Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 19 December 2014

The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


Hepatitis C is a formidable public health enemy which demands multi-pronged, pincer-action strategies. Can it really be true that Scotland’s alcohol treatment system has so much more capacity than the English? Perhaps one reason why the Home Office found ‘tough’ policies unrelated to drug use prevalence or harm is that prison poses major obstacles to effective rehabilitation.

Multi-pronged strategies can beat hepatitis C ...

Scottish alcohol treatment system has three times the capacity of the English ...

Home Office finds ‘tough’ policies unrelated to drug use or harm ...

Prison-based treatment: problems and promising solutions ...

A systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs.

Hagan H., Pouget E.R., Des Jarlais D.C.
Journal of Infectious Diseases: 2011, 204(1), p. 74–83.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Hagan at hh50@nyu.edu. You could also try this alternative source.

Despite the challenges, review confirms that hepatitis C infection can be prevented among injectors, but it takes multi-component strategies with elements such as substitute prescribing to reduce or eliminate drug injection, treatment of infection, and enabling safe injection practices by providing sterile injecting equipment and behaviour-change counselling.

Summary Preventing infection with hepatitis C in people who inject drugs is a tremendous public health challenge. The virus is very efficiently transmitted through injecting practices which expose the injector to infectious blood, and typically 40% to 90% of injectors are infected. Together this means each time injectors share injecting equipment, there is high risk that one will infected and transmit it to the other. This systematic review and meta-analysis synthesised results of research on the degree to which interventions to prevent such transmission are actually associated with fewer new infections, as demonstrated by biological tests for the seroconversion which marks transition from not being to being infected.

Though the search included reports in other languages, all the 26 studies found were reported in English and were from high-income countries. All tested for seroconversion in individuals who had versus had not (or not to the same degree) accessed a preventive intervention or set of interventions. No population-level studies (eg, comparison of infection rates among injectors across an area before and after the opening of needle exchanges) were found which used seroconversion as an outcome measure, and none reported on seroconversion in relation to supervised injection facilities or pharmacy sales of syringes. Four of the studies randomly allocated injectors to the intervention versus the comparator; the remainder tracked what happened when people did or did not (at least to the same degree) access the intervention in the normal way [meaning their results may be due to some extent to pre-existing differences between the groups or other influences rather than to the intervention].

Main findings

Behavioural interventions Two studies examined psychosocial interventions. One tested a six-session training programme to enable injectors to educate other injectors. It made no significant difference to the seroconversion rate. The same was true in another study of four sessions of motivational interviewing, and when the results of both studies were pooled.

Estimated risk reduction/increase of hepatitis C infection associated with each type of intervention

Substance use treatment Five studies assessed treatment (variously defined, including being in it at the start of the study, ending up in it, staying in it, or being retained for a certain period) for problem substance use without specifying what the treatment was. The relationship between treatment and seroconversion differed substantially: in two studies, higher rates with treatment; in two, lower. With such variation, the statistically insignificant estimate from pooling the results should be interpreted with caution [because it seems that like is not being combined with like].

Opioid substitution therapy Eight studies evaluated programmes like methadone maintenance which substitute another opiate-type drug for the one(s) the patient is dependent on. ‘Treatment’ was variously defined as being in treatment at the start of the study, ending up in it, or having stayed in it throughout, and was compared to not being in treatment at all or not continuously. Six of the eight studies found that proportionately fewer of the treatment group became infected with hepatitis C, one the reverse. Pooled results indicated that the chances of becoming infected among injectors who (as defined in the study) received opioid substitution therapy were 40% less than those of comparison injectors, [a reduction in risk which only narrowly missed being statistically significant according to the conventional criterion].

Needle and syringe programmes Seven studies – all from North America – evaluated programmes which distribute sterile injecting equipment to injectors. All but one compared seroconversion rates among injectors who used the service to any degree versus those who had never used it during the period assessed by the study. One study used a case-control design to evaluate the needle exchange in Tacoma in the USA, [calculating whether (versus injectors who had not become infected) newly infected injectors were disproportionately common among those who had never used the needle exchange]. It found exchange use associated with a substantially and significantly reduced risk of infection. On the contrary, a Canadian study of Vancouver’s needle exchange found the risk of infection significantly greater in frequent exchange attendees compared to other injectors. All other studies reported no significant association. Pooled findings from all the studies indicate there is a significantly greater chance that exchange attendees will become infected with hepatitis C, [but the findings differed so much that like may not be being combined with like].

Syringe disinfection Disinfecting syringes with bleach (defined as always using bleach or disinfecting all syringes) was evaluated in four US studies. Though the studies’ estimates ranged from substantial risk reduction to much greater risk, none were statistically significant, and the pooled estimate too was non-significant and very close to the risk being the same whether or not bleach was used.

Multi-component programmes Among patients being prescribed methadone or buprenorphine, a UK randomised trial evaluated four sessions of enhanced counselling aimed at preventing hepatitis C infection versus a brief, non-interactive hepatitis C information/advice session. The seroconversion rate after counselling was nearly half that after the briefer intervention, but this difference was not statistically significant, so could not be securely attributed to the counselling. In Amsterdam injectors prescribed at least 60mg daily of methadone and who had either stopped injecting or used only equipment from needle exchanges, were substantially and significantly less likely (equivalent to 3.5 per 100 people per year versus 23.9) to become infected than those less adequately engaged in either or both types of service. Pooling the results of the UK and Dutch studies led to a statistically significant risk-education estimate equivalent to one person becoming infected with the combined interventions versus four without.

The authors’ conclusions

Despite the challenges, infection with hepatitis C can be prevented among drug injectors; combined results from the two studies of multi-component programmes show risk reduced by about 75%. The extra impact of combining interventions is consistent with hepatitis C transmission being facilitated by an array of factors, including the large disease reservoir of already infected injectors, the ease with which the virus can be transmitted via several practices related to injecting, and the chaotic and rushed atmosphere of the injection setting. Given this context, multi-component programmes which promote a range of strategies (such as substitute prescribing to reduce or eliminate drug injection, and promoting safer injection practices through the provision of sterile syringes and drug preparation equipment and/or behaviour-change counselling) would be expected to be more effective than single-focus programmes.

Both the reviewed multi-component interventions included opioid substitution treatment as an element. On its own this treatment has less substantial and more inconsistent impacts on seroconversion, so cannot be assumed to be the sole active ingredient in the multi-component interventions. What may be important is the degree to which (together with other elements) it helps patients stop or greatly reduce their injecting.

The findings of this review are consistent with the conclusions of other reviews supporting packages of harm reduction interventions. Another meta-analysis from the same parent project as the featured review found that the expansion of syringe access and opioid substitution programmes in high-income countries was associated with a lengthening in the time from onset of drug injection to infection with hepatitis C. Findings are also consistent with those of a study of long-term injectors in areas where hepatitis C was common, but who nonetheless remained uninfected. They told researchers that they used a combination of strategies to avoid withdrawal symptoms and practice safe injection.

Among the limitations of the studies on which the featured review was based is that in some the definition of the intervention could have allowed for sporadic and ineffective degrees of engagement. However, in respect of opioid substitution treatment, studies which defined this as unbroken treatment found no more robust a link with reduced infection rates than other studies. All the studies of syringe disinfection with bleach stipulated 100% use, so the pooled findings strongly support the conclusion that even this degree of implementation has no effect on the transmission of hepatitis C. Also, the source studies were commonly unable to eliminate influences other than the evaluated intervention which might have accounted for the findings. In particular, needle exchanges attract and retain injectors who are already at a higher risk of infection, so comparisons with injectors who do not use exchanges can lead to the mistaken conclusions that exchange participation increases the risk of infection.

Findings logo commentary Transmissibility of the hepatitis C virus, and the fact that any time you do let down your defences, the other injector whose blood you come in to contact with is likely to be infected, mean there is at the moment no easy solution to preventing its spread. It takes a fusillade of complementary anti-infection practices and interventions to substantially impede the virus’s progress. At the heart of current strategies are methadone maintenance and allied treatments to reduce the number of injections, making it easier for needle and syringe programmes to ensure each remaining injection is with uncontaminated equipment.

The reviewers’ conclusion in favour of the parallel deployment of several risk-reduction interventions is supported by a synthesis of results from UK studies. It found that when injectors were protected by consistent participation in methadone maintenance treatment or adequate access to fresh injecting equipment (a fresh set for each injection) the chances of their becoming infected were halved relative to the risk faced by injectors who had not adequately participated in either type of service. But when they were protected by both interventions, their risk of infection was just a fifth of that faced by injectors who had used neither to the degree set by the study.

Such findings contributed to guidance from the UK’s National Institute for Health and Clinical Excellence, which also called for multi-strand prevention featuring adequate syringe distribution, substitute prescribing programmes and early detection and treatment of injectors already infected with hepatitis C.

Other factors cannot be ruled out

However, the reviewers’ caution that the studies are compromised by non-randomisation is no methodological nicety. Their estimates of the link between interventions and infections would only correspond to the impact of the interventions if we assume real-world selection processes have not weighted the balance for or against the interventions. Commonly these processes take the form of injectors who choose versus choose not to engage in interventions being at unequal risk of infection. It has meant that needle exchanges which (as intended) attract high-risk injectors, for that reason look as if they are generating infections – the ‘magnet effect’ identified by Drug and Alcohol Findings in its case studies of Vancouver and other cities. In fact, the main lesson of Vancouver and other cities is that ‘trickle feed’ supply of injecting equipment, with more of an eye on public reaction and minimising supply than preventing infection, cannot curb hepatitis C infection, and may not even dent spread of the easier-to-control HIV virus.

What seems a clear if unusual example of selection processes making an intervention seem counterproductive comes from the one study in the featured review to find methadone maintenance associated with more injectors becoming infected with hepatitis C. It was set in a general practice in Melbourne, Australia, which did not routinely re-test its continuing methadone patients for the virus. Probably, say the researchers, many patients were not re-tested because the clinic saw no reason to do so. Those who were re-tested would tend to be the higher risk cases – hence the impression that methadone treatment generated infections.

Tacoma shows needle exchange can prevent hepatitis C

For experts convened by the US National Academy of Sciences, studies in Tacoma, including the one highlighted in the featured review, constituted evidence of a “powerful retardant effect of needle exchange program attendance on infection with [hepatitis B and C]”. This judgment from 1995 remains valid, and the Tacoma hepatitis study remains a rare convincing demonstration that exchanges can intercept the spread of hepatitis C among injectors. It was the one needle exchange study in the featured review which found a significantly reduced risk of infection, and the only one to use a case-control methodology based on identifying new cases of infection and establishing whether they had used the exchange, then comparing these figures with injectors who remained uninfected.

Among the factors which set Tacoma’s exchange apart was legal approval (the first in the USA), what became a well resourced and comprehensive service including effective referral to methadone maintenance, unlimited supplies of injecting equipment, encouragement for service users to act as mini-exchanges for other injectors not directly using the exchange, and an engaged set of service users who saw themselves as part of an activist-led fight to establish exchanges in a hostile national environment. Against a background where little else was on offer, the exchange’s anti-infection impacts became visible in ways not seen elsewhere. Although selection processes might have biased Tacoma’s hepatitis C study, the benefits of exchange attendance were so clear cut that only unrealistic assumptions would have rendered them insignificant.

See this hot topic entry for more on controlling the hepatitis C epidemic.

Last revised 15 December 2014. First uploaded 07 December 2014

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Top 10 most closely related documents on this site. For more try a subject or free text search

STUDY 2010 Effect of motivational interviewing on reduction of alcohol use

STUDY 2011 The impact of needle and syringe provision and opiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: pooling of UK evidence

STUDY 2012 Association between harm reduction intervention uptake and recent hepatitis C infection among people who inject drugs attending sites that provide sterile injecting equipment in Scotland

STUDY 2014 Rapid decline in HCV incidence among people who inject drugs associated with national scale-up in coverage of a combination of harm reduction interventions

DOCUMENT 2013 Community loses from failure to offer maintenance prescribing in prisons

REVIEW 2009 The primary prevention of hepatitis C among injecting drug users

STUDY 2012 Can needle and syringe programmes and opiate substitution therapy achieve substantial reductions in hepatitis C virus prevalence?

DOCUMENT 2011 Prevention and control of infectious diseases among people who inject drugs

REVIEW 2012 The effectiveness of opioid maintenance treatment in prison settings: a systematic review

STUDY 2015 Randomized controlled trial of motivational interviewing for reducing injection risk behaviours among people who inject drugs

Assessing the availability of and need for specialist alcohol treatment services in Scotland.

Clark I, Simpson L.
NHS Health Scotland, 2014.
Unable to obtain a copy by clicking title? Try this alternative source.

Evidence that in 2012 Scotland’s alcohol treatment caseload equated to about 1 in 4 of the country’s alcohol-dependent adults, over three times the 1 in 14 ratio in England, partly a consequence of extra funding accompanying Scotland’s 2009 national alcohol strategy. Evidence too of a peer-based recovery orientation taking root.

Summary This research assessed the availability, demand and utilisation of specialist alcohol treatment services in Scotland following publication in 2009 of the national alcohol strategy. Additional resources accompanied the strategy, totalling £120 million over three years, an increase of over £85 million on previous funding. Primarily it was intended to improve the identification, support and treatment of problem drinkers as well as to develop the alcohol treatment workforce.

In 2011 guidance was issued on the commissioning and delivery of person-centred, recovery-orientated, outcome-focused local services. This also recommended that services and planning authorities should have robust needs assessment and equality impact assessments to ensure the needs of all groups are identified and met. Other key recommendations focused on service user involvement, outcome monitoring, staff development, and links with mutual aid organisations. To drive improvements the Scottish government set a target that 90% of people referred for alcohol treatment would wait no longer than three weeks to receive it, and that an estimated 75% of people who could benefit from an alcohol brief intervention should receive one by 2010/11.

The study assessed the impact of these measures partly by means of a survey in 2012 of specialist alcohol treatment services delivering structured, care-planned treatment to adults either on a non-residential (tier 3) or residential (tier 4) basis. Nearly 90% of the 149 services responded to the survey, of which 117 answered questions about how many drinkers they had in treatment. From these an estimate was made for all 149 services.

How many people in Scotland might need treatment was estimated from the 2012 Scottish Health Survey as the numbers scoring at least 16 (possible dependence) on the AUDIT questionnaire used to screen for risky drinking. Combining this with the numbers in treatment (see paragraph above) provided a ratio of the degree to which treatment capacity could accomodate the possible need for treatment – the service-utilisation:prevalence ratio.

The three alcohol and drug partnership areas prepared to undertake this acted as case studies and were subject to more in-depth investigation including interviews with staff and service users.

Main findings

The study identified 149 specialist alcohol treatment services which were delivering tier 3 and 4 interventions to an estimated almost 32,000 individuals (two-thirds men) across Scotland during 2012. Nearly two-thirds of the patients were in services delivering only non-residential/outpatient (tier 3) interventions. Fewer than a quarter of services provided information on service users by either age, ethnicity, offender status, homelessness, disability status, or whether asylum seekers, refugees, or gypsy/travellers. Over 8 out of 10 services also delivered drug treatment services. Half of all the services delivered only tier 3 interventions, 43% both tier 3 and tier 4, and about 1 in 14 only tier 4.

In the 2012 Scottish Health Survey about a fifth of adults aged 16 or over reported drinking behaviour consistent with an alcohol use disorder. Most scored on the AUDIT screening test as hazardous drinkers (8 to 15) but 3.1% of the population displayed signs of moderate or severe alcohol dependence (scores of 16 or more), equating to almost 138,000 individuals, twice as many of whom were men as women.

These figures can be used to calculate a service-utilisation:prevalence ratio of 1:4.3 – that is, about 1 in 4 alcohol-dependent adults accessed specialist alcohol treatment in 2012. This ratio was (as far as could be told from the limited data available) about the same for men and women. Retail sales suggest survey respondents under-estimate how much they drink. If instead of about 3%, some 6% of the adult population were potentially dependent on alcohol, the service-utilisation:prevalence ratio rises to 1:8.3 – that is, treatment service caseloads equate to about 1 in 8 of all adults possibly in need of treatment.

In response to an open-ended question about future challenges and opportunities, respondents from treatment services identified funding as the main challenge, expressing concern about anticipated future budget cuts and the impact this would have on services.

Case study areas

In the three case study areas, service commissioners, providers and users described the positive impact of the additional funding and resources that accompanied the national alcohol strategy. Extra staff helped extend support to more drinkers, reduce each worker’s caseload, and increase the frequency of therapeutic contacts. The strategy had also led to more holistic assessment of support needs and more effective treatment, with an increased understanding of the importance of recovery and preventive work. The waiting time target was also seen as a factor, though some criticised the work involved in meeting associated reporting requirements.

Other developments identified by staff included convergence with drug treatment services. In many cases, specialist drug and alcohol treatment services had merged and or co-located since 2008/09. Only a handful of interviewed staff dealt solely with alcohol. Growth of the ‘third’ or non-statutory sector since 2008 was seen as creating greater choice and facilitating tailored pathways for service users. These services too were able to extend their capacity through volunteers – often former service users who had sustained their recovery. Another development mentioned by commissioners and service managers, staff and users, was increased resources for peer-led recovery networks, such as Self Management Addiction Recovery Training (SMART), providing venues for service-user led meetings, suggesting activities for those in recovery such as hill-walking, and raising awareness of funding available to cover costs such as transport. Staff and managers across all three areas suggested these networks provide an additional resource that could increase recovery support capacity. Also mentioned were positive relationships between service commissioners and providers and increasing service user involvement in the design of services.

There was a concern however that in some cases new services had recently been scaled back or ended due to funding issues. One of the main gaps in service reach was seen as individuals who either do not recognise their need for treatment or are reluctant to access it, as well as gaps in treatment availability, such as for people affected by alcohol-related brain damage.

Staff in four services in two of the case study areas took part in a capacity assessment exercise. Recording their activities established that direct contact with service users accounted for about a third of the time staff spent on alcohol-related activities; slightly more time was spent on activities related to service users but not involving direct contact with the patient/client.

The authors’ conclusions

The study found that 149 specialist alcohol treatment services delivered tier 3 and 4 interventions across Scotland during 2012. Additional resources accompanying the national alcohol strategy enabled these services to support almost 32,000 individuals, about a quarter of those in need of help. Findings suggest that service commissioners and planners have used those resources to further the national strategy’s aims to improve local service delivery and accountability, and specifically to improve the identification, support and treatment of people misusing alcohol and the building of capacity in specialist alcohol treatment and care services. Nevertheless a service-utilisation:prevalence ratio of 1:4.3 means that about three-quarters of alcohol-dependent individuals could not have accessed treatment in 2012, supporting the views expressed in the case study areas that many individuals either do not recognise their need for treatment or are reluctant to access it.

For England it is possible to calculate a roughly equivalent service-utilisation:prevalence ratio by combining records of numbers in treatment for alcohol problems in 2012/13 and receiving tier 3 and 4 services, with the results of a national survey in 2007 which included the AUDIT alcohol screening questions. In the survey, 5.8% of men and 1.9% of women scored 16 or more, equating to about 1,526,000 possibly dependent adults, while the treatment caseload was 109,675; the resulting ratio is about 1:14. From these figures is seems a higher proportion of alcohol-dependent adults in Scotland (23%) access treatment than in England (7%), and this remains the case even if the Scottish prevalence estimate is inflated to take account of possible under-reporting. The Scottish figure also compares favourably with international standards; an access ratio of 1 in 5 would be regarded as high.

Though based on returns from a minority of services, the rough equality of the service-utilisation:prevalence ratio for each sex (about 1 in 4–5) suggests men and women in need are accessing treatment at broadly similar rates. It is a concern that even fewer services were able to break down their caseloads in to the other categories (including ethnicity, age and disability) which the Equality Act 2010 requires statutory providers to record in order to identify and rectify discrimination.

Many staff said their main focus was to meet the three-week waiting time target set by government, leaving little scope for additional work to increase the reach of services. Linked to this, there was a recurring theme about the reluctance of some NHS staff to expand their roles in terms of activity related to recovery. Commissioners and service managers and staff suggested the ways services undertake assessment and planning had moved beyond the traditional model of providing services to those in treatment, towards working in partnership with individuals in recovery. Peer-led recovery initiatives are an associated development and an additional resource welcomed by many service users and staff. However, there is limited research on how these initiatives link to specialist alcohol treatment services. Sustainability may be an issue, and there are potential risks in the delivery of recovery support by peers who may not be fully trained and who may not be able to sustain continuity of service, perhaps due to relapse or ill health.

Findings logo commentary For more on calculating the degree to which treatment systems can treat all drinkers who might need treatment, see this Findings analysis of the English report used as the basis of the featured study’s assessment that a much higher proportion of possibly dependent drinkers can access treatment in Scotland. That assessment seems based – as close as can be – on a like-for-like comparison. However, the Scottish figure for numbers in treatment was derived from a survey of treatment services, which benefited from direct contact with local area coordinators to identify those services, while the equivalent English figure derived from a routine data gathering system. The Scottish figure was grossed up to take account of services which had not responded to the survey, while the English estimate was derived just from those services which submitted data to the national database.

In England results from the AUDIT questionnaire relied on in Scotland – intended to identify risky drinking – could be combined with those from a questionnaire designed to assess severity of dependence. On this basis, the UK’s National Institute for Health and Clinical Excellence (NICE) calculated that 260,000 adults in England are at least moderately dependent, suggesting that numbers in treatment in England equate to over 40% of the ‘really’ in-need population. What such an exercise might reveal in Scotland is unclear, but certainly it would take the service-utilisation:prevalence ratio closer to the system having the capacity to treat all those who need treatment, as indicated both by the AUDIT screening questionnaire and by the dependence-specific questionnaire. But even if the ratio was 1:1, it would not mean that all drinkers who need treatment receive it, just that the system has the capacity to achieve this; it could still be that many seriously dependent drinkers avoid or are not identified as needing treatment, and that some treatment slots are filled by less serious cases.

Estimates both for England and Scotland based on surveys must be adjusted for the under-reporting indicated by comparing survey responses with how much drink is actually sold. There is reason to believe that the heaviest drinkers underestimate their drinking most when responding to surveys, perhaps actually drinking over twice as much as they say.

Last revised 22 November 2014. First uploaded 22 November 2014

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DOCUMENT 2013 Delivering recovery. Independent expert review of opioid replacement therapies in Scotland

DOCUMENT 2010 The Patel report: Reducing drug-related crime and rehabilitating offenders

REVIEW 2011 Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence

STUDY 2011 An evaluation to assess the implementation of NHS delivered alcohol brief interventions: final report

STUDY 2011 Scoping study of interventions for offenders with alcohol problems in community justice settings

STUDY 2011 Recovery innovations in Yorkshire and Humberside

STUDY 2010 Alcohol services in prisons: an unmet need

STUDY 2012 The forgotten carers: support for adult family members affected by a relative's drug problems

STUDY 2011 Prison health needs assessment for alcohol problems

STUDY 2011 Delivering alcohol brief interventions in the community justice setting: evaluation of a pilot project

Drugs: international comparators.

Home Office.
[UK] Home Office, 2014.

After seeing how drug policy worked overseas, UK government ministers and officials returned saying, “there is no apparent correlation between the ‘toughness’ of a country’s approach and the prevalence of adult drug use”, and that “better health outcomes for drug users cannot be shown to be a direct result of the enforcement approach”.

Summary The following text reproduces the executive summary of a report which fulfilled the UK government’s commitment in its 2010 national drugs strategy to review evidence about what works in other countries. During 2013 and 2014, ministers and officials conducted international fact-finding visits and discussions. The report reviewed the results of this fact-finding exercise and considered them against approaches taken in the UK. Most widely publicised from the report was its observation that, “Looking across different countries, there is no apparent correlation between the ‘toughness’ of a country’s approach and the prevalence of adult drug use.” The last section (Decriminalising: additional comments) of this summary reproduces passages relevant to that assertion from the body of the report.

This report describes the findings of the Coalition Government’s international comparators study of approaches to drugs misuse and drug addiction. The Government has considered a range of policy and operational responses to drugs in other countries and reviewed the evidence of their impacts, where possible drawing out contrasts and similarities with the Government’s own Drug Strategy.

During 2013 and 2014, ministers and officials from the Home Office took part in fact-finding visits to, and discussions with, eleven countries: Canada, the Czech Republic, Denmark, Japan, New Zealand, Portugal, South Korea, Sweden, Switzerland, the United States of America and Uruguay. Home Office officials also undertook desk-based research on policies in a number of other countries including the Netherlands. Based on what we saw during our fact-finding, and grounded in an understanding of the drugs situation in the UK, we identified a set of themes to focus on – responses to drugs which stood out as particularly innovative, widely discussed, or relevant to the UK situation. We undertook further research and analysis of the evidence base around each of these themes. In this report, we present the outcomes of this work.

The UK situation

There is robust evidence that drug use among adults has been on a downward trend in England and Wales since the mid-2000s. This trend seems to be reflected in drug use among children of school age. While, historically, levels of drug use in the UK have been relatively high, there are signs that, following several years of declining use, levels of drug use in this country are close to the European average.

The 2010 Drug Strategy sets out our response to drugs misuse and drug addiction. It is a balanced approach, encompassing activity across three strands: reducing the demand for drugs, restricting the supply of illegal drugs, and supporting users into recovery. Our legislative response to drugs is based in the 1971 Misuse of Drugs Act, which continues to provide a flexible yet consistent legislative framework to control emerging harmful drugs and target illegal suppliers, while supporting our public health messages and the delivery of our Drug Strategy.

Drugs present us with a continually evolving set of challenges. Changes over time in the types of people who use certain drugs, the types of drugs that are available, and the methods of supply, mean that we must adjust our responses. Through our Drugs Strategy and our Serious and Organised Crime Strategy, we are meeting new and longstanding challenges such as: the crime and public health harm associated with opiate and crack cocaine addiction; the variety of ways in which illegal drugs can reach the UK; the threat of prescription drug abuse; and the emergence of many New Psychoactive Substances, some of which are openly sold, often inaccurately, as ‘legal highs’.

Responses to drug use in other countries

Just as the UK has arrived at its current approach in response to an evolving set of challenges, the responses we saw in each country are a product of that country’s own issues. It is a common aim of every country to reduce drug misuse. The variety of ways in which countries seek to achieve this aim reflects the sometimes stark differences between legal frameworks and cultures.

Drug consumption rooms

In Canada, Switzerland and Denmark, we visited facilities into which drug users can bring illicitly purchased drugs – typically heroin or cocaine – for consumption under supervision. These ‘drug consumption rooms’ have emerged as a response to the public health risks associated with open drug scenes: public areas where drug users congregate in large numbers to purchase and inject or smoke drugs. There is some evidence for the effectiveness of drug consumption rooms in addressing the problems of public nuisance associated with open drug scenes, and in reducing health risks for drug users. Drug consumption rooms overseas have been controversial and legally problematic, and have been most successful where they have been a locally-led initiative to local problems. We do not experience scenes of public drug taking on the same scale in this country.

Heroin assisted treatment

We visited a clinic in Switzerland where patients are given injections of pure heroin under medical supervision, as part of their treatment for opiate dependency. Heroin assisted treatment is an emerging form of treatment which uses injections of medical-quality heroin, where traditional substitution treatment would administer oral methadone or buprenorphine. The evidence from trials in several countries, including the UK, shows that this form of treatment can be effective in reducing illicit drug use and improving retention in treatment among people deeply entrenched in opiate dependency, for whom other forms of substitution treatment have been ineffective. A limited pilot of this approach is underway in three sites in England.

Dissuasion commissions

A cornerstone of Portugal’s decriminalisation policy is the use of dissuasion commissions: lay panels which sit outside the criminal justice system, consider cases of drug possession, and decide whether individuals should be given administrative penalties or referred into treatment for addiction. Although dissuasion commissions are held in the context of decriminalisation, the concept of signposting treatment in drug possession cases can and does apply in the criminal justice system in this country.

Drug courts

We visited a drug court in Baltimore, Maryland, where people charged with a drug-related offence have the option of pleading guilty and entering a treatment programme overseen by a judge, in lieu of a traditional (possibly custodial) sentence. Drug courts apply a range of sanctions and rewards to encourage offenders to successful completion of treatment, with the aim of reducing their chances of reoffending. There are more than 2,500 drug courts in the USA, and the model has been exported to Canada, Australia and the UK. Drug court pilots in England and Wales have been affected by differences in court systems, sentencing practices and cultures. Crucially, there is a lack of evidence for their effectiveness, and drug court models in the UK (including Scotland) have shown no impact on reoffending rates.

Prison-based treatment

We visited prisons in Japan and Denmark, to look at how people are treated for drug dependency in different cultural contexts. Our consideration of the evidence for the effectiveness of prison-based treatment programmes confirmed the potential for these programmes to reduce reoffending. It also highlighted the vulnerability of offenders with a history of drug use during the transition from custody to the community. In the UK context, we are developing an approach to improve access to treatment for people with drug and/or alcohol dependency in custody to existing substance misuse treatment and associated health services in the community.

Prison-based harm reduction

In Switzerland, we discussed with officials the country’s prison-based needle exchange programmes. Needle exchanges started operating in Swiss prisons in 1992 during a surge in heroin use, and have since been adopted in a number of countries, including Spain and Germany. There is a body of international evidence indicating that needle exchanges are an effective way to reduce needle sharing and the transmission of blood-borne viruses in prisons. UK law prohibits the transportation of drug paraphernalia into prisons. In tackling drug use in prisons, we focus on measures that address the breadth of drug-taking behaviour, rather than injecting alone. We are committed to reducing drug use among offenders and provide a range of low, medium and high intensity drug treatment for prisoners.

New Psychoactive Substances

New Psychoactive Substances (NPS), or so-called ‘legal highs’, are synthetic substances designed to mimic the effects of established drugs. Unlike established drugs, NPS are not covered by the established international conventions which underpin the approach of most countries to controlling drug supply and drug use. We encountered a variety of approaches to NPS. In New Zealand, a regulatory regime will be established, similar to the regime for medicines in this country, under which producers must prove the safety of substances before they can be sold in licensed premises. In the Republic of Ireland, the supply of any new psychoactive substance is illegal. The legislative framework in the USA ensures that any substances designed to mimic existing controlled drugs are also subject to the same controls by default. The Minister for Crime Prevention appointed an expert panel to consider legislative options for controlling NPS in this country. The Government’s response to the panel’s recommendations is published concurrently with this report.

Supply-side regulation of cannabis

Uruguay and the American states of Colorado and Washington are adopting experimental policies which legalise and regulate the production, supply and recreational use of cannabis. These policies have common aims – disrupting organised crime and exercising greater control over the use of cannabis – but practices differ. The American states have a market-driven approach, with lighter regulation than Uruguay and fewer limitations on consumption and use. Uruguay, which has growing concerns about organised crime, has a stronger role for the state, with limitations to the size of the market, the strains and potency of cannabis, and the quantity of cannabis an individual can purchase in a month. It is too early to know how these experiments will play out, but we will monitor the impacts of these new policies in the coming years.

Decriminalising the possession of drugs for personal use

We encountered a range of approaches to drug possession, from ‘zero-tolerance’ to decriminalisation. The evidence from other countries show that levels of drug use are influenced by factors more complex and nuanced than legislation and enforcement alone. Levels of drug use vary considerably between countries with similar policies. With regard to Portugal, where decriminalisation was followed by improvements in health outcomes for drug users, it is difficult to disentangle the effect of decriminalisation from wider improvements in treatment and harm reduction during the same period.

Decriminalising: additional comments

It would be inappropriate to compare the success of drug policies in different countries based solely on trends which are subject to differences in data collection, and are affected by various cultural, social and political factors besides legislation, policing and sentencing. However, some observations can be made:
• It is not clear that decriminalisation has an impact on levels of drug use. Following decriminalisation in Portugal there has not been a lasting increase in adult drug use. Looking across different countries, there is no apparent correlation between the ‘toughness’ of a country’s approach and the prevalence of adult drug use.
• There is evidence from Portugal of improved health prospects for users, though these cannot be attributed to decriminalisation alone.
• It is not clear that decriminalisation reduces the burden on the police. Portugal appeared to apply similar police resourcing to drugs after decriminalisation as before.
• There are indications that decriminalisation can reduce the burden on criminal justice systems. Since decriminalisation, Portugal has reduced the proportion of drug related offenders in its prison population. There has been a reduction in cases going through the courts, but it is not clear if the impact of this is balanced by the administrative burden of the dissuasion commission process.

Close consideration of countries with quite different approaches to drug possession demonstrates that the issue is more complex and nuanced than legislation and enforcement alone. Reflecting on the approach taken in the UK, there are elements in common with a range of other countries. As in Sweden, the UK’s legislative framework reflects the fact that drugs cause harm to individuals and wider society. Possession of any amount of a controlled drug is treated as a criminal offence in the UK. The UK’s classification system aims to ensure penalties are proportionate to the amount of harm associated with a substance. Like the Netherlands and many other countries, the UK applies different enforcement practices in cases of cannabis possession to those applied in possession of other drugs. As in Portugal, prevention and treatment are a key element of responses to drugs in the UK.

The disparity in drug use trends and criminal justice statistics between countries with similar approaches, and the lack of any clear correlation between the ‘toughness’ of an approach and levels of drug use demonstrates the complexity of the issue. Historical patterns of drug use, cultural attitudes, and the wider range of policy and operational responses to drugs misuse in a country, such as treatment provision, are all likely to have an impact. Similarly, achieving better health outcomes for drug users cannot be shown to be a direct result of the enforcement approach.

Last revised 09 December 2014. First uploaded 09 December 2014

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Barriers to implementing effective correctional drug treatment programs.

Farabee D, Prendergast M., Cartier J. et al.
Prison Journal: 1999, 79(2), p. 150–162.

Expertly describes and evaluates the difficulties of mounting drug treatment programmes in prisons, drawing on the pooled knowledge and experience of leading US researchers on why real-world programmes sometimes fail to live up to expectations based on more ideal-world trials. Though focused on prison, much is relevant also to community sentences.

Summary A leading US researcher on criminal justice treatment programmes has described how these “have tried to achieve two purposes – enforcer and social worker – and have found the polar nature of the two tasks often conflicting.” Such difficulties were described and evaluated in the featured review, which pooled the knowledge and experience of US experts on why real-world programmes sometimes do not live up to expectations based on more ideal-world trials. Though focused on prison, much is relevant also to community sentences. The six barriers they identified are paraphrased below, along with their proposed solutions.

1 Client identification, assessment, and referral. The tendency for criminal justice systems to use limited criteria (eg, any lifetime drug use, small-scale drug sales, trafficking) to determine the need for treatment, and to exclude other offenders for reasons unrelated to their substance use problems (eg, having committed a sexual or violent offence), can mean many patients have low-level substance use problems and little scope for improvement. There is also a tendency for prisons to ‘dump’ problematic inmates at programmes in other prisons, regardless of treatment need.

One solution is to locate treatment services in each suitable institution and recruit patients only from that institution. That entails more and smaller programmes, which should be more manageable and more focused in their implementation. Treatment staff must be involved in the selection of new admissions to ensure their appropriateness and actively recruit participants from the general inmate population to avoid populating their programmes with less appropriate inmates in order to fill beds.

2 Recruitment and training of treatment staff. It is difficult to locate and recruit qualified and experienced staff in the remote areas where prisons are typically located. Also, counsellors suited for community-based programmes will not necessarily be effective in prison; over-familiarisation and resistance to rigid custody regulations are common among treatment providers who lack experience in criminal justice settings. High turnover rates and bans on employing recovering drug users exacerbate the situation. Common counselling techniques, such as mutual self-disclosure between counsellor and client, are limited in prison; even experienced community-based counsellors must learn to adjust their counselling styles to be effective in this environment.

Recruitment can be addressed by paying higher wages than in the community. Workload can be reduced by using recovering prisoners who have been through the treatment programme as counsellors and mentors. Mandatory, shared training for all treatment staff and programme-involved custody officers will help resolve their conflicting goals. Without this, custody goals will eventually eclipse treatment goals. Often both groups falsely assume treatment and control are mutually exclusive when in reality, both can be achieved simultaneously.

3 Redeployment of prison staff. Staff turnover undermines programme stability and effectiveness, yet in prison-based treatment programmes, turnover occurs by design to further professional advancement.

A written set of standards to guide the more subjective elements of the programme can maintain continuity despite staff turnover. This requires custody and treatment staff to work closely together before and during the initiation of the programme. Standards might, for example, cover: when inmate noncompliance merits an institutional versus a therapeutic response; how closely treatment and custody staff work together; and to what extent custody staff should be involved in the treatment process and treatment staff be allowed to carry out correctional duties. Another strategy for maintaining continuity among custody staff is to professionalise their treatment roles. Certification and financial incentives for officers who have a certain number of hours of cross-training and on-the-job experience with substance use treatment programmes would help retain staff and enhance their professional development and appropriateness for the treatment setting.

4 Overreliance on institutional versus therapeutic sanctions. In contrast to community programmes, in prisons noncompliance with treatment is often met with a correctional rather than a therapeutic response. Staff in the stressful and conflict-prone prison environment are often seduced by the immediacy of issuing formal disciplinary sanctions rather than relying on the therapeutic process. Conversely, treatment staff in prisons must also be able to invoke institutional sanctions (whether directly or through custody staff) with minimal delay. Research has found that one of the most significant barriers to successful implementation of treatment programmes is the providers’ lack of authority to issue sanctions for noncompliance. To preserve authority and integrity, programmes must be able to remove inmates who violate rules or threaten other participants.

5 Aftercare. The importance of post-prison aftercare is widely recognised, and research shows that low rates of aftercare attendance and/or retention can seriously diminish the impact of prison-based treatment, yet several aspects of the criminal justice system prejudice effective aftercare. Many prisoners enter treatment involuntarily, and only a minority volunteer to continue with/stay with these services once no longer required to do so. Poor aftercare uptake may be symptomatic of an over-reliance on institutional controls in managing inmate behaviour, leading to an underestimation of the importance of internal motivation. Once institutional controls are removed, the former prisoner is unlikely to voluntarily enter aftercare. Also, community-based treatment providers can be reluctant to admit ex-prisoners, particularly those with a record of violent or sex offences. Thirdly, there is limited control over the type and quality of treatment available in whatever area the former prisoner goes to, making it difficult to ensure a continuum of care consistent with that in prison.

Efforts to strengthen engagement (eg, providing more individual sessions during the initial phases, demonstrating the success of previous graduates, motivational interviewing) should be basic elements of the programme. Because providing aftercare requires coordination between the prison-based provider, the community provider, and criminal justice agencies, the emphasis on post-release treatment participation should begin at least three months prior to the release date. External motivators for aftercare participation might also help, such as offering inmates early release from prison with residential aftercare required as a condition of parole, featuring frequent, random urine testing and close parole supervision.

6 Coercion. Participants in prison-based treatment are not always involuntary clients, but coercion undoubtedly plays a role for most. Many inmates with substance use problems are unwilling to volunteer for treatment because of the associated stigma, the additional structure and rules of a treatment programme, loss of institutional seniority, and reduced opportunities for work in prison. Hence, denial is only one of a host of reasons why otherwise eligible clients choose not to enter treatment.

Overcoming these perceived – and often legitimate – barriers requires that programmes not only remove disincentives to participation, but incorporate meaningful inducements. Coercion alone is rarely sufficient. Possible incentives include early release, improved living quarters, enhanced vocational or employment opportunities, and reduced restrictions on parole. Also, the initial phase of treatment must emphasise problem recognition and willingness to change, before introducing the tools to do so.

Last revised 25 November 2014. First uploaded 25 November 2014

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