The evidence which led the UK government to accept its drug policy advisers' call for the legalisation of the supply of foil to drug users to promote transition from injecting to smoking heroin and cocaine.
On 4 July 2013 Home Secretary Theresa May told the House of Commons that "The government has accepted the advice of the Advisory Council on the Misuse of Drugs (ACMD) to allow for the lawful provision of foil by drug treatment providers subject to the strict condition that it is part of structured efforts to get people into treatment and off drugs" (reference 1).
Clothed with the new mantra of 'recovery' and abstinence, in this way an extension to harm reduction became acceptable. Just what that "strict condition" means remains to be seen, but it could simply be the main intended point of supplying foil in services such as needle exchanges – to promote transition from injecting to the safer (though still not ideal) smoking route, or to or sustain users in the choice to smoke rather than inject. Simply providing foil in the context of a needle exchange or drug help service will bring a wider range of users in to contact with services who previously had no reason to make themselves known.
Once the regulations are devised and implemented, foil will join injecting paraphernalia (needles and syringes, water ampoules, swabs, spoons, bowls, cups, dishes, citric and ascorbic acid, and filters) among the drug preparation equipment which can legally be supplied for illegal drug use.
Supplying foil is one of a suite of 'route transition interventions' reviewed for the Global Fund to Fight AIDS, Tuberculosis and Malaria, aimed at promoting non-injecting and safer routes of administration of illegal drugs.
The new law will rectify the anomaly that needle exchanges can legally supply equipment to make the most dangerous method of drug use (injecting) somewhat less risky, but not to supply equipment which might support transition to a far less dangerous method (smoking).
How did we get to the Home Secretary's decision, and what role did research play? First it is important to remember that this was not a major policy U-turn, but the rectification of an unintended consequence of section 9A of the Misuse of Drugs Act 1971, introduced by a previous administration to outlaw supply of the 'cocaine kits' (razor blades, foil and lemon juice) being marketed in the mid-1980s. Politically it a was a minor and relatively pain-free adjustment, evidenced by the lack of action against Exchange Supplies or against its customers after in 2007 the company started supplying foil tailored for needle exchanges to dispense to their visitors. If in the end logic, expert opinion and evidence held sway, perhaps it was because the issue was neither morally nor politically charged.
In the late 2000s attempts were made to remove or amend legal restrictions on supplying foil and other items by medical and drug services when acting in their professional capacity. These were accepted in principle by the government of the time but fell victim to the impending May 2010 election.
The year after Exchange Supplies put its head above the parapet, the Advisory Council on the Misuse of Drugs – an expert body set up under the Misuse of Drugs Act to advise government – "began its consideration of the issue of the use of foil as a harm reduction measure ... after a growing body of evidence of its potential benefits and also its distribution from drug services." In 2010 came their report which eventually the government acceded to (reference 2). The main conclusion was that "On the current balance of evidence, foil [should be] exempted under Section 9A of the Misuse of Drugs Act 1971" so it can legally be supplied to for illegal drug use.
At first that was not enough to convince government, which the following year asked the council for more on the health risks of smoking drugs on foil. This further investigation did not change the council's mind. At the end of 2011 they replied, reiterating their belief that "foil, as an intervention, can support an individual's treatment journey towards recovery ... the ACMD consider that there is a strong case that foil is exempted under Section 9A of the Misuse of Drugs Act 1971" (reference 3). Both documents are drawn on in this account.
For the council a major consideration had been its earlier conclusion that, "Ultimately we need to stop injecting to reduce the risk of [hepatitis C]".
Two small UK studies provided key evidence of how the provision of foil might further that ambition and more broadly reduce harm among injecting drug misusers. Published in 2008, an evaluation of supplying Exchange Supplies' foil packs to promote transition away from heroin injecting to inhalation analysed data from four needle and syringe programmes and interviewed injectors at one of them (reference 4). It found the packs were taken when available, that offering them could be a useful way of engaging attendees in discussions about ways of reducing injecting risks, and suggested that supplying foil could reduce injecting in areas where there was a pre-existing culture of 'chasing' heroin.
Among the most persuasive findings were that while foil was available, visits to the exchanges increased by a third from 1672 to 2216. To obtain foil, 32 new visitors attended the services who chased heroin but did not inject, drug users who would presumably otherwise not have made contact. At the second visit, all but two of the 48 exchange users interviewed said they had used the foil, and 41 said that as a result they had smoked when otherwise they would have injected.
The same year a report (reference 5) from Sheffield on a scheme for providing foil from a site-based and a mobile exchange said that this had reduced injecting and promoted less risky alternatives. Foil was taken by 85 service users, of whom 72% had injected in the last four weeks and 12% had not used the service before. A third provided feedback; nearly all said their injecting had reduced as a result of using the foil. Case studies of eight individuals revealed that new clients were seen due to the initiative. Most had reduced their injecting and some had replaced injecting entirely with smoking.
Both studies were only suggestive in their findings, but the suggestions were all in the right direction, especially when many injectors in an area already had experience of smoking.
Surveys in Britain had also shown that needle exchange managers, commissioners, users and workers believe that providing foil would encourage drug users not to inject, but also that two thirds of services did not provide it because it was illegal.
Another reassuring source was the long experience with foil provision in the Netherlands. It convinced the ACMD that foil can provide a platform – "when coupled with harm reduction messages and appropriate service provision" – for transition away from injecting. In Amsterdam the proportion of drug users sampled over several years who were or had started injecting had fallen steadily following the introduction of harm reduction policies, including foil provision.
A review of more than 15 years of Dutch experience in switching injectors to foil reported positive public health outcomes. Among other influences, it concluded that "The availability of aluminium foil seems to have played a significant role in the transition process". In the Netherlands any service willing to provide foil in order to stimulate or facilitate (transition to) non-injecting can do so. Widespread provision of foil in the country suggests that it may well have been a factor in the trend away from injecting, but isolating the influence of foil from other factors was beyond the review's scope. Such an attempt may in any event be misguided: providing foil, health campaigns, cultural and sub-cultural trends, and peer influences, probably interacted, each reinforcing the others.
The main downside mentioned by the Dutch review was the common and sometimes severe respiratory complaints among drug smokers. Inhaling the fumes of street heroin or crack cocaine or inhaling hot vapour in general is not a good idea, but, the ACMD judged, considerably less dangerous than injecting.
Other risks considered by the ACMD include a rare but potentially fatal form of brain damage from inhaling heroin (or its contaminants), and constructed airways due to heroin or cocaine, which can be particularly severe in asthmatic patients. One study found a link between smoking heroin and shortness of breath. However, some of these results may, said the committee, have been partly due to a greater than usual prevalence of tobacco smoking among heroin users, particularly heroin smokers.
Long-term cocaine smoking can lead to significant damage to the lungs, resulting in a range of chronic diseases. Smoking crack cocaine can also cause intense vasoconstriction resulting in severe chest pain, difficulty in breathing and fever, which may become a chronic condition with prolonged use.
Damage may also occur due to the inhalation of chemical by-products or the products of the combustion of highly inflammable solvents used in the drug production process. Inhalation of hot drug vapour may in itself be associated with thermal damage to the lungs, but no studies were identified which had examined this in detail.
Inhalation of aluminium itself from the heated foil may happen, but on the evidence the levels were too low to constitute a risk.
A further concern was the risk of infection such as happens with injecting. Rates of infection in non-injecting heroin users are much lower than among injectors, though in respect of hepatitis C, still higher than in the general population, particularly among older users, those with tattoos, and crack cocaine users who share inhalation implements. How this happens is unclear, but given the high boiling points of cocaine base and heroin, and the very high temperature of foil when heated, it would seem very unlikely that viral infection could occur by this route, even if the cocaine or heroin was contaminated.
Key conclusion was that the physical harms of smoking are significantly less than those associated with injecting, leading to a recommendation that foil should exempted as a harm reduction intervention under Section 9A of the Misuse of Drugs Act 1971.
In particular said the council, the evidence indicates that there are no harmful effects from provision of foil and that it does not encourage use of illegal drugs. Potential benefits include: increased contact and engagement with drug service workers, offering opportunities to affect user behaviour and provide public health messages; fewer systemic infections; less soft tissue and venal damage; lower risk of overdose; and less litter related to drug use. Though unlikely in itself to significantly reduce blood-borne viral infections, providing foil may (like other paraphernalia) play an important role in a programme of interventions if used to reinforce harm reduction messages on the dangers of injecting.
Among the council's practice recommendations were that:
• Services should provide a range of responses that support people away from injecting, which can include substitute prescribing.
• We should be mindful/aware of the signs and occasions when engaging with the service user to offer alternatives could instigate a change in behaviour.
• Harm reduction providers should supply foil as part of a holistic range of harm reduction interventions which support a hierarchy of needs to promote individualised recovery goals and general health and well being.
• Services must provide an environment affording privacy and dignity, where service users can speak confidentially and be supported by workers who are empathic and non-judgemental.
• Services providing foil should ensure staff can effectively assess someone's risktaking behaviour including injecting risk. They should be able to articulate the risks versus benefits of safer alternatives such as smoking and 'chasing'.
Further detailed practice guidance is available from a national supplier of foil for drug services.
1 Written ministerial statement on the government's acceptance of Advisory Council on the Misuse of Drugs advice on the lawful provision of foil. Theresa May. [UK] Home Office, 4 July 2013.
2 Consideration of the use of foil, as an intervention, to reduce the harms of injecting heroin and cocaine. [UK] Advisory Council on the Misuse of Drugs, 2010.
3 Re: Consideration of the use of foil as an intervention, to reduce the harms of heroin and cocaine. [UK] Advisory Council on the Misuse of Drugs, 2011.
4 Distributing foil from needle and syringe programmes (NSPs) to promote transitions from heroin injecting to chasing: an evaluation. Pizzey R., Hunt N. Harm Reduction Journal: 2008, 5:24.