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HM Government, 2017
Continuing in the vein of its precursor, the UK Government’s new drug strategy pledges to tackle drug use and dependence through reducing demand, restricting supply, and building recovery, and adds to this a further ambition to drive global action.
Summary Aligned around “common goals we all share – to build a fairer and healthier society, to reduce crime, improve life chances and protect the most vulnerable”, the strategy stresses the importance of a co-ordinated, and partnership-based approach (both home and abroad) to drug use and dependence in the United Kingdom.
The four pillars of the strategy – reducing demand, restricting supply, building recovery, and global action – are summarised in turn below, each beginning with an extract (with emphasis included as it appears in the document). Not all the policy areas mentioned extend across the UK due to nations having devolved responsibilities. For example, areas relating to the work of the police and the criminal justice system apply only to England and Wales, and the work of the Department for Work and Pensions to England, Scotland and Wales.
“We will take action to prevent the onset of drug use, and its escalation at all ages, through universal action combined with more targeted action for the most vulnerable. This includes placing a greater emphasis on building resilience and confidence among our young people to prevent the range of risks they face (eg, drug and alcohol misuse, crime, exploitation, unhealthy relationships).”
A universal preventative approach to drug use and dependence across the life-course includes action in schools to promote health and wellbeing among young people, and to build their resilience and confidence so they feel able to resist risky behaviours and recover from set-backs. The Department for Education will engage widely on the scope and content of Personal, Social, Health and Economic (PSHE) education with this in mind.
The strategy also outlines the need for a more targeted approach for those most at risk of misusing drugs, and for new types of drug misuse. Trends and vulnerable groups are identified, but the emphasis is placed on local areas to determine needs and services. Target populations include: vulnerable young people; those not in education, employment or training; offenders; vulnerable families; victims and perpetrators of domestic abuse; sex workers; homeless people; veterans; and older people. Evolving and emerging threats include: new psychoactive substances; the use of drugs before or during planned sexual activity (‘chemsex’); image and performance enhancing drugs; and the misuse of or dependence on prescription medicines.
Supporting vulnerable families to break inter-generational pathways to dependence is part of the approach to prevent and reduce the demand for drugs and to help build recovery, and has already included the expansion of the Troubled Families Programme which supports local areas to ensure their services take an integrated and co-ordinated whole family approach. Public Health England will also work with Family Drug and Alcohol Courts and local public health teams to help them to work together to improve outcomes for families and children. [Both the Troubled Families Programme (1) and Family Drug and Alcohol Court (2 3) have previously been covered in the Effectiveness Bank.]
“We will take a smarter approach to restricting the supply of drugs: adapting our approach to reflect changes in criminal activity; using innovative data and technology; taking coordinated partnership action to tackle drugs alongside other criminal activity.”
The Misuse of Drugs Act 1971 and the Psychoactive Substances Act 2016 provide the legal framework for the control of substances.
Following advice from independent experts the Advisory Council on the Misuse of Drugs, the Government will continue to act swiftly to control substances where new evidence of harms or potential harms emerges. The featured strategy rules out decriminalising drugs, saying “Drugs are illegal because scientific and medical analysis has shown they are harmful to human health.” And though “aware of decriminalisation approaches being taken overseas, […] it [would be] overly simplistic to say that decriminalisation works.”
Most illicit drugs consumed in the UK are trafficked from abroad. One priority is therefore to tackle overseas transit routes (set out in the Serious and Organised Crime Strategy) and drugs at the border.
“We will raise our ambition for full recovery by improving both treatment quality and outcomes for different user groups; ensuring the right interventions are given to people according to their needs; and facilitating the delivery of an enhanced joined-up approach to commissioning and the wide range of services that are essential to supporting every individual to live a life free from drugs.”
The Home Secretary will personally oversee a new Drug Strategy Board, which will include representation from other government departments. A Recovery Champion will sit on the Board to provide national leadership around the recovery agenda.
UK clinical guidelines for the management of drug use and dependence have been updated, providing advice on pharmacological and psychosocial interventions known to be effective. Clinical guidelines have also been published on the management of new psychoactive substances.
Improving health among drug users includes action to prevent blood borne infections by vaccination (where available) and by maintaining the availability of injecting equipment through needle and syringe programmes, including through non-drug specialist outlets such as sexual health clinics. Infections like hepatitis C and tuberculosis should be identified via regular and repeated offers of testing, and infections like hepatitis C should be treated through co-ordinated services.
Drug overdoses can be prevented by ready access (and return) to drug treatment and by overdose awareness and response training for people who use drugs and their families. Heroin-related deaths can also be prevented by the provision of naloxone, and all local areas should have appropriate naloxone provision in place. [See Effectiveness Bank hot topic for more on overdose antidote naloxone.]
Aligned with the independent inquiry from Public Health England and the Local Government Association on the rise in drug use deaths since 2014, this strategy is committed to:
• Enabling a coordinated, whole-system approach to meet the complex needs of people who use drugs, including better access to physical and mental healthcare (particularly for older users).
• Maintaining the personalised and balanced approach to drug treatment and recovery support recommended by national drug strategies and clinical guidance.
• Maintaining the provision of evidence-based, high-quality drug treatment and other effective interventions.
• Reaching out to those not currently in the treatment system.
• Ensuring that the risk of drug-related death is properly assessed and understood, and eliminate poor practice that could increase risk.
The government is committed to improving the co-ordination of mental
health services with other local services, including police forces and drug and alcohol rehabilitation services. To tackle this, they will:
• Work with Public Health England and NHS England to publish new national guidance which supports local areas to effectively collaborate across drug, alcohol and mental health services, preventing exclusion based on presenting need, to meet obligations in the Five Year Forward View for Mental Health and the Crisis Care Concordat.
• Improve the data to enable providers and commissioners to better understand the scale of unmet need, and to monitor impact.
• Work with Health Education England and other stakeholders, in line with the Five Year Forward View for Mental Health recommendation, to support the development of an appropriately trained and competent workforce to meet the needs of people with co-occurring substance misuse and mental health conditions.
Access to employment and meaningful activity is a critical element of recovery. The government wants individuals to engage in a range of meaningful activities, such as volunteering, education and training, to enhance skills, gain experience and confidence, and ultimately move into employment if they are able to. Actions include introducing the new Work and Health Programme in 2017 which will provide intensive and tailored support to people with a disability and the long term unemployed and will include early access for priority groups such as people with a drug dependency so they can get additional support at any point in their claim; and continuing the ‘See Potential’ campaign launched in 2015 to encourage employers to recruit more people from disadvantaged groups, including those recovering from drug and alcohol dependence, by highlighting the business benefits.
The 2010 Drug Strategy put recovery at its heart and measured success based on the numbers coming out of treatment, and being free from dependence for six months. To support the ambition to increase rates of recovery from dependence the government will: expand the measure to capture those free from dependency for 12 months; segment the data to provide a better picture of the treatment population, and track progress for those for who the evidence suggests could recover at higher rates (eg, newer opiate users and non-opiate users); and provide a breakdown of local and national treatment penetration rates, and time taken to access treatment.
The government will also develop a framework of joint measures across key domains:
• Homelessness and housing: a joint outcome measure between homelessness/housing support services and drug and alcohol treatment providers to ensure that appropriate housing and housing-related support is given to those who need it.
• Crime and offending: a joint outcome measure with relevant criminal justice partners to understand the support provided to drug-misusing offenders and its impact on reoffending.
• Mental health: a joint outcome measure for people with co-occurring mental health conditions.
• Employment: a joint outcome measure between public employment services and drug and alcohol treatment providers, and other associated measures which give more consideration to distance travelled towards the labour market eg, volunteering, training and meaningful activity.
NHS England is introducing an integrated Health and Justice Information System, which will provide robust measures against which to evaluate the effectiveness of drug treatment systems in custodial settings. This will be used to identify and disseminate good practice to contribute to improved outcomes in relation to prison-based drug treatment and the prevention of drug related deaths – for instance, evidence of the protective effect of opioid substitution therapy in preventing drug related deaths on release from custody.
The ring-fenced Public Health Grant to local authorities will continue until April 2019, funding treatment and prevention in drug and alcohol services; as will the condition for local authorities to “have regard to the need to improve the take-up of (and outcomes from) drug and alcohol services”. £10 million has been announced for outcomes payments for long-term rough sleepers or single homeless people as part of the Homelessness Prevention Programme. This will include outcomes relating to substance use.
“We will take a leading role in driving international action, spearheading new initiatives eg, on new psychoactive substances, sharing best practice and promoting an evidence-based approach to preventing drug harms.”
“Leading the global response” to new psychoactive substances, the government pledges to:
• Collect and share data on the emergence, use and harms of substances, as well as analytical data that can support forensic identification.
• Work with the World Health Organization, the United Nations Office on Drugs and Crime and others to ensure international controls on the most harmful substances.
• Strengthen cross-border law enforcement action on the supply of new psychoactive substances, including by stepping-up engagement with the source countries of these substances.
• Promote the work of the Advisory Council on the Misuse of Drugs in international fora.
• Use international networks to share best practice from the United Kingdom.
The government will also champion human rights internationally, and support low- and middle-income countries to have greater access to medicine and to address HIV infections among people who inject drugs.2010 Drug Strategy before it, this strategy reflects a world view that the best way to tackle problem drug use is to encourage people to live drug-free lives. Though it affirms a commitment to evidence-based measures, the strategy only tentatively or partially (1 2) extends this commitment to harm reduction.
The term ‘harm reduction’ itself only appears once in the strategy, and that is in relation to smoking: “Smoking is also highly prevalent among alcohol and drug misusing populations, and is a significant contributor to illness and death. Drug treatment services should work with local stop smoking services to offer smoking cessation to all, and harm reduction for people unable or unwilling to stop smoking” (emphasis added).
Opioid substitution therapy is acknowledged only as a legitimate life-saving tool for people transitioning from custody to the community, and as a method of addressing the spread of HIV in low- and middle-income countries; and there is no reference to drug consumption rooms, despite the Advisory Council on the Misuse of Drugs advising the government in 2016 that they have been shown to “reduce injecting risk behaviours and overdose fatalities”, and recommending that “consideration be given … to the potential to reduce drug-related deaths and other harms through the provision of medically-supervised drug consumption clinics in localities with a high concentration of injecting drug use.”
Echoing the Conservative Party’s 2015 election manifesto, the strategy uses the term “full recovery” to connote a treatment system that aims for abstinence “instead of the routine maintenance of people’s addictions with substitute drugs”. However, unlike the government’s 2012 ‘roadmap to recovery’ which pledged to “bring an urgent end to the current drift of far too many people into indefinite maintenance, which is a replacement of one dependency with another”, there wasn’t any overt hostility to opioid maintenance treatment. If we think of the strategy as providing the broad brushstrokes, the accompanying clinical guidelines give the details – and these did not signal the end of longer-term opioid maintenance prescribing. Professor John Strang – who chaired a group that rejected repeated demands from within government that the duration of opioid substitute prescribing be curtailed – introduced the guidelines with a statement that “Pharmacological approaches remain extremely important and of clearly demonstrated efficacy and effectiveness for those with problems related to use of heroin or other opiates”.
In the strategy the government rules out any intention of decriminalising drugs, asserting that drugs are illegal because they are harmful. This complements the world view that people should strive to live drug-free lives, but excludes evidence that distinguishes between different types of use or levels of harm. In 2014, the Home Office accepted that there is “no apparent correlation between the ‘toughness’ of a country’s approach [meaning the criminalisation of drugs] and the prevalence of adult drug use”. This was omitted from the strategy, as was the acknowledgement that harms have been seen as partly or largely due to prohibition itself, and the life-saving benefits that can come from harm reduction strategies (eg, the supply of injecting equipment and prescription to addicts of otherwise illegal drugs) that implicitly ‘accept’ that illegal drug use is taking place.
Speaking at the symposium UK Drugs Policy: More Harm Than Good? the same day the strategy was launched, Police and Crime Commissioner Ron Hogg presented an alternative to the government’s criminal justice approach to drug use and dependence – based he said not on policy-based evidence, but evidence-based policy:
“Addicts should be treated and supported into recovery, removing them as consumers. Their entrapment in criminal justice is a waste of police time, a waste of public spend, does not help them to recover, provides a continued market to dealers and dissuades addicts from revealing themselves for treatment for fear of the criminal consequences … If the aim is to stop people taking drugs, and to stop people committing crime in order to fund their habit, we must follow the evidence and support people to recover rather than send them to prison.”
His Durham and Darlington police force caused controversy in 2014 when it announced that it would no longer be targeting people growing cannabis for personal use, and between 2006 and 2011, when it was home to a pilot project for heroin-assisted treatment, involving heroin users being prescribed the Class A drug to inject in designated facilities with trained staff present. The UK heroin prescribing pilot as a whole saw a two-thirds reduction in crimes committed per user, and the police force announced earlier this year that it would introduce the facilities in the county to tackle drug-related crime.
Public Health England, which supported the Home Office in developing the prevention and recovery strands of the strategy (informed by the findings of their drug treatment evidence review published earlier this year) points to a number of promising themes in the strategy, including:
• A focus on resilience-based prevention: The evidence indicates that education-only approaches are not effective on their own at reducing drug use and harm, but what does work is a broader approach which builds resilience and confidence among young people, giving them the skills and motivation to resist risky behaviours and recover from any setbacks. Public Health England believes the drug strategy reflects this.
• The recognition of housing and employment support: A key strength of the strategy is its focus on addressing the wider health and social inequalities often faced by those with drug problems. One of the biggest challenges is ensuring that treatment works as part of a wider response to recovery. Public Health England is pleased the Government is taking action to ensure that drug users are supported in gaining access to employment support at all stages of their recovery, as well as help in securing decent housing.
The creation of a new Drug Strategy Board – reminiscent of the earlier Anti-Drugs Coordination Unit, established in the late 1990s under the New Labour government – moves beyond the previous inter-ministerial group to include other bodies. This could signal a number of things, for example the re-prioritisation of drug policy, or an acknowledgement of the need to oversee currently fragmented funding and responsibilities.
The potential for the further development or provision of school-based prevention (praised by Public Health England above) is marked in part by the strategy’s commitment to the Department for Education engaging widely on the scope and content of Personal, Social, Health and Economic (PSHE) education. As it stands, drug education remains optional under the Children and Social Work Act 2017, while sex education in contrast is mandatory.
Lastly, when the strategy was launched, the lack of additional funding to support its objectives was noted (1 2 3) – not only this, but shrinking budgets with which to tackle the strategy’s ambitious agenda. According to the King’s Fund, it was estimated that local council spending on substance use would fall by more than £22m in 2017–18 – a 5.5% cut. Speaking to the British Medical Journal about the new strategy, Ian Hamilton, a lecturer in mental health at York University, said: “I think we’ve reached the limit of how efficient local authorities can be in commissioning drug treatment, and now what we’re going to see is less drug treatment, not more efficiently provided drug treatment.” In moments like the launch of this strategy, the perceived under-resourcing of public services (1 2) is inevitably contrasted against the increasing expectations of services and workers, such as the ideals of cooperation and collaboration between health, social care, mental health, housing, prisons, and probation.
An evaluation of the 2010 Drug Strategy can be found here.
Thanks for their comments on this entry in draft to Blaine Stothard, an independent consultant in health education. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 15 August 2017. First uploaded 23 July 2017
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