Tuesday, 10 June 2008

Risk and Substance Use: The Impact of Drug Laws

In yesterday’s Blog I wrote, ‘We are calling for a society that does not stigmatise people with substance use problems’.

In response, Derek Williams wrote, ‘I agree that needs to be a first step, but it simply isn't possible when the very basis of the drugs policy is prohibition which treats the casualty as a criminal. You're getting very close to calling for a review of our prohibition based approach, I hope you can go that extra mile and do so.

I don’t get drawn into such arguments, Derek. There are plenty of people in the UK fighting hard for this policy. I want to devote my energies and time to fighting the case for improving access to recovery for people affected by substance use problems. 

I will say the following though. By making a drug illegal, society increases the risks for a person using such a drug. Whilst applying technology to reduce the risks of using legal substances, society often withdraws technology to increase risks from use of prohibited drugs. 

“We prohibit a “bad” drug on the rationale that it is dangerous, and then construct social policies that assure high risks related to the drug’s use.”  William L White, ‘Pathways from the Culture of Addiction to the Culture of Recovery’


Let’s compare legal and illegal drugs. The legal drug could be highly addictive, such as a benzodiazepine.

With legal substances, we reduce risks by ensuring that substances are not contaminated, adulterated or misrepresented. This is rarely done for prohibited substances, greatly increasing the risks associated with their use.

With legal substances, we reduce risks by packaging the substance in ‘doses’ that provide predictable and desirable effects. The person using a prohibited substance rarely knows the purity of the substance purchased – this is determined by the actions of illicit suppliers, when they cut the product – and therefore the dose they are taking.  This increases risks when using, with potential overdose sometimes being a reality on a day-to-day basis.

With legal substances, we screen out and discourage use by those people who might be susceptible to the detrimental effects of a particular substance. The packaged drug carries a message saying that it should not be used if a person has such-and such a problem, or if the person is using another particular substance. The person using a prohibited drug does not generally get this form of information, thereby increasing the risks they are likely to face.

Legal substances are administered into the body in a way that is designed to reduce untoward consequences, such as the spread of disease. Injecting drug users can contribute to the spread of blood-borne viruses such as HIV and hepatitis C by sharing needles, syringes and other injecting paraphernalia. Therefore, users in the UK are given access to clean injecting equipment – e.g. via treatment agencies, some pharmacies - to reduce the likelihood of blood-borne viruses being spread.

However, this harm reduction practice does not occur in other parts of the world, including a number of states in America. It is argued by some people that provision of clean needles and syringes encourages drug use. In essence, technology is being withheld in order to keep the risk of prohibited drug use high, in the hope it will deter use. This is morally wrong. The price of this approach is that people contract disease and die not because of the drug, but because of the social policy that prevents society from reducing risks associated with its use.

Harm reduction and harm minimisation techniques can be applied to the other points raised above, and in this country are applied to at least some extent. For example, warnings are put out if a particularly high purity sample of heroin is identified to be available on the street. At the same time, however, it is argued that if prohibited drugs were made legal, then issues of purity, adulterants, etc would become a thing of the past, because people would purchase heroin from a government-controlled source.

There is another major way that legal status affects the substance-using culture and the way that people behave and think. When a drug is classified as illegal or prohibited, a powerful social stigma develops that impacts on the emotions and behaviour of people who use the substance. This arises because of the attitudes of society towards users of prohibited drugs – drug users become stigmatised, stereotyped and prejudiced against. You can see an example of this prejudice in research that we have conducted.

Now at the end of this you may turn around and say, “Certain drugs are illegal, so people should not use them. The risks they face are at their own peril.’ On the other hand, you might be wondering why certain psychoactive drugs have been made illegal and whether the actions of the state are justified. Check out some of my early Background Briefings from Drink and Drugs News, which you can find on a related Blog.

[This Blog was inspired by a section in William L White’s book, ‘Pathways from the Culture of Addiction to the Culture of Recovery’]

8 comments:

Anonymous said...

PROHIBITION never works it just CAUSES CRIME & VIOLENCE. Illegal drugs are way easier for kids to get than legal ones. The USA spends $69 billion a year on the drug war, builds 900 new prison beds and hires 150 more correction officers every two weeks, arrests someone on a drug charge every 17 seconds, jails more people than any nation and has killed over 100,000 citizens because of the drug war. In 1914 when ALL DRUGS WERE LEGAL 1.3% of our population was addicted to drugs, today 1.3% of our population is STILL ADDICTED TO DRUGS. The only way to control drugs is to REGULATE THEM AND END THE PROFITS AVAILABLE TO CRIMINALS just like ending alcohol prohibition did. There’s only been one drug success story in history, tobacco, THE MOST DEADLY and one of the MOST ADDICTIVE drugs. Almost half the users quit because of REGULATION, ACCURATE INFORMATION AND MEDICAL TREATMENT. No one went to jail and no one got killed. JOIN EMAIL LIST, WATCH VIDEOS:
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Derek Williams said...

David

>>
I don’t get drawn into such arguments, Derek. There are plenty of people in the UK fighting hard for this policy.
>>

I wish there were, but sadly the number is very small.

Everything you say about doses and purity is true of course, by being prohibited the dangers of drugs - and hence the harm they cause - is indeed magnified many times.

There is also the general lack of control and regulation of the supply side. Frankly if you don't know who is selling stuff, where they're selling it from or indeed just what they're selling, then you can only react to the consequences of it all. If you don't control the supply of a substance, you can't even begin to control that substance.

But surely at the heart of what you want to do is the desire to treat the problem user as a casualty, a victim if you like, I don't see how you can do that whilst also regarding them as low-life scum, which is what a criminal is. There is a really important issue here.

Although I have never been a problem user, I have, lets say, seen things "from the other side" and I can't see how you can sit on the fence on this one. It's all about trust and if you're seen as really supporting those who have an agenda of law enforcement, how can you be trusted by the people whose trust you really need?

David Clark said...

Mmm, Derek,
Did I say that I support those who have an agenda of law enforcement?
And if I did not disagree with drug laws, are you saying that I (or anyone else) would not be trusted by those people who need help?
DC

Blair Anderson said...

"Injecting drug users can contribute to the spread of blood-borne viruses such as HIV and hepatitis C by sharing needles, syringes and other injecting paraphernalia."

Insofar as Needle Exchange and other harm reduction protocols ranging from shooting galleries and heroin on prescription have a focus on reducing prohibition consequences there is a sector that is consistently omitted from this discussion. The intersect of methamphetamine and other ATS's and risky sexual behaviors leading to HepC and HIV (and other STD's) is completely omitted from the harm reduction model. This is particularly evident in New Zealand where NEP's is du jour in the major centres (thanks to Dr John Dobson) but ANY mention of user orientated methamphetamine interventions brings institutionalized prejudice to the fore. Lessons from what was wrong with opiate management and is now mediated by appropriate health driven interventions is lost to the meth user, and thus the contingent harm on otherwise innocent public is a burden we never measure. Meanwhile all the mayhem associated with an illicit trade that has punishment set at 'mandatory' life, equivalent to premeditated murder fills body bag after body bag. None of this is created by the pharmacology of Meth. Both the prevalence of meth and the contingent harms from ignorance of the bio-psychosocial set and setting (esp in the gay community) puts a burden on everyone.

Meth harms AND prevalence are a product of a policy that sets out to solve the very problem it creates.

Again, in New Zealand, this is exacted under the Warrant of the Minister of Health. Could this be more perverse? In order to correct this we have to overturn the government and then convince the UN to butt out.

We have opened a can of worms and the worms are us.

Could we (collectively) be more foolish?

Peter O'Loughlin said...

David, your view that by making a drug illegal increases the risk of its use does not appear to apply to alcohol or nicotine, therefore I question your conclusion.

Alcohol use has escalated with increased promotion, availabiility and in real terms, reductions in price. On the other hand, smoking has reduced by a combination of health education and restrictions on where one can smoke.

Your statement that the risks of legal substances such as benzodiazepine are not contaminated is of course true, however that in no way reduces their addictive potential. On the contrary, virtually every anti-anxiety drug is potentially a drug of dependence or addiction. It is also a fact that in the majority of cases, where things have 'gone wrong' that providers have been permitted to conceal how badly, or to what extent.

Your comments that with legal substances we 'screen out and discourage use' among those more vulnerable to the side affects of legal drugs holds good only insofar as both the provider and user of the drug, exercise 'due care'. I've lost count of the number of people with alcohol problems who have been prescribed drugs which are contraindicated. Until quite recently 65% of doctors prescribing addictive legal substances did not know how to screen for alcohol, or other drug use, nor for that matter do the majority enquire too closely into such use. Nor is the potential for those who are misusing alcohol,or other drugs, to reveal the extent of their use very great. Therefore the potential for things 'going wrong' with legal addictive substances, are still very much with us.

Insofar as contamination of street drugs is concerned, I believe you are aware of the extensive Australian research, which assuming I have not misinterpreted, clearly shows that deaths arising from heroin, were mainly due to overdose, following a period of abstinence resulting in the users tolerance declining. Further that PM examinations of the heroin content in almost every case showed a purity to pharmaceutical standards.

Insofar as blood born diseases are concerned, it has to be noted that notwithstanding the availability of clean injecting materials, the levels of HIV among IDUs in the UK,since the start of the present decade, has increased to 1 in 75. Overall hepatitis C infections have increased with almost half of IDus infected. There has also been a marked increase (two thirds) in the number of IDUs receiving Hepatitis B vaccinations. (Health Protection Agency)

Attempts to decriminlise prohibited drug use with a view to reducing the total harms caused by measures such as reclassification in the case of cannabis, has also been shown to be ineffective. In fact the only 'evidence that its use has gone down comes from the unreliable British Crime Survey. However increased imports from Holland and the growth of cannabis factories in the UK strongly suggest otherwise.

The economics of legalising drugs fall apart under close scrutiny, not least because the most widely used are controlled by organised crime and Islamic forces of terror, now unless someone can devize how those organisations are willingly going to let go of their 'franchise', it follows that pharmaceutical companies licensed to manufacture such drugs would still have to get their raw materials from those scources. No doubt an accommodation could be reached wherby 'respectible front organisations' would be set upt to supply legal manufacturers. However since as you point out we attempt to 'screen out' those we believe should not use such drugs, that would leave an unfulfilled demand, which, in the absence of a remarkable change in their integrity, illegal drug dealers would seek to satisfy.

There is also the incontrovertible fact that diversionery use and abuse of prescription drugs is widespread and that many of the addictive pain killers which are should only be avaialble by prescription can and are easily obtained.

Finally we cannot deny the stigma attached to drug use by the majority of the general public. Much of that is due to their ignorance of why people use drugs in the first place, together with the fact that no one sets out to become addicted, Without 'educating' in a manner which would help them to identify drug use as a treatable mental and behavioural disoder, they wil continue to regard users with the same disgust and contempt, that many hold for drunks.

There is no simple or easy solution to alleviating the damage caused by the use of legal, or prohibited drugs, but we could focus more on recovery and prevention. The former is finally beginning to get the recognition it deserves. Sadly measures for prevention seem to lack a will of purpose. The supplies of illicit drugs entering UK grow year on year, whilst the percentage seizures appear to be diminishing. How could that be without a measure of connivance from the highest authorities in this country?

Derek Williams said...

David

>>
Mmm, Derek,
Did I say that I support those who have an agenda of law enforcement?
>>

No, to be fair you didn't and I don't think you ever have. Indeed from my reading – perhaps too much between the lines - you don't seem to.

>>
And if I did not disagree with drug laws, are you saying that I (or anyone else) would not be trusted by those people who need help?
>>

There's a few double negatives there! If you or others in the field agree with prohibition then basically I guess so, yes, I am saying that.

I think if I were in need I'd want to know that anyone I went to for help did not regard me as a criminal for doing the things that created the problem. Trust is about respect and you can't respect someone who regards you as a criminal.

I do accept (and this might surprise some) that for problem users the ultimate goal should be abstinence, even maybe has to be abstinence. But the only way to get there is for the person themselves to really want it. If they're forced into abstinence they will relapse at the earliest opportunity and as Peter wrote above:

>>
I believe you are aware of the extensive Australian research, which assuming I have not misinterpreted, clearly shows that deaths arising from heroin, were mainly due to overdose, following a period of abstinence resulting in the users tolerance declining.
>>

I have lost friends that way, which is why I oppose enforced abstinence. Prohibition is enforced abstinence and it kills.

I would disagree with Peter's claim that street drugs are anything like pure though. Even cannabis is frequently cut these days and street heroin is filthy stuff. Worse, the aim of the present prohibition policy is to decrease purity and to make street supplies less reliable. High levels of purity of illegal street drugs is used as an indicator that the policy is failing, proof if any were needed that prohibition is based on harm maximisation.

Methadone works as far as it goes because it helps keep people away from the street scene. I agree that is the most important first step, but (being careful not to generalise too much) it's not the best stuff to do it with more often than not.

The illegal trade prohibition has created is hard nosed capitalism, unrestrained exploitative profit driven supply and demand that feeds on the very people you want to help.

As with anything capitalist, if the demand falls, the trade withers. Kill the trade and you don't get new recruits. You don't kill the trade by upping it's profits, you do it by removing its customers and you do that by providing a reliable, better and above all legal alternative to those who need it.

In my experience big problems are solved by making them smaller. You make problems smaller by reducing the number of issues contributing to the problem, but prohibition does the exact opposite by adding, as you accept, many issues of its own.

Removing the fear of being without the fix is a good and I would argue important first step in helping chaotic users get their lives back. Not by forcing them into something they don't want, but by totally removing the desire to use the street trade.

Offering and showing people the way forward and letting them go at their pace is surely the best way to get results.

Over the past few days we've heard the word "recovery" quite a lot, not least of all from the likes of Annabel Goldie in Scotland. Sadly she and others like her use the term to mean enforcement lead abstinence, more and harder line prohibition. I would have thought that should make you very angry.

From reading your blog, David, I think you're genuine in your desire to help people recover and you seem to have a clear idea of what recovery means which I support. But if that word is taken by those who wish to promote hard line prohibition, you and people like you will have been used. That's why I argue you need to be very clear not only what recovery means, but also what it doesn't mean.

David Clark said...

Absolutely key last paragraph Derek.
I am sincere in my desire to help. And I am very clear that our agenda will be seized, hijacked, etc for other people's purposes. These will not just take the form of effect that you have eluded to, but other forms as well. It is already happening in several directions.
Over time, I will continue to make it as clear as I can what we mean by recovery and what it takes, etc. I am sure that other people will put their own interpretation on recovery, and on what WIred In says recovery is. So I will just have to keep stating what we believe.
Let me be aware, criminalising drug users does not help people overcome drug problems, it does not facilitate recovery.
However, decriminalising all drug use will not lead to the disappearance of the so-called drug problem.
Placing the treatment system within the criminal justice sector is totally wrong. It sends out completely the wrong message and demonstrates a clear prejudical attitude of government. I would be delighted to argue this case to Gordon Brown, David Cameron and Nick Clegg if they would give me some of their time.

Peter O'Loughlin said...

Derek,

If i might intervene on the matter of purity, what I said is not my claim but the outome and conclusions from extensive Australian research. I'm simply carrying that message.

Anyone in the recovery business who regards 'problem users as criminals is in the wrong business. We do not have the right to judge others. We do have a responsibility to help them achieve recovery, if that is what they want.

Yes, you are right abstinence is the only option for 'problem users'. In fact it is the inevetiable outcome of such a condition, it is only a question of whether it occurs by choice, death or insanity.