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Time for safer injecting spaces in Britain?

Are the drugs enough? Counselling and therapy in substitute prescribing programmes

Can testing and sanctions displace addiction treatment?

Time for safer injecting spaces in Britain?

Drug consumption rooms provide a hygienic and supervised space for users to inject or otherwise consume illicitly-obtained drugs, the overarching aim being to reduce or eliminate public injecting and its adverse effects on the environment, public order, and the health of drug users. Evidence does not support concerns that drug consumption rooms might encourage drug use, delay treatment entry, or aggravate problems arising from local drug markets, suggesting instead that they facilitate safer drug use, increase access to health and social services, and reduce public drug use and associated nuisance. However, cutting across the grain of prohibitionist policies, they remain highly controversial.

There are an estimated 90 facilities across Europe, Canada and Australia, with intermittent calls to see them extended to the UK. In areas blighted by a ‘perfect storm’ of visible injecting scenes, discarded paraphernalia, and injecting-related overdose and deaths, could drug consumption rooms which provide an alternative to public injecting be part of the solution?

Legal ‘fixing rooms’: history and current status

Cubicles for hygienic, supervised injecting inside a drug consumption room

Cubicles for hygienic, supervised injecting inside a drug consumption room

Also known as ‘medically supervised injecting centres’, ‘safe injecting facilities’, ‘safe injecting sites’, ‘drug injection rooms’, and ‘drug fixing rooms’, drug consumption rooms are legally sanctioned spaces where people can bring their own pre-obtained drugs, and either inject them or inhale them using sterile equipment under the supervision of nurses or other medical professionals illustration. They are distinct from illegal ‘shooting galleries’ run for profit by drug dealers, low-threshold hostel or housing services that tolerate drug use among residents but provide no medical supervision, and programmes which prescribe pharmaceutical heroin (diamorphine) for consumption by their patients under medical supervision (1,2).

Though there are no official drug consumption rooms in the UK, until the 1970s there were informal, ad hoc facilities including the ‘fixing rooms’ of London’s Hungerford and Community Drug Projects, and Blenheim in west London which had a toilet where people routinely injected. These stopped running primarily due to the knock-on effects of people using barbiturates, a sedative which can result in ‘drunken’ behaviour. The increased risk of overdose, and aggressive, chaotic and violent behaviour, meant that staff felt unable to support users safely and felt disillusioned at the facilities becoming ‘crash pads’ for people turning up already stoned.

The first officially approved supervised consumption room opened in Basle, Switzerland in 1986. Rooms were introduced in Germany and the Netherlands in the 1990s, and in Spain, Australia and Canada in the early 2000s. As of February 2016, there were: 31 facilities in 25 cities in the Netherlands; 24 in 15 cities in Germany; 12 in three cities in Spain; one in Norway and one in Luxembourg (with both countries planning to open second facilities in 2016); five in three cities in Denmark; and 12 in eight cities in Switzerland map. Outside Europe there are two facilities in Vancouver, Canada and one medically supervised injecting centre in Sydney, Australia.

Today’s drug consumption rooms tackle the harms associated with injecting, but some also host clients who smoke crack cocaine, heroin or other drugs. The latter are found across the Netherlands, and in increasing numbers across Germany and Switzerland. Most rooms are integrated into existing, easy-access (or ‘low threshold’) services, for example for drug users or homeless people. Location and number of drug consumption room facilities throughout Europe Their ‘survival-orientated’ services include food, clothing and showers, needle exchange, counselling, and activity programmes. Less common are facilities exclusively for drug consumption room users, which offer a narrower range of services directly related to supervised consumption (1,2). Spain, Germany and Denmark have mobile facilities offering a more flexible service (ie, going where the users are) but with limited capacity.

In 2016 a pilot drug consumption room reportedly opened in Paris near a busy central station where drug crime is common. Annual running costs are estimated at £1.1m, and close to 200 visitors are expected daily. For France’s health minister it was “a very important moment in the battle against the blight of addiction”, but for a politician from the centre-right opposition, the country was “moving from a policy of risk reduction to a policy of making drugs an everyday, legitimate thing. The state is saying ‘You can’t take drugs, but we’ll help you to do so anyway’” – wildly differing perspectives on the same facility.

Evidence of the need for and impacts of drug consumption rooms tends to be divided into “public harms which affect communities, such as discarded syringes in public parks and toilets”, and “private harms which affect individuals, such as overdose death and blood-borne viruses”. The extent to which each justifies the introduction of drug consumption rooms differs from country to country. Overdose deaths were a key driving force in Norway, Spain, Canada and Switzerland, while public nuisance and local concerns about drugtaking in public places were important in Canada and pivotal in the Netherlands.

Is public injecting (enough of) a problem in the UK?

Some open drug scenes have become infamous, notably Sherman Park in New York, mythologised in the 1970s film The Panic in Needle Park starring Al Pacino, and Platzspitz Park in Zurich, which drew worldwide attention in the 1980s after a decision to allow illegal drug use and dealing there resulted in chaotic scenes of mud and used needles, and an influx of 20,000 users from across Europe.

Less extreme examples of public injecting are a reality in many cities and towns, including in the UK, where of the estimated 356,593 problem drug users in 2006, in England alone about 117,000 were injecting. Yet the same year the Independent Working Group on Drug Consumption Rooms concluded that while there were “high levels of injecting drug use in particular areas of the UK, these did not appear to be associated with the sort of extensive public injecting that had been instrumental in the setting up of some of the European [drug consumption rooms]”.

The lesser salience of public injecting in the UK probably reflects several factors: visibility (eg, proximity to places such as shopping centres, tourist locations), concentration (the accumulation of drugtaking in particular areas or micro-locations), number of people and the scale of the associated problems, and the profile of the affected drug users. The extent to which local residents and businesses support drug consumption rooms largely depends on the extent to which they see public injecting as a problem in their area. It means that just as there is visibility, there is invisibility too: public injecting problems may be obscured, particularly when confined to a pocket of a city already deprived and neglected, or when it primarily affects deeply marginalised (‘hidden from sight’) groups, such as those who are homeless.

In turn this means that people and places most in need of drug consumption rooms may not be seen as a priority. Homeless drug users are the prime example. Drink and drug problems disproportionately affect people who are homeless; compared to the general population, if you are homeless there is a far greater chance of experiencing these problems, of injecting drugs, and of dying as a consequence of substance use (1,2,3). Homeless people die on average 30 years before the general population, and a third of these deaths are related to drink and drugs. Homeless injectors would likely be a core demographic of drug consumption rooms due to links between homelessness and high-risk behaviours (such as public injecting, sharing injecting equipment, and poor injecting hygiene), and because unstable housing can preclude or hinder treatment and recovery.

Very few studies in the UK have investigated the extent of public injecting despite location having a significant impact on hygiene, safety and public nuisance. One study found that “public injecting is very common among drug users accessing syringe exchange facilities”. Of 398 surveyed at needle exchanges in Glasgow, Leeds and London, 42% said they had injected at least once in public areas, including toilets, streets and parks. This proportion increased with housing instability; while 24% living in their own accommodation had injected in public in the past week, among hostel residents the figure was 49%, and among rough sleepers, 98%. In 2005, 84% of attendees surveyed at five needle exchanges in London and Leeds said they would use a drug consumption room if one was available.

Scenes of public injecting in Birmingham documented by harm reduction advocate Nigel Brundson Scenes of public injecting in Birmingham documented by Nigel Brundson

Scenes of public injecting in Birmingham documented by Nigel Brundson

Harm reduction advocate Nigel Brundson spent a day walking around Birmingham, photographing evidence of public injecting. He visited three known injecting areas: two were waste-grounds next to car parks, one a main walkway in the centre of town. His images show the ground covered in injecting equipment and general waste, needles alongside garbage and human excrement – in this environment, it would be very difficult to inject in a sterile way images. Aggravated by the risk of being overlooked by the public or police, hasty unsafe injecting seems more than likely. “No one ‘chooses’ to inject in these spaces, this is where the most desperate people in our society have been driven”, comments Mr Brundson. Alluding to the human cost of not having safe injecting facilities, he argues while these are “almost always deemed as ‘controversial’ ... this isn’t the case; the controversial approach would be to not have these spaces.”

Could drug consumption rooms be introduced in the UK?

At least since the turn of the millennium, drug consumption rooms have on several occasions been seriously considered in the UK, primarily in response to heroin injecting.

In 2002, a Home Affairs Select Committee on drugs policy recommended that “an evaluated pilot programme of safe injecting houses for [illicit] heroin users [be] established without delay and that if, as we expect, this is successful, the programme is extended across the country”. Alongside this the committee recommended an evaluation of diamorphine prescribing for heroin addiction. To support both, the committee recommended “[reviewing] Section 9A of the Misuse of Drugs Act 1971, with a view to repealing it, to allow for the provision of drugs paraphernalia which reduces the harm caused by drugs”, and “[amending] Section 8 of the Misuse of Drugs Act 1971 … to ensure that drugs agencies can conduct harm reduction work and provide safe injecting areas for users without fear of being prosecuted”.

The ‘New Labour’ government rejected the recommendation for drug consumption rooms, expressing a number of concerns:
• Potential for public confusion between drug consumption rooms and existing supervised heroin prescribing pilots.
• Potential for drug consumption rooms to be perceived as inconsistent with the government’s commitment to being “tough on crime, tough on the causes of crime”.
• Potential for the government to be accused by the media and others of opening ‘drug dens’.
• Being open to legal challenges.

They also said evidence was insufficient to justify implementation – not entirely relevant, as the recommendation was for a pilot to generate evidence in the UK context.

In 2004 the British Medical Journal published a paper arguing that “the case for piloting supervised injecting centres in the United Kingdom is strong”, and that its rejection should be overturned. The authors reasoned that the supervised heroin prescribing scheme endorsed by the Home Office and drug consumption rooms would appeal to, and benefit, different groups – the former, long-term heroin addicts who have not responded to traditional treatment, the latter, people who are socially excluded and homeless: “neither is a panacea and … holistic provision should include both”.

Why the rejection by central government?

Why did the British government say ‘Yes’ to expanding heroin prescription, approving a trial of three heroin prescription maintenance clinics in London, Brighton, and Darlington between 2005 and 2007, yet say ‘No’ to drug consumption rooms?

Depiction of Kingdon’s Multiple Streams Theory

Depiction of Kingdon’s Multiple Streams Theory

John Kingdon’s influential Multiple Streams Theory suggests policy tends to get made in brief windows of opportunity, when three separate streams align: problems; policy options; and political circumstances diagram. Analysts have argued that political conditions were “not ripe for drug consumption rooms” during New Labour. The government believed their future electoral success largely depended on being (and appearing to voters as) “tough on crime”. Drug consumption rooms risked appearing to condone the use of illegally bought drugs. Supervised heroin prescribing, on the other hand, could be framed as “tough on crime”, circumventing the need for patients to commit acquisitive crimes to fund dependent heroin use. At this time, even had there been high quality evidence of the effectiveness of drug consumption rooms, it would still have been unlikely to influence policy – it was politically unviable.

Asked about drug consumption rooms as leader of the Conservative opposition and a member of the 2002 select committee, David Cameron said: “Anything that helps get addicts off the streets is worth looking at”. When in government, in 2013 his administration issued a flat-out refusal to consider them: “The Government has no plans to allow drug consumption rooms.” The 2010 election of David Cameron’s Conservative-Liberal Democrat coalition closed the policy window for both drug consumption rooms and diamorphine maintenance. Current Prime Minister Theresa May leads a majority Conservative government, and it is improbable that she will risk alienating supporters with controversial drug policies.

The next time drug consumption rooms came under review in the UK was in 2006 by the Joseph Rowntree Foundation’s Independent Working Group on Drug Consumption Rooms made up of senior police officers, senior academics, GP consultant, and a barrister specialising in drug offences. It noted that the evidence base had grown since the UK government had rejected the idea, and concluded that drug consumption rooms should be piloted:

“The [Independent Working Group] considers [drug consumption rooms] to be a rational and overdue extension to the harm reduction policy that has produced substantial individual and public benefits in the UK. They offer a unique and promising way to work with the most problematic users, in order to reduce the risk of overdose, improve their health and lessen the damage and costs to society.”

The response to the Independent Working Group report was warm, but the proposition was rejected. The concerns described above were still perceived to stand.

Cities make up their own minds

Cities have often taken the lead in continental Europe, and in Britain too, they have not simply accepted the central government’s position. In 2012 an Independent Drugs Commission was set up in Brighton, prompted by a call from a local Green Party MP. The city had an unenviable reputation for generating one of the nation’s highest rates of drug-related mortality. The following year the commission agreed that “where it is not possible to stop users from taking risks, it is better that they have access to safe, clean premises, rather than administer drugs on the streets or in residential settings.” Brighton’s Safe in the City Partnership should, they recommended, consider the feasibility of incorporating “consumption rooms into the existing range of drug treatment services in the city,” focusing on ‘hard-to-reach’ groups and those not engaged in treatment.

The feasibility study was undertaken, but in 2014 the commission’s final report concluded “that a consumption room was not a priority for Brighton and Hove at this time – the working group was convinced by the international evidence on the potential benefit from these facilities, but thought that they would have little impact on the types of factors that were contributing to deaths in the city”. In addition, “members of the working group were … concerned at the cost implications, in a time of budget pressure, and also advice from the Home Office that opening such facilities would contravene UK law”.

A month later, in June 2014 the feasibility working group explained that there was insufficient support at the time to consider drug consumption rooms. Both the Association of Chief Police Officers and Sussex Police were opposed, as were other organisations. This was attributed to a shift “for substance misuse services from a focus on harm reduction to recovery [which] has put a greater emphasis on abstinence from drugs”, and to the financial and political climate, in which it was felt unlikely that statutory agencies would consider providing resources unless there was very good evidence of benefits and cost-savings.

These statements reveal multiple reasons for the rejection of drug consumption rooms in Brighton, and some overlap with the issues raised in 2002:
• Perception that they would have little impact on injecting-related mortality.
• Lack of support from key stakeholders.
• Cost implications/budget pressures.
• Advice from the Home Office that drug consumption rooms would be unlawful.
• Lack of evidence about benefits and cost-savings.
• Not in line with current focus on recovery and abstinence (as opposed to harm reduction).

Recently the focus has shifted to Glasgow. In “Taking away the chaos”, the local health service and the city’s drug service coordinating partnership reviewed the health and service needs of people who inject drugs in public places in the city centre. The review was a response to evidence that the city’s injectors were “vulnerable to significant health harms, with those involved in public injecting in the city centre at particular risk”, and concerns voiced by local residents and businesses about large amounts of discarded injecting equipment in public places in the city centre and neighbouring areas, compromising community safety and spoiling the environment.

Resulting recommendations were to develop existing services, but also to introduce new services, including a pilot safer injecting facility in the city centre to “address the unacceptable burden of health and social harms caused by public injecting”. An HIV outbreak among people who inject (47 new diagnoses in 2015 compared to an annual average of 10) was at the forefront of the discussions: “Given the scale and persistence of public injecting in Glasgow, these problems are likely to persist or worsen unless new approaches to harm reduction are considered. The potential for the HIV outbreak to continue or spread further, including among people without a history of drug use, is particularly concerning.”

Safeguarding injectors’ health

Addressed in turn in a 2004 briefing, whether drug consumption rooms will supplement the UK’s repertoire of substance use interventions depends on the resolution of three broad areas of controversy which may inhibit policymakers:
Principle: “How do policy makers justify providing a service that enables people to engage legitimately in activities that are both harmful and illegal?”
Messages: “Do [drug consumption rooms] legitimise drug use, encourage more people to use hard drugs or – at the local level – increase drug-related problems in the areas where they are situated?”
Effectiveness: “Do [drug consumption rooms] reduce drug related harms and, even if they do, are they the most appropriate and cost effective way of reducing these harms?”

First and foremost, drug consumption rooms are intended to be a form of harm reduction. Along with needle exchange, overdose education and naloxone provision, they operate on the premise that if people are going to take drugs, they should be informed about the risks, enabled to use drugs as safely as possible, and know what to do if something goes wrong. Harm reduction interventions do not exclude the possibility of people choosing to stop taking drugs or engaging with treatment, but as one writer put it, “may enable … users to live long enough to have the opportunity to pursue effective treatment when they are ready”. If they do not work on this level, the case for them is fatally undermined.

Drug consumption rooms can help prevent overdose by enforcing rules about safe injecting and supervising the injecting process, and prevent overdoses becoming fatal by aiding users’ breathing and administering the opiate-blocking drug naloxone. In 2004 a report knew of only one death in a drug consumption room since the first opened in 1986 – in 2002, a drug user died from anaphylaxis (an acute allergic reaction) in a German facility. Conversely, a conservative estimate of lives saved by just one facility in Sydney (Australia) was four per year. Though studies generally focus on what happens in the facilities, outside drug consumption rooms reductions have been seen in clients’ risk-taking behaviour, and it seems likely that ‘safer use’ messages could be transmitted to a wider population of users via consumption room attendees.

Professor John Strang, a leading figure in British substance use practice and policy, argued in 2004 that “claims” of harm reduction from drug consumption rooms need to be more robustly tested. Although evidence has grown considerably since then, it remains difficult to evaluate the rooms’ impacts in ways that meets the scientific ‘gold standard’ – the ‘randomised controlled trial’, which randomly assigns participants to an intervention versus an alternative intervention or no intervention at all. Instead, researchers undertake evaluations in real-world settings, in which the effects of drug consumption rooms are obscured by a complex set of factors not under their control. For example, the calculation of lives saved in Sydney (above) was complicated by “dramatic changes in the availability of heroin”, colloquially referred to as the ‘Australian heroin drought’, which affected the amount of heroin being used, probably resulting in a reduction in associated problems such as heroin-related overdose. But even without a randomised trial, it may be possible to at least estimate the likelihood that an intervention (in this case, a drug consumption room) is having a positive or negative impact. For instance, it may not be possible to determine impacts on the transmission of infectious diseases, but it is possible to observe impacts on self-reported needle and syringe sharing, the key cause of transmission among drug users.

As the report of the 2006 Independent Working Group on Drug Consumption Rooms put it, “the methodological problems involved here should not detract from [drug consumption rooms’] considerable success”. On balance, said the report, these services can have a positive impact on the health of their clients, for example through ensuring (relatively) safe and hygienic injecting in the facility, providing personalised advice and information on safe injecting practices, recognising and responding to emergencies, and providing access to a range of other on-site and off-site interventions and support. Overall the evidence from rooms across Europe demonstrates their potential to alleviate injecting-related harms.

However, realisation of this potential may be quite limited. Having a drug consumption room doesn’t necessarily mean every injection will occur within its walls, or that every local user will attend it. In 2014 a survey by the International Network of Drug Consumption Rooms found that (among participating organisations) drug consumption rooms across Europe were open for on average eight hours a day, and 20 of the 34 opened on weekends, leaving large periods of time when clients who would otherwise use the facilities must inject elsewhere. Though they also used drug consumption rooms, in Hamburg over a third of survey respondents had used drugs in public during the past 24 hours, citing among their main reasons waiting times at injecting rooms, distance from place of drug purchase, and limited opening hours.

To encourage regular use and achieve adequate coverage of the injecting population, it is necessary to understand the needs and drugtaking of local drug users, providing sufficient capacity to meet demand and making sure rooms are easily accessible in terms of location and opening hours. Facilities focusing on sex workers, for example, may need to remain open in the evening and at night. The location of consumption rooms should be compatible with the needs of drug users, but also take account of the needs and expectations of local residents.

Acceptance is at the root of benefits and criticisms

Safeguarding the health of a stigmatised and relatively voiceless population is unlikely to be seen to be enough to justify resourcing drug consumption rooms. There must also be no sufficiently strong countervailing harms, especially to the more ‘voiced’ in the population. Even within the ambit of harm reduction, it is conceivable that drug users will experience reduced harm while the locality and sections of the wider public – if only due to the diversion of resources from other social programmes – experience increased harm. Ambiguity of objectives within harm reduction is nested within a policy frame which may see any form of harm reduction as acceptable (if at all) only as a gateway to the overarching goal of stopping illegal drug use.

According to a 2004 review by the European Monitoring Centre for Drugs and Drug Addiction, there is no evidence that drug consumption rooms increase drug use, encourage riskier use, or increase morbidity and mortality. Even if all that were accepted, for some they would still undoubtedly cross an ideological red line, being seen to facilitate illegal and harmful behaviours.

Drug consumption rooms create a bubble of acceptance of drugtaking within a broader context of criminalisation, an essential feature which lies at the root of their support and of their condemnation. Acceptance is unpalatable to detractors, but also helps create an environment in which clients can engage in less risky and more hygienic drug use, and gain access to further support and treatment.

Ethical concerns include condoning drug use, in particular injecting, and undermining prescribing treatments – doing rather than mitigating harm. Speaking out against the proposed pilots in Brighton, Kathy Gyngell from the right-wing Centre for Policy Studies questioned the premise of a ‘safe space’ for injecting altogether, saying that drug consumption rooms are “described as safe despite the very unsafe street drugs used in them, and despite the intrinsic risk of addicts continuing to inject drugs at all”. It is true that while drug consumption rooms do provide safer spaces for injecting, “dangerous situations that require intervention arise frequently ... (as they do in any drug-injecting context)”. The difference is the capacity to respond to these emergencies and prevent them progressing to serious harm or death.

Acceptance of drugtaking can clear the path for prevention, treatment and support

Such concerns are mitigated by the fact that few clients use the facilities only for drug consumption; most at some point use other services. For highly marginalised drug users in particular, consumption rooms can be the first step into the health and social care system, or even drug treatment. Given the nature of the target population – socially excluded drug users, such as street users and older, long-term users who have never been in treatment – it is vital that the house style encourages rather than deters potential clients. The temperament and attitude of staff is important – they should be sympathetic and non-judgemental towards people with multiple problems, yet at same time be clear and consistent about admission criteria and house rules. Just such an environment was found in Danish drug consumption rooms, where staff conveyed a welcoming, non-judgemental attitude and prioritised forging relations with drug users. Both clients and staff saw the rooms as providing a safe haven, one in which acceptance could clear the path for prevention, treatment and support.

Mitigating public crime and nuisance

The primary political justification for drug consumption rooms is to mitigate the public nuisance, disorder and crime associated with public injecting. They are usually sited where concentrated public drug use and discarded paraphernalia spoils the environment, and hampers or undermines regeneration. Failure to address these problems will mean that services which could preserve drug users’ lives never open. Being seen to actually aggravate these problems would drain support from an existing service.

Research suggests consumption rooms can significantly reduce public drug use, but how much depends on their accessibility, opening hours and capacity. Compelling evidence comes from Vancouver (Canada), where acceptance of the facility among residents and workers had been generated by the distressing sight of public injecting and injecting-related litter. Despite a large local needle exchange, risky injecting, disease and overdose deaths remained high. After the facility opened there was a significant reduction in users seen injecting in public places, from a daily average of 4.3 to 2.4. Also roughly halved were discarded syringes and injecting-related litter in the surrounding area.


‘Honeypot effect’ applies to bees, not consumption rooms

One of the concerns about drug consumption rooms is that they will aggravate public disorder and crime in their vicinity by attracting users and dealers from elsewhere – the ‘honeypot effect’. In passing, we should note that if this did happen, it would also extend the benefits to non-local drug users. In fact, neither the adverse nor the beneficial results of the honeypot effect materialise in practice. Most consumption room users live locally, and typically they reflect the profiles of people buying drugs in local markets. Facilities located any distance from drug markets tend to attract very few users.

Explaining why, drug users who gave evidence to the 2006 Independent Working Group pointed out that “an addicted injecting heroin user is likely to be primarily driven by the need to obtain their drugs. If they have the money, their first port of call will be a dealer. If there is somewhere nearby where they can safely use their drug (and obtain a clean syringe), then this is likely to be their next step. If they need to go any distance to reach such a place, their need to inject their drug is likely to lead to them using somewhere else (often a public area nearby)”.

Though in themselves drug consumption rooms seem not to draw in users from other areas, they may well be drawn if a new drug market grew around a facility. Cooperation with the police should ensure that action against those or other drug markets do not deter drug users from attending approved consumption facilities.

Could there be a legal challenge to drug consumption rooms?

A repeatedly cited barrier to drug consumption rooms has been their supposed contravention of UK drugs laws. In 2013 the Home Office stated, “The Government has no plans to allow drug consumption rooms, which [would break] laws whereby possession of controlled drugs is illegal.” But this view seems mistaken; depending on how the facility is run, consumption room staff and managers might be liable, but this need not be the case, and even under existing provisions a carefully managed facility could operate within the law despite its customers breaking laws prohibiting possession of controlled drugs. Possible legal challenges might be seen as a big barrier, but given the introduction of drug consumption rooms in eight other countries in Europe, and two outside Europe, clearly it is not insurmountable.

Release, the national centre of expertise on drugs law, has clarified that the UK Misuse of Drugs Act does not make it illegal to allow someone to possess or inject controlled drugs on your premises, but does make it illegal to allow their production or supply or the smoking of cannabis and opium. To inform its work, the Joseph Rowntree Foundation’s Independent Working Group on Drug Consumption Rooms commissioned an analysis by a leading expert on UK drugs law. Based on Rudi Fortson’s opinion, while some adjustments of the law might further shield rooms from legal challenge, the group was “not persuaded that this would be a necessary and unavoidable first step. Pilot [drug consumption rooms] could be set up with clear and stringent rules and procedures that were shared with – and agreed by – the local police (and crime and disorder partnerships), the Crown Prosecution Service (CPS), the Strategic Health Authority and the local authority.”

However, ambiguity over the rooms’ domestic and international legal footing has prevailed. To help clarify the issues, Rudi Fortson looked at how Canada’s Insite project in Vancouver and Australia’s injecting centre in Sydney managed to run within the law in countries with legal systems similar to that of the UK. For more click here Unfold supplementary text.

Signatories to the United Nations’ international drug control conventions (including the UK, Australia and Canada) have another issue to consider: whether drug consumption rooms violate their obligations under those conventions. Charged with policing adherence to the conventions is the International Narcotics Control Board or INCB. From in 1999 an extreme condemnation claiming the rooms breach the conventions because they “facilitate illicit drug trafficking”, by 2015 the board seemed to admit that if a facility “provides for the active referral of [persons suffering from drug dependence] to treatment services”, they might be admitted within the spirit and letter of the conventions. For more click here Unfold supplementary text.

For Rudi Fortson the thousands of words on whether drug consumption rooms contravene UN conventions had missed the wood for the trees. There has, he observed, been a tendency to focus on the parts that impose restrictions and prohibitions, yet “conventions often embody statements of political will, intent, or hope”, and in this case prohibition was intended to be at the service of promoting public health and wellbeing, not its opposite. Secondly, none of the three main UN conventions have direct application in the UK; they are interpreted into UK law by parliament, and it is those interpretations on which the courts rely in their judgements.

Contemplating drug consumption rooms…

Proposal for a drug consumption
room in Ireland

“A reception area is used to greet, assess and register clients. The main section of the service is an injecting room, with spaces for individuals to inject in privacy, but with medical supervision and interventions available. A social section allows clients to avail of non-medical support and interventions before they exit the service. The service is staffed by a mix of medical and social care personnel, all specifically trained for work in [a drug consumption room] environment”.

Ana Liffey Drug Project position paper (June 2015)

It seems likely that drug consumption rooms will be piloted in Dublin in the next year. The Irish Times has reported that the Minister of State with responsibility for drugs wants to see drug consumption rooms in Ireland, and has the backing of the Taoiseach (head of government or prime minister of Ireland) and the Minister for Health. Legislation has been proposed by Dublin’s Ana Liffey Drug Project in collaboration with the Bar Council that would allow people to take drugs in a safe, medically supervised injection centre. The current focus is on Dublin, “where public injecting is a well-established phenomenon, as is overdose”, but the legislation could allow them to open anywhere in Ireland.

This development, and ongoing discussions in Glasgow, have the potential to reinvigorate discussions about drug consumption rooms in the UK, but for now, the closest contemporary Britain comes to having safer injecting centres are the few clinics where patients inject legally prescribed pharmaceutical heroin (diamorphine) under clinical supervision. These clinics are unlikely to engage the target group of drug consumption rooms, but nonetheless provide a service to people with addiction who have not benefitted from typical treatment. Furthermore, it could be argued that they provide an experience- and skills-base for drug consumption rooms in the UK, as they have to exercise the same monitoring of patients, and have the same capacity to respond to overdose incidents, as drug consumption rooms.

Moreover, Britain already has a good-practice blueprint to guide implementation. In 2008, the Joseph Rowntree Foundation published guidance for local multi-agency partnerships looking into opening a drug consumption room. It addressed minimum operational standards identified in the 2006 report of the Independent Working Group on Drug Consumption Rooms, domestic and international legal issues, as well as the commissioning process, operational policies and procedures, monitoring and evaluation – but also stressed that local agreement is absolutely essential, something not generated in Brighton despite the serious nature of the city’s problems and overdose fatalities in the area, but which may be seen in Glasgow.

Concluding thoughts

Evidence is stacked in favour of drug consumption rooms being an effective strategy for tackling public injecting and the harms associated with it, particularly among the most vulnerable and marginalised drug users, and as long as the context is conducive – when part of a “wider framework of … services that aim to reduce individual and social harms arising from problem drug use; based on consensus and active cooperation between key local actors, especially health workers, police, local authorities and local communities”. There is no evidence of the feared adverse consequences on communities or drug use and users. Yet since 2002, proposals to pilot drug consumption rooms in UK cities have fallen flat.

There seem two scenarios in which support for drug consumption rooms could be generated in the future: firstly, if there were to be a policy shift towards harm reduction, not just as a mechanism to engage drug users with treatment, but as a legitimate goal in itself; and secondly, if the UK were to reach a ‘tipping point’ in the degree of distress and nuisance perceived to be caused by public injecting, or the degree of concern over the concentration of overdose fatalities and infectious diseases in certain locations. In the meantime, the needs of the target group of drug consumption rooms continue not to be met by existing services, and the human cost of public injecting – the lack of dignity, and the disproportionate burden on health, wellbeing and safety – keeps adding up.

Last revised 23 November 2016. First uploaded 27 October 2016

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Are the drugs enough? Counselling and therapy in substitute prescribing programmes

Specialist programmes which prescribe substitute opiate-type drugs to opiate-dependent patients are supposed to be a securely knotted package of medications, the medical care needed to oversee them, and psychosocial support in the form of counselling and ‘talking’ therapies. But what happens if you untie the knots and take out the one dispensable element – the psychosocial support? Is most of the talking that goes on in methadone and allied services under the heading of ‘counselling’ or ‘therapy’ a waste of time and money, or one way to rehabilitate these services’ recovery credentials by helping elevate patients to the point when they can safely leave?

What happens when you untie the methadone treatment package and dispense with counselling and psychosocial therapies?

What happens when you untie the methadone treatment package and dispense with counselling and psychosocial therapies?

Official guidelines are it seems in no doubt: counselling/therapy is essential; drugs alone are sub-standard treatment. In 2009 the World Health Organization said, “Treatment services should aim to offer onsite, integrated, comprehensive psychosocial support to every patient.” Latest UK guidelines on methadone maintenance and allied treatments stipulate the “range and quality of psychosocial interventions” as one of the components which elevate effectiveness in recovery terms. As in the USA, regular counselling may even be legally required.

The UK guidelines took their lead partly from evidence analysed by Britain’s National Institute for Health and Care Excellence (NICE). It is at this level – the level of scientifically credible evidence – that this aspect of the guidelines have been erected on a shaky foundation. In 2007 NICE had commended some social network therapies and the systematic application of rewards and sanctions as adjuncts to maintenance. But other approaches, including cognitive-behavioural therapy, relapse prevention techniques and motivational interviewing, were not recommended, leaving the most commonly implemented (if often only loosely) methods without the backing of this official evidence adjudicator.

NICE’s verdict was followed in 2011 by an update of an authoritative Cochrane review of rigorous studies. Surprisingly, it found that adding psychosocial therapy to opiate substitute prescribing plus routine counselling has overall made no difference to retention or substance use. Included among the ineffective supplements was the systematic application of rewards and sanctions, which the earlier NICE report had favoured, deleting yet another psychosocial intervention from the list of effective adjuncts.

Starting without counselling better than starting later or not at all

The studies which led to the Cochrane review’s conclusions can be divided into those which tried dispensing with usual counselling only as a means of getting patients more quickly into fully fledged treatment, versus those which extended this stripped-down phase into the treatment itself.

In the first category, trials have taken advantage of US regulations allowing an ‘interim’ initial phase to methadone programmes of up to 120 days when only crisis counselling is available. Their findings provide the most convincing evidence that at least at the start of treatment, counselling is not routinely required.

The most significant trial was conducted in Baltimore, where two clinics randomly and rapidly assigned new patients (usually within three days) to an interim programme, to a standard methadone programme featuring weekly group and/or individual counselling, or to an enhanced programme which also offered on-demand counselling by a highly regarded counsellor with a low caseload. The 230 patients in the study were typically unemployed single black men in their early 40s who used heroin daily, with on average over 20 years of heroin use and over four years in jail behind them.

Despite this seemingly unpromising population, patients who started their first four months of treatment with virtually no counselling generally did as well as those individually counselled about once a month, and even as well as those counselled once a fortnight by the counsellor handpicked for excellence. This equivalence was sustained for at least eight months after the interim programme had ended. It seems possible that over their decades of heroin use the patients had heard already experienced advice and counselling to which the study’s programmes could add little, but what most had never experienced before was being on methadone.

This and similar studies (including some in the UK) reviewed in detail by Findings have shown that subject to sufficient assessment and monitoring to ensure clinical safety, starting prescribing in the absence of regular counselling or other psychosocial supports is preferable to simply leaving patients waiting, even for a few weeks. Patients reduce their drug use, health risks and criminal activity, and more go on to enter the main programme.

Key studies of long-term treatment

Rather than confining low/no counselling to the start of treatment, programmes similar to the US interim arrangements have been trialled as longer term alternatives to more intensive support. For some patients the studies show little more may be needed, and across all patients, evidence of the effectiveness of extra therapy is surprisingly thin – thin, but not non-existent.

Two US trials provided the strongest evidence that counselling methadone patients is not a waste of resources. They were among those analysed in detail in these background notes under the heading, “Are cut-down services a viable alternative to more comprehensive programmes?”

The first involved 92 US military veterans who on starting methadone treatment had been randomly allocated for 24 weeks either to: no regular counselling (though counsellors did maintain monthly contact); standard counselling – weekly to begin with, then adjusted to the stability of the patient; or standard counselling enhanced with extra services including regular medical and psychiatric care, social work assistance, family therapy and employment help on-site. Patients were typical of the area’s caseload: black single men with extensive criminal histories and most of serious psychiatric disorder.

Each step up in psychosocial inputs produced better outcomes over the roughly six months they were operational. The effects were apparent in the proportions of patients who (largely due to regular illicit substance use) met criteria for ‘emergency’ transfer to usual care: 69% not offered counselling versus 41% of standard care patients, and just 19% in enhanced care. Urinalyses revealed significantly more illicit opiate and cocaine use in the minimal contact patients. When the standard and enhanced groups were compared, improvements were greater in the enhanced group on 14 out of 21 measures and significantly so in respect of employment, drinking, crime, hospitalisation for medical problems, and proportion abstinent from opiates and cocaine, though not in average days of use of these substances or overall drug problems.

Six months after the trial had ended, over which time all patients had reverted to usual care, there remained a lingering statistically significant effect on the proportion abstinent from heroin, contributing to the finding that proportions abstinent from both heroin and cocaine were 29% in the minimal care group but 47–49% in the other two groups. This small study of an atypical set of patients remains the best evidence that supplementing methadone maintenance with extra psychosocial inputs further reduces the key outcome for these treatments – illegal opioid use. But when findings from similar trials were amalgamated, its contribution was outweighed by other studies, leading overall to only a small and possibly chance advantage in proportions abstinent.

For the second study, 353 patients admitted to a US methadone programme were randomly assigned to minimal counselling, standard counselling, or standard counselling enhanced with group therapy and training in relapse-prevention skills. It offered only weak support for extra counselling. Compared to standard care, urinalysis results over the first 18 months of treatment indicated that illegal opiate use was significantly more likely among minimal care patients, but the effect was minor, and enhanced services did not further reduce opiate use. However, these results could only be obtained from patients retained in treatment, and by the end all but a fifth had left. Cocaine use was unaffected by the intensity of support.

Not just methadone; buprenorphine too

Most studies of extra psychosocial inputs have involved methadone maintenance, but it seems added value is hard to find whether the maintenance medication is methadone or buprenorphine.

In a US randomised trial, buprenorphine patients allocated to cognitive-behavioural therapy did no better in reducing drug use and sticking with treatment than those offered a programme approximating usual medical care by their doctors. The findings were all the more remarkable because the therapy was additional to rather than instead of medical management. They seemed to confirm the implications of another buprenorphine maintenance study from the same lead researcher which found standard medical management as effective as more intensive medical management – the implication being that “for some patients, a relatively low level of supportive services ... is sufficient for generating abstinence and retention in treatment.”

A third US study recruited patients dependent on prescription opioids Studies have rarely found consistent and substantial advantages from extra counselling or therapies and stabilised on buprenorphine before attempted detoxification. Those randomly allocated to relatively brief weekly medical management visits versus this plus more extended specialist counselling did equally well in avoiding ‘on-top’ opioid use during the stabilisation phase.

What we can gather from these studies is that across all methadone or buprenorphine patients in a sample, studies have rarely found consistent and substantial advantages from extra counselling or extra psychosocial therapies. But what of particular sorts of patients – and perhaps it is not the extent or content of counselling or therapy which counts, but some other quality? An affirmative answer to both questions is suggested by a few studies.

Nuances: does impact depend on patient need and counselling quality?

Perhaps it is no surprise that extra psychosocial inputs have little impact when trials commonly exclude psychologically unstable patients, the very ones some US studies suggest might benefit from psychotherapy. Published in 1983, among these was a randomised trial at a methadone programme in Philadelphia which recruited patients early in treatment who were representative of the entire caseload. Just 1 in 10 were excluded because they might have to move out of the area, though later another 1 in 10 were excluded because they did not attend the first three counselling or therapy sessions.

The conclusion was that patients benefited from being randomly allocated to weekly sessions with professional psychotherapists because these helped ameliorate the psychiatric problems common in the caseload. Benefits were apparent in some ways (but not in substance use) among patients with moderately severe psychiatric problems, but more clear cut for the high-severity patients, who consistently improved more when allocated to professional psychotherapy, including a greater reduction in days of opiate use. Without psychotherapy, among these patients opiate use remained virtually unchanged. Clinical records showed that the two groups of patients with appreciable (moderate or high) psychiatric problems had more drug-positive urines when offered drug counselling alone without psychotherapy and had required higher doses of methadone, typically a response to continuing problems. Unfortunately, the study left open the question of whether extra therapeutic contact accounted for the findings, or the psychotherapeutic nature of that contact.

Later the study was broadly replicated among patients selected for severe psychiatric symptoms attending three more typical US methadone programmes. Many were not interested in the trial, but 123 were sufficiently severe and agreed to be randomly allocated to an extra therapy session a week for 24 weeks of either a form of psychotherapy, or drug counselling of the kind they were already receiving, though a quarter were later excluded from the analysis due to poor initial attendance.

On nearly every measure, by the final follow-up psychotherapy patients were doing better than those allocated to extra drug counselling, though usually the differences were modest. After the initial impacts of being on methadone had evened out, patients allocated to psychotherapy evidenced somewhat better psychiatric adjustment and a move towards a more conventional and law-abiding lifestyle. However, in some respects the effects were not as substantial as in the earlier study and were not seen at the initial follow-up, perhaps partly because both groups of patients were offered an extra therapy session a week. This was intended to eliminate concerns that the earlier findings might have reflected the amount of therapeutic contact rather than its type. Given the relative findings of the two studies, it seems these concerns might have been at least partly justified. Though this concern was addressed by the second study, the highly (self-)selected participants raised another concern – that the findings would not be replicated across a typical caseload.

The hand-picked, expertly supervised professional psychotherapists employed by these studies can perhaps be expected to be experts at forging therapeutic relationships with troubled individuals, raising the issue of the quality of the interaction with patients. If counselling was truly ineffective, quality would be irrelevant, but that is not what is found. As described in these background notes, The quality of counselling seemed decisive at a US methadone clinic the quality of counselling seemed decisive at a US methadone clinic where patients were allocated in a virtually random fashion to four drug counsellors. Two were moderately effective, the third very effective, and the fourth not effective at all. The most effective counsellor was able to bring his clients to a point over a six-month period where their drug use and unemployment were significantly reduced when compared with the prior six months, while at the same time reducing their use of both methadone and psychoactive medications. By contrast, the clients of the least effective counsellor showed increased unemployment, drug use and criminal activity, and needed more methadone and medications. When the case notes were examined, it became clear that the most effective counsellor was distinguished from the rest by their ability to help clients anticipate problems and develop ways of dealing with them in advance.

Another US study started off investigating methadone dose, but found that when tailored to the individual it made no difference. What did make a big difference to retention and illegal substance use (the two were related) was which of 13 counsellors the patient had (essentially at random) been assigned to. Of the counsellors with appreciable numbers of patients, the patients of one averaged around 20% of urine tests indicative of opiate use and 24% cocaine, while at the other end of the range, another counsellor recorded corresponding figures of 60% and 57%.

Spread methadone programmes thin and wide?

Sometimes denigrated as ‘merely’ substituting one drug for another, findings on the impact of extra support are a testament to the power of routine methadone and buprenorphine maintenance. For patients who previously had to offend several times a day to sustain the roller-coaster of repeated daily heroin injections, a legal supply of a more normalising, smoother and longer acting drug like oral methadone, is in itself typically a quick-acting and powerful intervention. Adding a specific programme of counselling or psychological therapy seems less important than the basics identified in UK guidelines: a structured treatment with clear objectives, involving an adequate dose of methadone, long-term treatment with no hurry to withdraw, and an accepting, non-judgmental therapeutic alliance.

It may be important to note that even counselling-free substitute prescribing programmes are not devoid of potentially therapeutic and stabilising human contacts, especially if they require daily or near-daily supervised consumption. The attitudes and inputs of reception staff, doctors, nurses and others may determine whether someone wants to keep coming to the service, and retention is the key factor in impacts on substance use. Human beings too react to the symbolism and meaning they attribute to a service or object as well as to the thing itself. In the case of substitute prescribing programmes, the therapeutic and affirming value of having someone care enough to provide a medication to a person society has written off should not be underestimated.

Inevitably there are exceptions, among whom may be the psychologically unstable patients often excluded from trials and who do seem to benefit from extra therapy, and the (in the UK) minority of patients in a position to engage in family or couples therapy. And with such limited research, it is not possible definitely to conclude that extra psychosocial support is on average ineffective – just that generally it cannot be shown to have been effective.

With this evidence base, we cannot be sure of the effectiveness (and allied to that, the safety) of switching to virtually counselling-free programmes on a long-term basis. Shaun Shelly, an expert in addictions at the University of Cape Town, has pointed out that effective psychosocial inputs might be expected to affect recovery indicators like quality of life perhaps more than substance use, to help sustain recovery more than to make a short-term impact, and to help more troubled patients in particular. It could be too, he suggested, that the typical offer of more drug counselling or cognitive-behavioural therapy misses the mark by not addressing the “character healing” or “capacity building” and “self-renewal” needed to solidify recovery. On all these counts, the research is particularly lacking.

Such findings as we do have, however, raise the issue discussed in the Effectiveness Bank’s Drug Treatment Matrix of whether in order to gain harm-reduction and recovery benefits for the greatest number of patients, methadone should be spread ‘thin and wide’, or deepened with recovery-oriented interventions for the fewer patients who want and will benefit from these – and to whom we can afford to offer them.

Thanks for their comments on this hot topic to Shaun Shelly of the University of Pretoria in South Africa. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 05 November 2016. First uploaded 29 November 2012

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Can testing and sanctions displace addiction treatment?

Is treatment the best way to overcome dependent substance use, or can we suppress it more cost-effectively by credibly threatening sanctions? Influential researchers have argued that some US programmes (evaluations of which are collected together in an Effectiveness Bank bulletin) show many dependent individuals stop using substances if non-use is enforced through intensive monitoring and swift, certain, but not necessarily severe sanctions. Rather than mandating treatment, these programmes directly mandate abstinence on penalty of sanctions like a day in jail or temporary interruption of professional practice. Among the researchers were top White House drugs advisers. Their perspective found its way in to US anti-drug policy and is now gaining ground in Britain.

‘Test and sanction’ schemes can be thought of as lying at the ‘heavy’ and more coercive end of contingency management programmes, which punish people or deprive them of rewards when they use substances in ways we don’t want them to, and reward them when they behave as we want. Commonly rewards like shopping vouchers or a more relaxed treatment regimen are offered if the patient avoids use of the targeted substance(s) or complies with therapy, and withheld if they do not – not so drastic as a spell in jail or threatening your livelihood, and usually intended to reinforce rather than replace conventional therapy.

As in contingency management schemes, to maximally affect behaviour it is thought test-and-sanction schemes should impose consequences swiftly and inevitably on the infringement, strongly linking the two in the offender’s mind. In turn these advantages depend on the intensity of testing and the relatively minor nature of the sanctions. As a report on a scheme in Hawaii put it, “Severity is the enemy of swiftness and certainty, because a severe penalty will be more fiercely resisted and requires more due process to support it.” Importantly too, minor sanctions mean the offender remains in a position to get swiftly back on track without too much damage having been done, rather than being forcibly parked in a dead-end which is either irrevocable (like permanent loss of professional status) or cannot be reversed for months or years (like an extended prison term).

Though this hot topic focuses on evidence, there is also a strong ethical component to the acceptability of test-and-sanction schemes, especially in societies which classify dependent substance users as suffering from a medical or mental disorder. Despite being charged with supporting international, sanctions-based, drug control treaties, the United Nations Office on Drugs and Crime nailed its colours to the mast in the title of its document on this issue: From coercion to cohesion: Treating drug dependence through health care, not punishment. It points out that “The conventions encourage the adoption of a health-oriented approach to both illicit drug use and drug dependence”, and argues that since “Drug dependence is a health disorder ... punishment is not the appropriate response”. Rather than coercion coming first and treatment being reserved for non-responders, the document argues for treatment as the first-line response with coercion reserved for offenders who reject this opportunity.

Rare randomised trial

Running this search shows the UK also has a considerable history of implementing testing-based programmes for offenders, though generally as a way of monitoring progress and as part of a criminal justice element ‘gripping’ offenders while treatment exerts its effects. The US programmes challenge this subsidiary role, elevating testing and sanctions to the primary role, Results challenge the view that relapse is an essential feature of substance dependence and sometimes relegating treatment (if available at all) to those unable to comply without it. Results are said to challenge the view that relapse is an essential feature of substance dependence, and to demonstrate that the key to long-term success lies in sustained changes in the environment in which decisions to use or not use are made. If this rewards substance use, it is likely to continue, but the drinking and drug use of many dependent individuals stops if the environment not only prohibits use in principle, but enforces this through intensive monitoring of substance use and meaningful consequences.

The face validity of these approaches and the persuasiveness of advocates has yet to be matched by rigorous and positive research findings – not unusual in the criminal justice sector, where allocating offenders to different types of punishment at random can fly in the face of ethical practice and attract legal challenge.

One prominent scheme has however been tested in a randomised trial – but one which seems never to have been published in a peer-reviewed journal. Hawaii’s HOPE programme randomly and frequently drug-tests substance-using offenders to promote compliance with a probation requirement not to use illicit drugs. Each violation results in a brief jail stay of typically just a few days; continued violations attract longer sentences. There is no attempt to universally impose treatment; probationers are ordered into treatment only if they continue to test positive for drug use, or if they request it. HOPE’s goals are reductions in drug use, crimes, and imprisonment. Those goals were shown to have been achieved, both in an initial pilot programme among high-risk probationers, and in a trial which randomly allocated 493 probationers to HOPE versus probation-as-usual. They had been selected by their probation officers as being at the highest risk of failing probation, and averaged about 17 prior arrests. In the follow-up year 21% of HOPE probationers were rearrested compared to 47% allocated to usual probation. HOPE’s lead was just as substantial in the tally of drug-free urine tests, days not spent in prison, and in avoiding revocation of the probation sentence.

Alcohol-detecting anklets popular in USA

Though moving in the direction of US examples, the UK still relies largely on conventional sentencing and treatment. British courts do have Drug Abstinence Orders at their disposal, which can require certain drug-related offenders, including those dependent on illegal drugs, to remain abstinent from drugs and to prove it by submitting to testing. In contrast, similar provisions for alcohol are reserved for non-dependent drinkers. For these offenders, the Alcohol Abstinence and Monitoring Requirement allows for electronic monitoring (for example, by ankle bracelets which detect alcohol secreted in the drinker’s sweat) as well as more conventional testing. As for drugs with the Drug Abstinence Order, drinking contravenes the court order and means the offender can be recalled to court to face a possible sanction.

A ‘sobriety tag’ used to detect alcohol consumption during periods of court-ordered abstinence

A ‘sobriety tag’ used to detect drinking during periods of court-ordered abstinence

In Britain interest has centred on using SCRAM alcohol-detecting anklets manufactured by Alcohol Monitoring Systems Ltd, which effectively monitor drinking continuously and 24 hours a day illustration. Widely used in the USA, but it seems never rigorously evaluated, the anklet was one of the strategies employed by the US state of South Dakota’s 24/7 Sobriety programme, an exemplar for test-and-sanction strategies. It started as a court order for drink-driving offenders, who were subject to immediate 24-hour imprisonment if found to have drunk alcohol, but was extended to other criminal justice situations to enforce abstinence. At least during the sentence, recidivism reductions and compliance among programme participants were on the face of it impressive, but the programme has never to have been benchmarked against an adequate comparison group.

It seems the closest we have come to an adequately benchmarked evaluation was a US study which recruited drink-drivers sentenced to wear a version of the SCRAM anklet piloted in London below. Explained further in the commentary on the London study, the study identified an individually matched comparison set of convicted drink-drivers. However, the analysis was silent on whether SCRAM wearers overall were reconvicted less often. Instead it focused on the relative conviction reduction among a subgroup of repeat offenders who wore the anklet for at least three months. Fewer than half as many as in the comparison group were reconvicted, but the analysis no longer retained the reassurance of a matched sample, because no equivalent subgroup could be identified among comparison offenders. The study as a whole was vulnerable to differences between offenders (or circumstances) for whom courts ordered the anklet and those for whom they did not, differences which may have contributed to the results, regardless of the anklet.

Anklets tested in London

Inspired by US examples, the UK coalition government in power until 2015 committed to funding a trial of alcohol-detecting bracelets for serious drink-related offenders. That mantle was later taken up by the Major of London, whose office in 2014 announced a pilot during which anklets would be fitted to offenders in four London boroughs to enforce an Alcohol Abstinence and Monitoring Requirement.

Offenders were eligible for the anklet if they had committed a drink-related offence but were not dependent on alcohol. Over on average 75 days wearing the anklet, 92% complied with their court order and did not drink. Whether there were longer term effects is unknown. Evidence of a bounce-back to offending after anklet removal among some US drink-driving offenders makes this a concern.

Publication in 2016 of the pilot’s results led to a decision to make the anklet-based sentence available across London, and formed part of the evidence base for the UK government’s plan to introduce sobriety as a court-imposed community order to reduce alcohol-related reoffending.

The Mayoral pilot in London was not the only time the SCRAM anklet had been trialled in the UK, but the other study was very different, involving male student drinkers. They volunteered for a study which for a fortnight randomly allocated them to be instructed not to drink either wearing or not wearing the anklet. If by the end of the first week the anklet revealed drinking, the student concerned was phoned and reminded of the instruction not to drink. Another set of students wore the anklet, but were told to drink as normal during the two weeks.

When drop-outs were assumed to have drunk alcohol, there were no statistically significant differences in drinking between students told not to drink, regardless of whether they had been allocated to the anklet. This result reflected grater drop-out among anklet-allocated students, sometimes because the device made them feel “uncomfortable, anxious, or dehumanized”. Among remaining students, far fewer drank if they were wearing the anklet, but this result cannot be relied on as an indicator of the overall impact across all students.

‘Don’t prosecute and I won’t drink’

In addition to convicted offenders, testing has also been used in the UK to control offenders who wish to avoid prosecution and instead agree to be cautioned. After piloting, the new ‘Conditional Caution with Sobriety Conditions’ became nationally available to courts as one way to deal with low-level alcohol-related offending. In lieu of prosecution, the offender agrees not to reoffend and to completely abstain from alcohol for a specified period on days when they are likely to offend as a result of drinking, enforced by regularly breath-tests. Failure to comply could result in prosecution for the original offence.

Roll-out was approved despite the unconvincing results of the pilot programmes. Run from May 2012 in five areas of England, the pilots “highlighted a general lack of understanding of the process”. What made the Home Office admit this was the fact that just 10 out of 92 offenders who qualified for the new cautions were given them, largely because (despite the intention being to make them acceptable) 68 refused the option. Of the 10 who did start the new court orders, just six completed them.

All depends on the leverage

A distinctive feature of the US programmes is the strong leverage available to sanction substance use and reward abstinence: in physician health programmes, removal from practice and ultimately the loss of one’s license to practice medicine, versus continuing to practice in a prestigious and well paid profession; in programmes for offenders, immediate brief imprisonment versus freedom.

Wider application of such programmes hinges on finding or engineering this leverage, and on having both the legal authority and the resources to swiftly and certainly sanction transgressors. Without leverage, programmes risk simply siphoning non-compliant offenders into conventional penal sanctions; without sure sanctions, the programme exists only on paper and can safely be ignored by offenders.

Test-and-sanction programmes also require considerable administrative reorganisation and commitment. In 2014 the lead researcher of the HOPE evaluation knew of “at least 40 replications of HOPE-style models on the [US] mainland”. Whether they were producing the results seen in the original was unclear, and dependent she thought on adherence to the strategy’s core principles: “swift, certain and proportionate sanctions”. From her account, it seems that generating and maintaining this approach is not straightforward and cannot be expected to work everywhere, requiring a committed judge, the cooperation of probation and other partners, effective, engaging leadership, increased efforts to detect probation violations, and substantial reorganisation of procedures. The strategy is simple – detect and punish – but putting it into effect is not.

Thanks to David McDonald of Social Research & Evaluation Pty Ltd in Australia for suggesting this hot topic.

Last revised 30 October 2016. First uploaded 29 June 2012

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