Responding to Drug Misuse

Research and Policy Priorities in Health and Social Care

Susanne MacGregor, Susanne MacGregor

• Publisher: Routledge
• Year: 2009
• ISBN:
  9781135211691
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Responding to Drug Misuse provides a unique insight into the current shape of the drugs treatment system in England.

Reporting findings from research linked to the government's ten year drugs strategy Tackling Drugs to Build a Better Britain, the book places these in the context of policy, practice, and service development. It goes on to discuss the implications of these findings for the government's new strategy Drugs: Protecting Families and Communities. Throughout the book contributors reflect on current debates on drug strategies and social policy and consider the relevance of the findings for policy and practice. Topics discussed include:

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• recent trends in drug policy and how these link to crime
• responses of dedicated drug treatment services
• service users' perceptions and suggestions for improvement
• the impact of drug misuse on children, families and communities.

This timely addition to the literature on drug misuse will be essential for substance use practitioners, including social workers, psychiatrists, psychologists and nurses. It will also supply helpful guidance for health and social care commissioners and policy providers.

1 Policy responses to the drugs problem

Susanne MacGregor

Policy developments

An account of New Labour’s drugs policy can usefully start with the claim made repeatedly by Paul Hayes, Chief Executive of the National Treatment Agency (NTA), that it was only by stressing the link between crime and drugs that increased resources for drugs treatment were levered from the Treasury. It is worth noting also the role played by Tony Blair in these changes. As Prime Minister, he made a personal commitment to the crime and drugs strategy, keeping the issue in the public eye and giving it high priority.

Spending rose substantially. In 1993/4, £526 million was being spent in total on tackling drug misuse across the UK: within this, £61 million was devoted to treatment and rehabilitation. In 1994, about 67,000 people were counted as in treatment; by 2004/5, this number was 160,450; and by 2006/7, 195,000 (MacGregor 2006a, 2006b; NTA 2007a). In 2007/8, £398 million was allocated for the pooled treatment budget provided by the Department of Health and Home Office (NTA 2007a). [The total spend on treatment in 2005/6 was estimated to be £508 million (Reuter and Stevens 2007:56).]

Underlying this was the confident claim that ‘treatment works’ and that it is cost-effective. It was said that for every £1 spent on treatment at least £9.50 would be saved in crime and health costs (Godfrey et al. 2004; HM Government 2008:51–52). Treatment was the way to break the link between drug misuse and crime. The vehicles for rolling out this strategy at local level are drug partnerships [which now take a variety of forms such as Drug Action Teams (DATs) or Crime and Drug Reduction Partnerships (CDRPs)]. The Home Office is responsible for coordinating the drug strategy across government at a national level.

Continuities with Conservative policies

The origins of New Labour’s approach to illicit drugs lie in the policies of the previous Conservative government. Tackling Drugs Together: A Strategy for England 1995–1998 (HM Government 1995) set the template for drugs policy. This introduced DATs and Drug Reference Groups. The key aim was to take effective action by vigorous law enforcement, accessible treatment and a new emphasis on education and prevention, in order to:

• increase the safety of communities from drug-related crime;
• reduce the acceptability and availability of drugs to young people;
• reduce the health risks and other damage related to drug misuse.

This White Paper entrenched the division between alcohol and drugs as separate strategies. Tackling Drugs Together (TDT) marked a shift from the harm-reduction approach which had dominated from the 1980s onwards – an approach which had been influenced by recognition of the then new problem of HIV and AIDS. TDT stated clearly that the principal objective of treatment services should be to assist drug misusers to achieve and maintain a drug-free state. But it added, ‘whilst abstinence remains the ultimate aim, steps will continue to be taken to reduce the spread of HIV and other communicable diseases by drug misusers’ (HM Government 1995:1.6).

TDT emphasised the link between illicit drugs and crime. The Conservative strategy also established ideas of partnership, aiming at an integrated response. There would be a joined-up policy, coordinated from the centre of government. Statutory and voluntary sectors would work together and health and social care would be linked to the criminal justice system. The details of policy would be worked out at the local level through the newly established DATs, taking advice from their Drug Reference Groups.

At the same time, a link to community concerns was made in TDT. John Major, the then Prime Minister, in his introduction to the Strategy, referred to the idea that drug misuse ‘blights individual lives, undermines families and damages whole communities’ – themes which were periodically reiterated by both Conservative and Labour ministers in forewords to policy initiatives.

One year on from TDT, on 1 May 1996, the Effectiveness Review was published (DH 1996). This reported on a fundamental review of treatment services and their effectiveness, informed by input from commissioned research and expert papers and judged by a specially selected panel. The main conclusion was that ‘treatment works’. (This choice of phrase should be understood within the context of the dominance in political debate at the time of the notion that ‘prison works’. ‘Treatment works’ was deliberately counter-posed to this phrase.)

The Chairman of the Review, Dr Polkinghorne, concluded:

Drugs misuse is a complex and diverse issue. It causes immense harm to individuals and to society. Our review clearly shows that treatment works in reducing harm. It also makes clear that there are no ‘magic bullets’ and that treatment must be matched to the needs of individuals. A key finding is that to be effective, treatment must embrace care in the widest sense. This might include addressing housing needs, child care issues, retraining for employment and general support.

(Press release, 1 May 1996)

Polkinghorne also said that:

drug misuse is a chronic relapsing condition and … a number of attempts may be needed before an individual can become drug free…. Syringe exchanges and the prescribing of substitute drugs help minimise harm and need to be firmly at the centre of the overall approach to treatment…. We hope that the critical examination of the effectiveness of treatment approaches which we have begun will be built on through a continued programme of rigorous research and evaluation.

(Press release, 1 May 1996)

There are clear continuities therefore in the New Labour strategy with what went before. The Conservatives’ initiatives laid the groundwork for the new policies, although some changes were introduced. One important feature of New Labour’s strategy was precisely that it was a ten-year strategy rather than the three years of TDT. The ideas would be given time to bed in and to develop, and sufficient monies would be devoted to implementation.

The New Labour approach

The Ten Year Strategy rested on the existing classification system for illegal drugs. It was based on the key assumption that ‘treatment works’. But, more emphatically than in earlier Conservative initiatives, it stressed the use of diversion into treatment from the criminal justice system. Over time, and markedly by the time of the Updated Drug Strategy in 2002 (Home Office 2002), the main focus of attention was to be on the ‘hard-core’ of problematic drug users – the ‘PDUs’, including injecting drug users and users of crack and opiates.

This Drug Strategy set out a range of interventions that concentrated on the ‘most dangerous drugs’, the ‘most damaged communities’ and individuals whose addiction and chaotic lifestyles were most harmful. Later developments increased the use of testing to trigger diversion into treatment. The expanded services, supported by increased expenditure, would be rigorously monitored through the use of systems of performance management: only thus could such additional expenditure be justified to the Treasury and to the wider public. Underlying concepts, typical of the Third Way approach to social policy, were those of partnership and community involvement. In these arrangements, commissioning would have a key role with clearly separated funds and distinct institutions.

Influenced by the advice of Senior Medical Officers, and building on consensus views from experts in the field, ‘Orange Guidelines’ on treatment were issued in 1999 (DH 1999a). These made recommendations and referred to the

responsibilities of all doctors to provide care to drug users for both general medical needs and for drug-related problems, improved safety through good assessment procedures, urine analysis, dose assessment where possible, regular reviews and shared care working, reducing diversion through daily dispensing and supervised ingestion, provision of evidence based interventions and the need to work within a shared care framework.

(Gerada 2005:75)

These guidelines were revised and updated in 2007 (DH 2007) and operated along with a series of further guidelines from the NTA and from NICE to provide the frameworks within which medical practitioners and others were expected to make clinical decisions in order to develop good practice and maintain cost-effectiveness.

One organisational difference between the Conservative and Labour strategies was to shift prime responsibility at local level from health authorities to local authorities. Another significant contextual aspect flowed from devolution – one of the most important features of the changes wrought by New Labour to British politics and society. In implementing the Drug Strategy, there have developed some differences in arrangements in England, Scotland, Wales and Northern Ireland. But the broad goals of the UK strategy until 2008 were supported by all administrations.

Tackling Drugs to Build a Better Britain, published in 1998, aimed to:

• help young people resist drugs;
• protect communities from drug-related anti-social and criminal behaviour;
• enable people with drug problems to overcome them and live healthy and crime free lives; and
• stifle the availability of illegal drugs on the streets.

(HM Government 1998)

The most distinctive new element however was drawn from evidence from the USA, where it was observed that treatment delivered through the criminal justice system could be effective: this approach was transplanted into British policy. The key principle was that coerced treatment is as effective as voluntary treatment and offending could be reduced in this way.

New Labour also aimed to improve the procedures of government and the delivery of public services through the adoption of more modern systems of management, with a stress on performance and innovation (Cabinet Office 1999). Key aims here were that policy making would be more joined up and strategic; that public service users, not providers, would be the focus; and that public services would be delivered efficiently and be of high quality. Core competencies were developed for civil servants so that they would become forward-looking, outward-looking, innovative and creative, use evidence, be inclusive, work jointly across departments, establish the ethical and legal basis for policy, evaluate, review and learn lessons. A great deal of stress was placed on using the evidence base to decide what works. Public Service Agreements were introduced in 2001. Equally in the drugs field as in other social policy areas, initially a great deal of emphasis was placed on the value of a ‘pragmatic’ and evidence-based approach to policy and practice. This included funding new research and testing ideas in pilots before rolling them out. There would also importantly be more service user involvement, as users were seen as a counterweight to a heavy producer interest in public services.

The anti-drugs strategy is a cross-government initiative. It was initially coordinated by the Anti-Drugs Coordination Unit (son of the Conservatives’ Central Drugs Coordination Unit), located in the Cabinet Office and led in its early years by a Drug Czar (Keith Hellawell) and Deputy Drug Czar (Mike Trace). With the arrival of David Blunkett as Home Secretary, the Updated Drug Strategy in 2002 gave overall responsibility to the Home Office for delivery. But other departments such as the Department of Health and the (then) Department for Education and Skills would also have key roles.

In April 2001, the NTA was set up with the remit of expanding the availability and quality of drug treatment. Some saw this as an astute compromise between the care and control lobbies, giving attention to treatment but masking the shift of power from the Department of Health to the Home Office. The new Chief Executive, Paul Hayes, came from a background in the probation service. The NTA is responsible for monitoring expenditure of the pooled treatment budget. This pooled budget was introduced in 2001/2 with £129 million available in that year. As we have seen, this budget rose substantially over subsequent years. In addition, there was approximately £200 million of mainstream local expenditure available for drug treatment.

The updating of the Drug Strategy in 2002 was influenced by a policy review by the Home Affairs Select Committee (2002). This review contained some criticisms of the former ‘Drug Czar’ approach. The committee accepted the benefits of focusing on the relatively small group of PDUs and stressed that policy should concentrate here, where harms were greater, rather than on the larger numbers whose drug use poses no serious threat to their own wellbeing or that of others (Home Affairs Select Committee 2002: para. 38). They also recommended a review of the classification system with regard to the less harmful drugs. They were critical of the overly ambitious targets contained in the original strategy and they wished to see more attention to treatment for cocaine and crack users, substantial increases in funding for treatment for heroin addicts, and for methadone therapies to be widely available. They also favoured a proper evaluation of heroin prescribing and a pilot programme of safe injecting houses. The Select Committee also recommended that a target be added to the National Strategy explicitly aimed at harm reduction and public health.

A key aim of the 2002 Updated Drug Strategy was to reduce the harm that drugs cause to society – communities, individuals and their families – and so it concentrated on the ‘most dangerous drugs and most dangerous patterns of use’ – most dangerous being defined as class A drugs (which include ecstasy as well as heroin and cocaine). Strategy focused on the ‘most damaged communities’ and on ‘those individuals whose addiction and chaotic lifestyles are the most harmful both to themselves and others’, i.e. the then estimated 250,000 PDUs in England and Wales. And it focused particularly on the young, especially the ‘most vulnerable’ young. It was to involve a selective and targeted approach. In particular, the revision involved dropping many of the over-ambitious performance targets set out in the 1998 strategy.

A key element of these later developments was the aim to increase the participation of problem drug users in drug treatment programmes by 55 per cent by 2004 and 100 per cent by 2008 and to increase year on year the proportion of users successfully sustaining or completing treatment programmes.

Policies aiming to deal with drugs and crime in local communities have included: arrest referral schemes; Drug Treatment and Testing Orders (DTTOs); Drug Rehabilitation Requirements (DRRs); intensive community-based programmes; Progress2work, a JobCentre Plus initiative which helps recovering drug users find jobs; Communities Against Drugs; and the Drugs Interventions Programme (DIP). The aim in addition is to provide comprehensive programmes of throughcare and aftercare for treated drug misusers returning to the community from prison, including post-release hostels. (These initiatives are discussed more fully by Duke in Chapter 2.)

November 2004 saw the launch of Tackling Drugs: Changing Lives (Home Office 2004). This involved a plan of action through to 2008. The Prime Minister, Tony Blair, said that tough measures were needed to deal with drug dealers and offer more support to users. The policies aimed to:

get as many drug addicted offenders into treatment as possible. The measures already in place to test offenders at the point of charge are working well but need to be strengthened to increase the number who take up this offer of help … so we will introduce testing at arrest as well as charge and require a person who has tested positive for a specified class A drug to attend an assessment by a drugs worker. Those who are assessed as needing further assistance or treatment will be required to attend a follow up appointment to draw up a care plan … we will introduce a new presumption that those caught in possession of more than a certain amount of drugs are guilty of intent to supply rather than possession for personal use … tough on dealers but support for those who need a way out of the vicious circle of drug-related crime.

(Prime Minister’s speech, 25 November 2004)

The head of the NTA, Paul Hayes, commented on this ‘most significant increase in Government investment … [which] has enabled more drug misusers to access treatment more quickly than ever before’ (press statement, 28 September 2004).

So in the years after 1998, the numbers in drug treatment doubled and the government invested £1.5 billion in its Drug Strategy. The aim was also to shift provision of drug treatment more towards the voluntary and community sector. In 2001, 80 per cent of drug treatment places were provided through the National Health Service (NHS); by 2005, this had reduced to 65 per cent, with 35 per cent of the cost of drug treatment going to third-sector providers.

There is no doubt that this period witnessed unparalleled attention to the issue of drug misuse with substantial investment of funds, energy and attention in improving responses and, it was hoped, making a noticeable impact. Over time, for researchers, concern shifted from demonstrating need to ways of expanding and improving services and thus the outcomes of treatment. An important additional moment was the publication of Hidden Harm in 2003 (ACMD 2003), which marked a change in perspective from attending solely to the needs of the service user to recognising also those of service users’ families and especially the children of drug-using parents.

In 2005, the NTA launched its treatment effectiveness agenda, emphasising however that the focus would remain on the service user (NTA 2005). The aim was also to reinvigorate harm reduction. Critical success factors would be to improve the client’s journey through treatment, improving engagement with treatment, retention and completion. ‘The NTA does not advocate enforced reduction regimes or enforced detoxification’, but they wanted staff to be more ambitious for their clients and to aim at reintegration, and by this they meant getting them into employment, education and housing. The retention target would become part of the performance management of the NHS, thus giving it more influence over commissioners and managers. The aim was also that each client would have an identifiable and written care plan and better aftercare (Dale-Perera 2005).

After time, of course, the strategy was no longer about ambitions but could be judged by results. Initially, the biggest criticisms of the strategy were about implementation. Later, challenges to the central goals began to be voiced. A range of evaluations of the strategy have appeared...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• List of tables
• List of figures
• List of boxes
• List of contributors
• Preface
• Acknowledgements
• 1 Policy responses to the drugs problem
• 2 The focus on crime and coercion in UK drugs policy
• 3 Drug-taking and its psychosocial consequences
• 4 ‘Treatment as Usual’
• 5 Care co-ordination in drug treatment services
• 6 The effect of waiting for treatment
• 7 Early exit: estimating and explaining early exit from drug treatment
• 8 Barriers to the effective treatment of injecting drug users
• 9 Prescribing injectable opiates for the treatment of opiate dependence
• 10 Cognitive behaviour therapy for opiate misusers in methadone maintenance treatment
• 11 Involving service users in efforts to improve the quality of drug misuse services
• 12 Comorbidity in treatment populations
• 13 Epidemiology of drug misuse and psychiatric comorbidity in primary care
• 14 Offering a service to BME family members affected by close relatives’ drug problems
• 15 A review of services for children and young people with drug-misusing carers
• 16 Dilemmas in intervening effectively in families where there is parental drug misuse
• 17 Evidence and new policy questions
• References