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Despite the long-lasting political notoriety of the drug issues, relatively sound policies and considerable investments, the United Kingdom has the highest prevalence of dependent drug use and some of the highest numbers of recreational drug users in Europe (Reuter, 2007). There are vast arrays of different policies and programmes working towards solving problems related to drug use, but while the dedication and level of investment may shift with political change, the UK has tried to cope with the drug problem for at least 15 years. . This chapter will focus on drug abuse policies and strategies in Europe and the UK. It will conclude with a focus on reducing drug related harm in the United Kingdom in general and England in particular. It will be shown that pharmacists have a vital role to play in harm reduction.
4.1 Illicit drug regulation at the EU level
Similarly to the present-day UK drug policy, Germany has decentralised the implementation of its drug strategies. There is an overall national drug law, yet specific drug policy falls under the jurisdiction of the federal states. However, the policy gap between northern and southern states is very wide, which means there is no nationally representative approach to drug use. Most of the northern states have adopted tolerant, pragmatic policies -some which are even more liberal than the Dutch ones when considering the quantities of drugs authorised for personal use. In the southern states the policy is more restrictive and only very small amounts can be kept for personal use (Van Solinge, 1999). This variety in policy within a country filters through the European Union. Different countries implement different methods to control or manage drug use, with varying succe ss rates as it appears there is no cohesive agreement to push the management of drug misuse to the top of the agenda at the EU level. It thus seems unlikely that there will be an EU-wide policy to particular drugs in the near future. Despite significant financial investment in drug prevention and control, it is noteworthy that two European countries that are frequently used as contrasting examples of tough versus liberal drug policies, Sweden and the Netherlands, both have lower rates of overall and problematic drug use than the UK (Reuter, 2007).
4.1 Illicit drug regulation in the UK
The United Kingdom consists of England, Wales, Scotland and Northern Ireland, and the Isle of Man, of which England accounts for 85% of the UK population (Office for National Statistics, 2012). Over the years many general responsibilities have been devolved from the UK Parliament to Wales, Scotland, and Northern Ireland, but each continues to have different levels of decentralised responsibilities. The UK Government is responsible for determining the general approach and also ensures its delivery in the devolved administrations where it has reserved power (Department of Health, 2011). Recently (after the 2010 election) in the face of financial restraints, the UK government has moved to pass control of policing, justice, health and alcohol and drug dependency problems to local areas, while maintaining their role as overall reviewer. We will consider this new direction later.
In the UK, illicit drug policy and attitude towards harm reduction strategies has shifted with government changes. Between 1987 and 1997, there was a public health approach with the objective to assist specific individuals, known as problem drug users, to improve their lives, become healthier, and limit the damage they may do to themselves and those around them (Stimson, 2000). Harm reduction strategies developed within a health policy framework - although it was difficult to get consensus on drug use as a health policy issue rather than a criminal one, in general the strategies were well integrated into an existing framework (Stimson, 2000). It should be noted that the UK acted swiftly during this period to prevent the spread of HIV and hepatitis by introducing neddle exchange programmes for drug users, thus reducing future costs to the health care system.
In 2002, the Liberal Democrats attempted to address the artificial divide between the harm caused by the use of legal and illegal drugs by launching an evidence-based drug policy which suggested that incarceration should not be a punishment option and cannabis should be legalised. In addition, the policies rejected enforcement and imprisonment as primary policy tools, as there is evidence this has limited effect. The Lib Dems were unsuccessful at the time in promoting their policies, but in 2011, backed by experts, ideas to decriminalise drugs were floated again and a parliamentary committee considered the issue , stating that such a move would not result in an increase in drug demand (Travis, 2011). But it had no effect on changing the classification of drugs 'according to harm' or legalising cannabis , for example. . This call came not long after the introduction of a new drug strategy called ',Drug strategy 2010: 'reducing demand, restricting supply, building recovery: supporting people to live a drug-free life' which was launched in December replacing that of the previous Government. Despite the Lib Dems liberal line, the 2010 strategy sets out a dramatically different line of attack to preventing drug use in the general population and in assisting recovery from drug dependence. Some of the main aspects include the responsibility it puts on the drug user himself to get assistance and overcome drug dependency, rather than it being imposed. In addition, it aims to provide a more holistic approach, by dealing with other concerns such as education, housing and employment, plus the treatment supporting individuals dependent on drugs. The 2010 strategy hopes to lower demand and it takes a hard approach to tackle the supply of drugs both nationally and internationally. With the devolution of power, it increases the accountability of local communities to fight drugs and their associated harms. The coverage of the 2010 strategy is as follows:
â€¢ Health, education, housing and social care - confined to England
â€¢ Policing and the criminal justice system - England and Wales
â€¢ The work of the Department for Work and Pensions - England, Wales and Scotland
(Home Office, 2012)
The Scottish Government and Welsh Government's national drug strategies were published in 2008 and all three strategies aim to make considerable head way on harm reduction (Department of Health, 2011).
The new drug policy is not without its critics. Perhaps, the main concern is around the transfer of responsibility to local authorities with budget cuts. The UK DPC put out a report in April 2011 raising concerns about the effects of substantial reductions in funding, along with severe cost cutting and structural changes to the NHS, as well as in policing and criminal justice. The report raises serious concerns about whether the success of some of the current treatment programmes can be maintained. Over the past decade much has been achieved be there could be setbacks leading to negative effects for drug users, their families and the community. They question the metrics that will be used by the Home Office to evaluate progress in their yearly reports as there is a lack of evidence based research on recovery-orientated treatments? There is a concern that the local Health boards will give a low priority to drug dependency and transfer funds to other areas. The report notes (UKDPC, p 10) that in the first year only 16% of the Health and Wellbeing boards had justice representatives, which are seen as critical partners in drug dependency and mental health areas. Of interest is Appendix 6 which gives a timeline from 1963 of the UK governments involvement in policy and funding of drug related issues. This mentions the 1998 ten year policy, an update in 2002 and a new policy in 2004. Of course, now replaced by the newly elected 2010 government with a radical shift in health and policing services to local control partly accomplished by setting up Public Health England.
From time to time articles appear on BBC and in the press about aspects of the UK approach to illicit drugs. In the Guardian (June 26, 2012), Mary O' Hara describes some effects of local tendering of alcohol and drug treatment programmes to the volunteer sector. Some charity groups have won bids and taken away some projects formerly operated by NHS. Of course, concerns are raised by unions and others (Head of the Royal College of General Practiciners) concerning the quality of service that will be provided by the new agencies and the dangers of severe cost cutting. Clients will be transferred to new programme sites with different staff. With an emphasis on costs there is a push for quick recovery as well.
In April 2012 the Home Office Secretary Rt. Hon May made a 17 page report on progress with the new policy since its introduction and plans for the year ahead. She noted that being drug free is the end goal (apparently without drug substitutes like methadone which has a long history of use). Payment tied to results, began a new website for what works, and helped support 10,000 drug specialists. Treatment wings are open in some prisons and more support is available to help with employment. Next year the programme will tackle housing and family integration as well as the serious issue of stigma associated with drug dependency. She sees demand being reduced by intercepting shipments (although this has failed in the past in the UK and the USA: a supply is usually available and at a similar price) and by enforcement locally. Users will be encouraged into treatment (perhaps not coerced as 6 to 8 years ago which was seen by some as a violation of civil rights). Again education programmes will be directed towards the young and the website FRANK will be upgraded to allow for interaction. Past research (?? )on educational programmes has in general failed to show any reduction in drug experimentation by teens. But like Nancy Regan's popular USA school programme in the 1980s of "Just Say No to Drugs', anti drug educational has an appeal to logic. The report focuses on efforts to stay on top of new drugs coming onto the market, often sold over the internet.
Some of the most pointed responses ro the government's new drug policy has appeared in the press. In the Guardian (April, 24,2012) Mary O'Hare reports on a group of charities that deal with drugs addiction and AIDS who have sent a critical letter to the Prime Minister and Lord Henley (in charge of drugs) expressing their concern about the drug policy's focus on drug abstinence and full recovery as top priorities. They believe that the policy is ignoring the well accepted practice of harm reduction treatments such as methadone replacement for heroin. They fear that this treatment approach will be dismantled resulting in a rise in blood borne diseases. It appears to be driven by ideology rather than evidence based interventions. The Guardian states that only a month ago the blueprint for the new drug policy of 2010 was set forth and supported by eight government departments ,including the Home Office and the Department of Health,.
4.2 UK policy approach
As is the case in most European countries, drug-related deaths, communicable diseases, co-morbidity and other health outcomes are main policy issues within the United Kingdom's drug strategies (EMCDDA, 2012). In the effort to keep blood borne disease under control interventions include information campaigns on the risks associated with drug use for different target groups, as well as information on safer injecting and safer sex practices, needle exchange schemes, infection counselling, support and testing, and vaccinations against hepatitis B. Besides the recognised value of maintenance prescriptions of methadone and buprenorphine, opiate detoxification, naltrexone and variety of psychosocial interventions including cognitive behavioural therapy have been recommended by the National Institute for Health and Clinical Excellence (NICE, 2007).' Stevens et al,( 2006) list some treatments that have also been effective in reducing drug dependency. These include motivational interviewing, counseling and residential rehabilitation..
4.3 Drugs and the law
Throughout Europe and the world, the laws regarding different types of drugs and their penalties for possession or use vary considerably. This is especially the case for cannabis, which is by far the most frequently used drug throughout Europe. The approach of the UK government has been cacophonic over a period of time. For instance, , cannabis was reclassified from Class B to Class C in 2004. This resulted in a considerable reduction in the level of criminalisation associated with cannabis possession. This has benefits for youths who might get caught experimenting with cannabis, as they will not have a life-long criminal record for their potentially one-off encounter with cannabis. However, in January 2008 cannabis was reclassified from Class C to Class B, raising the maximum penalties to five year's once again. Despite this, revised national police guidelines continue to support an informal warning for a first offence (EMCDDA, 2011).
On the other hand, two European countries, the Netherlands and Portugal, have effectively decriminalised the possession of small amounts of cannabis. In Portugal, this was done by replacing criminal with civil penalties, and in the Netherlands, though the drug itself remains illegal, there is a formal written policy for the tolerance of distribution and possession of a specific amount of the drug (Reuter, 2007). Many countries, however, still implement heavy drug laws, with the aim to reduce drug use by discouraging and preventing the distribution and use of drugs. Drug enforcement laws generally have the following aims:
Reduce demand for drugs by catching, punishing and sentencing users, suppliers and producers;
Disrupt the operation of wholesale and retail drug markets;
Seize of drugs at the point of import;
Eradicate crops at point of production.
The current UK drug policy incorporates different aspects of all these approaches.
In their analysis of the efficacy of UK drug policy up to 2007,. Reuter and Stevens find that there has been little headway made in reducing the amount of drug dependency in spite of all the efforts placed on enforcement. Most of Europe and the USA are examples of the failure of the war on drugs which has done little to stem the flow of illegal drugs while increasing the scope of organised crime. . . As such, it is often considered unreasonable to judge the performance of a country's drug policy by the prevalence of drug use, as there are many other factors at play (Reuter and Stevens, 2007). Unfortunately, the public and media are often focussed on drug reduction policies and their expected results in terms of reduction in drug use.
4.5 Harm reduction
In 2007 the Department of Health released an action plan to reduce drug related harm in the UK. The aim of this document, "Reducing Drug-related Harm: An Action Plan" is to increasingly reduce the number of drug-related deaths and transmission of infectious diseases such as HIV and hepatitis (Department of Health and National Treatment Agency, 2007). The approach outlined in the action plan has broad aims of preventing drug abuse, and of promoting treatment and support for abstinence from illicit drug use. Providing successfully tested substitution treatments, such as methadone, and effective support for abstinence are complementary aims of this plan (Department of Health and National Treatment Agency, 2007). The plan focuses on three key areas:
Increased surveillance and monitoring
Improved needle exchange and drug treatment delivery
Public health campaigns focused on those most at risk
(NHS, 2009/10, Department of Health & National Treatment Agency, 2007).
Of specific interest in harm reduction are a range of services most of which have been used for 20 years which need to continue in pharmacies to reduce the harm associated with injecting drug use. A few examples are as follows:
Needle exchange schemes; pharmacy, centre-based, or if appropriate, outreach
Comprehensive protocols to raise awareness of risks from blood borne viruses which promote and deliver testing and appropriate pathways into treatment for hepatitis B, hepatitis C and HIV, and vaccination against hepatitis B
Programmes that move people away from injecting drug use
Appropriate substitute opiod doses and quality treatment
Treatment for co-existing alcohol misuse risks
Improved through care and after care from prison
Neddle exchange and methadone therapy has been practiced by pharmacists in many countries where allowed. For example, in 2001 researchers (Fleming GF, McElnay JC, Hughes CM, Sheridan J, & Strang J.) in Belfast, Northern Ireland, collected data from local pharmacists and compared it with data from a 1995 study in the UK. It was found that they were willing but had only limited involvement compared to their UK peers who had been active in the campaign against HIV. A search of Pub Med readily turns up reports of community pharmacists in New York state and California active in neddle exchange programmes. I(??????)
At their meeting in 2006 in Brussels the Pharmaceutical Group of the European Union (PGEU) which is the European association representing community pharmacists in 29 European countries including EU Member States, EEA countries and EU applicant countries considered the roles that community pharmacists play in drug abuse treatment. In the report they observe that over the past two decades pharmacists in some member states have supervised the administration of heroin substitutes, along with needles and syringes. As an example, in The National Treatment Agency for Substance Misuse in England (NTA), was set up as a special health authority under the National Health Service in 2001 to facilitate the availability, capacity and effective treatment for drug abusers. The NAT has a goal to double the number of clients under this treatment by 2008 (as compared with 1998) . It is estimated that community pharmacists in England have more than 14 million contacts with illicit drug users so they can play a vital role in harm reduction.. In order to meet the treatment demands the NTA
has estimated 25% of community pharmacists will need to be
involved in needle exchange services and 75% in supervised consumption of heroin substitutes such as methadone. They can also supervise maintenance
regimens, or assist with plans for withdrawal from opiods using non-opiod medications such as lofexidine as prescribed by a physician. Contact with the pharmacy is an important of the drug abusers life and the pharmacist can play a role in health maintenance.
The needle exchange programme has two functions. One is to help the user to stay healthy until they are willing or able to stop injecting and live a drug free life with support.
with appropriate support. A second aim is to protect public health by reducing the transmission of blood-borne infections such as HIV and hepatitis C
health and reduce the rate of blood-borne infections such as HIV and hepatitis C which are costly to the medical system long term. A study published in the British Medical Journal (1986;292:527) in February of that year indicated that 51 % of 164 heroin users in Scotland were infected with " AIDS related virus" (unnamed as HIV at that time). This led to the introduction of needle exchange services in the UK in 1986. A related feature is the collection and disposal of used needles by the pharmacy. It has been estimated that the value of each needle exchange represents a 350% savings in costs (of future infections). Risk reduction is always an important part of drug treatment.
In some countries, supervised administration (or consumption) is needed so that the user does not leave the premises and share with another person. This means that only daily quantites are dispensed in a private area of the pharmacy. Of course, the pharmacist will ensure compliance with the treatment plan and follow with the prescriber (NTA, 2006 , Best Practice Guidelines).
The report goes on to speak of the supervised narcotic substitution programme with methadone Ireland. In an article in the Irish Times (18 September 2006), the chairman of the Irish National Advisory Committee on Drugs told of the importance of this approach to the user, families and the benefits to the community in less crime. . He stated that "the dispensing of methadone should not be seen as a threat but as a benefit to community, in that it reduces crime rates and drug abuse. Rehabilitation is in everyone's interest. The service has been provided with minimal difficulty at many pharmacies throughout the State. It should be expanded and given support by all the political parties and by the population as a whole".
A research study project was conducted by the National University of Ireland in Maynooth concerning the value of methadone replacement therapy for drug users and the community. Prior to treatment three in five of the addicts supported their habit by crime whereas afterwards this was one in seven. Further, there was a 30 % drop in heroin use and 25% gave up all drugs except for alcohol. The research found significant improvements in physical and mental health and some began looking for work and housing.