summary on drugs and crime

• Crime is falling.
• Proportion of crime by drug users likely to be
  less than estimated.
• Value of crime by drug users likely to be less
  than estimated.
• Plus, doubts that the relationship between drug
  use and crime is causal
• Search for the third variable.

23
The use of evidence in drug policy2. The Drugs
Act 2005

• Available evidence on drug problems
• Drug use high in UK, despite prohibition.
• Strong correlation of drug use and crime.
• High rates of drug-related death.
• High and increasing rates of hepatitis C
• Emerging concern over neglect and abuse of
  children of problematic drug users
• Evidence then filtered through the Prime
  Ministers Strategy Unit

24
Example 1 Drugs Act 2005

• A piece of pre-election window dressing, or
• An attempt to use some of the evidence on drug
  problems.
• Following work of John Birt and the Prime
  Ministers Strategy Unit.

25
PMSU report on drug problems (2003)
26
PMSU 2003 policy suggestions

• Grip and treat high harm causing users.
• Move the funding and accountability for drug
  treatment from the Department of Health to the
  Home Office.
• Make heroin use an offence and introduce a
  compulsory registration scheme for those found
  guilty of it. Users would be identified by
  compulsory testing on arrest.
• Provide a case manager from the National Drugs
  Service for every registered heroin user to
  manage and purchase services for the user.

27
Policy responses in Drugs Act 2005

• Repeal previous provision which criminalised
  hostel workers.
• Creation of ISO to run alongside ASBO
• Creation of new crimes
• Possession and supply of unprocessed psilocin
  mushrooms
• Presumption of supply for certain amounts
• Dealing near schools
• Refusing intimate searches and X-rays
• Using under 18s as couriers
• Refusing a drug test at arrest
• Refusing to be assessed for treatment

28
Ex2 The UK cannabis kerfuffle, 2004-2008

• 2004 In response to various reports (including
  ACMD 2002), govt reclassifies to class C.
• Max sentence for supply of class C increased to
  14 years.
• Police in England Wales introduce presumption
  of non-arrest of adult cannabis possessors.
• 2005 In run-up to election, Charles Clarke
  refers decision back to ACMD.
• 2006 ACMD reaffirms class C and is accepted.
• 2007 Brown refers decision back again to ACMD
• 2008 ACMD re-reaffirms class C, but cannabis
  re-reclassified to class B.
• Police continue presumption of non-arrest for
  first offences.
• Meanwhile, cannabis use continues to fall in
  England Wales, while rising in Scotland.

29
Cannabis The evidence

• No risk of fatal overdose
• Cannabis (even skunk) is not lethal.
• Significant association with schizophrenia
• Ongoing debate on causality
• Some evidence of association with cancer and
  heart disease.
• English market becoming dominated by stronger
  forms of domestically cultivated skunk
• 10 average THC content, compared to 6 THC in
  cannabis resin.
• No evidence that legal changes affect patterns of
  use.

30
Cannabis the debate

• Cannabis is dangerous because its stronger
• Than when we took it.
• Cannabis causes mental illness
• The criminal law sends out signals to young
  people
• So ignore the experts and further criminalise
  cannabis users.

31
Ex 3 The new harm reduction

• Rises in deaths, HIV and HCV suggest we need to
  reinforce efforts to reduce risky injecting,
  fatal overdoses and the spread of blood-borne
  viruses.
• Especially for vulnerable groups
• Young injectors.
• Heroin users who have not engaged, or who have
  dropped out of treatment.
• Prisoners.
• Methods
• Outreach, peer carer interventions.
• Drug consumption rooms.
• Heroin assisted treatment.
• Prison needle exchange.

32
Drug consumption rooms (Hunt Lloyd 2008)

• Protected places for the hygienic consumption of
  preobtained drugs in a non-judgemental
  environment and under the supervision of trained
  staff. (Akzept)
• Available in Germany, Switzerland, the
  Netherlands, Spain, Norway, Luxembourg, Australia
  and Canada.
• Evaluation results
• Effective in reaching homeless public injectors
• Statistically significant reductions in
  drug-related death, despite one death (from
  anaphylaxis) in German DCR.
• Reductions in risk behaviour and public nuisance.

33
Heroin assisted treatment (Uchtenhagen 2008)

• Has been evaluated in Switzerland, Germany, the
  Netherlands and Spain (English pilots under way).
• Provides heroin for on-site injection and
  psycho-social support to people who have not
  stabilised in methadone treatment
• Results
• Reduced illicit heroin use
• Improved health
• Reduced crime
• More employment
• Switzerland - Reductions in heroin initiation and
  many participants move on to abstinence (Nordt)

34
Prison needle exchange

• Available in Switzerland, Germany, Spain,
  Portugal (soon).
• At least six evaluations (Dolan et al 2003)
• All favourable results.
• Reduction in sharing of injecting equipment
• Drug use decreased or stable
• No new cases of HIV or HCV reported
• No use of needles as weapons
• No reports of new initiations into injecting

35
Political response

• Interesting bifurcation between DCRs and HAT
• Drug consumption rooms rejected
• Localised dealing
• Anti-social behaviour
• Increase in acquisitive crime
• Heroin assisted treatment
• Cautiously accepted, depending on pilot
• Explaining the difference
• HAT seen as reducing crime
• HAT consistent with the supervisory element of
  the health discourse coalition
• DCRs too close to accepting drug use as normal

36
Drug use as non-deviant

• Normalisation mistakenly taken to mean
• That a majority of people use illicit drugs.
• That people should take illicit drugs.
• Drug use as non-deviant because
• Using substances to change brain functioning is a
  human universal.
• Drug use is not always a sign of illness or
  criminality
• The idea of drug use as non-deviant is ignored by
  both crime and health coalitions
• Which share discursive affinity around the idea
  of drug use as deviation from the norm either
  criminal or pathological

37
Conclusions

• British drug policy is the result of ongoing,
  long-running arguments between crime and health
  discourse coalitions.
• In recent years, evidence has been used
  selectively to support the criminalisation of
  drug users and drug services.
• The dissident idea that drug use is non-deviant
  has had little effect on policy.