Scotlands Drug Problem

Report of a conference organised by the Royal Society of Edinburgh Tuesday 27 May 2003

SCOTLANDS DRUG PROBLEM

ACKNOWLEDGEMENTS

The Royal Society of Edinburgh would like to thank the following people and organisations :

ORGANISING COMMITTEE
Professor John Beck, FRSE Programme Convenor, The Royal Society Edinburgh Professor Robert Kendall CBE FRSE Honorary Professor of Psychiatry, University of Edinburgh, Former Chief Medical Officer, The Scottish Office. Sadly Professor Kendall passed away in December 2002. The Royal Society of Edinburgh would like to express their deeply felt gratitude to Professor Kendall who was the main inspiration and driving force behind this event Professor Neil McKeganey Director, Centre for Drug Misuse Research, University of Glasgow

SPONSORS

A ROYAL SOCIETY OF EDINBURGH CONFERENCE. 27 M AY 2003

CONTENTS
INTRODUCTION ................................................................................... 3 THE SCOTTISH SCENE ............................................................................ 5
Mr Hugh Henry MSP Deputy Minister for Justice, Scottish Executive Professor Neil McKeganey Director, Centre for Drug Misuse Research, Glasgow What kinds of drugs are being used? What kinds of people are using them? What damage is this causing? How widespread is the problem and is it growing?

A CHOICE OF EVILS: POLICY OPTIONS

Professor Alan Maynard University of York

IN THE ILLICIT

DRUG MARKET ................ 6

THE DUTCH EXPERIMENT ........................................................................ 7

Mr Robert Keizer Head of Addiction Policy Division, Dutch Ministry of Health and Welfare. The 1970s Dutch legislation enabling the establishment of cannabis cafes and the subsequent consequences, good and ill, of this.

AN INTERNATIONAL PERSPECTIVE ON DRUGS POLICY ..................................... 8

Dr Peter Reuter Professor of Criminology and Criminal Justice, University of Maryland USA What an evidence based national drugs policy might look like.

THE ROLE

OF THE

POLICE ....................................................................... 9

Mr Richard Brunstrom Chief Constable, North Wales Police The drug debate; time for change.

THE EUROPEAN SCENE ......................................................................... 10

Mr Richard Hartnoll European Drug Consultant The Prevalence of and trends in drug abuse in different European countries and how the UK compares with these.

DEMONISING DRUGS THE ATTITUDE

Dr Magnus Linklater FRSE

OF THE

MEDIA .................................... 11

CONCLUSION ................................................................................... 12 THE ROYAL SOCIETY OF EDINBURGH ........................................................ 13

SCOTLANDS DRUG PROBLEM

It has become inescapably clear to us that the eradication of drug use is not achievable and not therefore either a realistic or sensible goal of public policy.
Report of the Independent Inquiry into the Misuse of Drugs Act, established by the Police Foundation and chaired by Viscountess Runciman 2000.

A ROYAL SOCIETY OF EDINBURGH CONFERENCE. 27 M AY 2003 INTRODUCTION

Modern society is engaged in what is often seen as being a war against illegal drugs. It is a war that has created many casualties. Drugs can destroy the lives of those who take them, they devastate communities where drug taking is rife, they create a wave of crime across the country and are a drain on public services and on the public purse. It is also a war that some believe can never be won. People who take this view believe that change is essential to help minimise the misery caused by

drug taking. But what sort of change is needed? Does the answer lie in greater liberalisation of illegal drugs? What evidence exists of effective interventions? What obstacles lie in the path of progress? The Royal Society of Edinburgh brought together a group of experts from the UK and overseas to examine how best to respond to the drug problem and to identify the best way forward. This report summarises the main presentations and the conclusions of the Conference.

SCOTLANDS DRUG PROBLEM

A ROYAL SOCIETY OF EDINBURGH CONFERENCE. 27 M AY 2003

THE SCOTTISH SCENE

The Deputy Minister for Justice at the Scottish Executive, Mr Hugh Henry MSP, opened the Conference by welcoming the delegates, particularly those from other parts of the UK and abroad. The Minister provided an overview of drugs policy in Scotland. He explained that it is designed to reduce the amount of drugs available on the streets through a range of enforcement activities, whilst also working to reduce the demand for them. However, he emphasised that a policy based solely on limiting the supply of drugs will not solve the problem. Demand is being tackled by educating and informing young people about the dangers of drugs (eg through the Know the Score campaign) to prevent them taking up the habit, helping communities affected by the impact of drugs, and providing treatment and rehabilitation for those already addicted. He identified the twenty two locallybased Drug Action Teams in Scotland as a key element in the policy. This is the way forward having a suite of national strategic objectives that incorporate local partnership delivery mechanisms. We have considerable scope to design and implement solutions in Scotland and, as an Executive, we continue to be open to new ideas. Mr Henry said that treatment works. For every 1 spent on treatment, over 3 is saved in other areas such as in the courts or the health service. Scotland has been improving the services it offers to drug users, supported, The Deputy Minister said, by record levels of investment by the Executive, but he accepted that, in many areas, waiting times for treatment and rehabilitation are still unacceptably long. He said he was interested in new developments elsewhere, such as the legal

prescription of heroin. Although the Executive has no current plans to introduce this in Scotland, we should not rule out a treatment which might improve the health and rehabilitation of a small minority of patients for whom all other approaches had failed, Mr Henry said. The Executive is keeping in touch with progress with the pilot schemes south of the border. Among the obstacles to progress are the strong opinions which are held about drugs policy by members of the public, the media, those engaged in the drugs field and by politicians. Instant solutions are often put forward that are unworkable. Media coverage can be sensationalist and unbalanced. Simple solutions will not work, said Mr Henry. A one-size-fits-all policy will just drive us to failure. We need to recognise that we work in a very difficult, complex environment. The problems which Scotland is facing are no different than in many other nations, and he hoped that the delegates would share experience and expertise, both within the UK and internationally. In a question session after his presentation, Mr Henry was asked about the attitude of the Scottish Executive to other developments such as safe injecting rooms. Mr Henry said that the Executive is willing to look at approaches which are backed by robust research and success, but there is currently a lack of evidence to support the benefits of injecting rooms. Figures on the extent of illegal drug use in Scotland were presented by Professor Neil McKeganey, Director of the Centre for Drug Misuse Research at the University of Glasgow. Recent research has established that there are around 56,000 heroin users in Scotland which, is considerably higher than the previous best estimate of 30,000. There

SCOTLANDS DRUG PROBLEM

are more than 300 drug-related deaths a year. Professor McKeganey stressed that it is important to see this in perspective. The impression often given by the media is that everyone in Scotland is taking illegal drugs all the time and such attitudes can lead to defeatism. The reality is that problem drug use remains confined to a relatively small proportion of the population of around 1-2%. In addition, drug use is always changing and can reduce as well as increase. Cannabis use among people in Scotland fell from 8.2% in 1996 to 5.5% in 2000 and similar reductions have occurred with many other drugs, with the exception of heroin. Heroin remains the biggest problem in Scotland, while use of cocaine and crack cocaine is increasing. Crime is the main means of obtaining money for drugs. A survey of people arrested for a variety of offences in Scotland found that 80% had used illegal drugs and nearly a third had used heroin. There are also health and social consequences. There are high rates of hepatitis C infection among drug users in Scotland and between 40,000 and 58,000 children are growing up in homes where one or more parents is addicted. Public attitudes are also changing. Findings from the Scottish Social Attitudes surveyed show that support for the legalisation of cannabis has increased from 15% in 1983 to 37% in 2001. There is greater support for drug users to be given help, with 62% of people supporting the supply of clean injecting equipment, 47% who believe young people should be told to use drugs more safely and 25% who support doctors being able to prescribe to addicts. There is also strong public support for tough action against people who sell drugs and 70% believe users should be prosecuted for dealing cannabis, 91% for dealing ecstasy and 96% for heroin. Professor McKeganey said people who live in communities affected by drugs have their own answers. Research in Lanarkshire which asked people what they wanted done found that the response was kill the junkies. He said such views are uncomfortable but had to be listened to. They came from people who did not think that existing services were responding to the problems that drugs were causing in their neighbourhood. Professor McKeganey listed the drug policies four main aims of to help those addicted to drugs; to reduce the number of people starting to use drugs; to punish those profiting from drugs and to protect those whose lives are being ruined by drugs. It is easy to deliver on some of these, but difficult to deliver on all four. We have to move forward with an equal emphasis on all four of these. We swing unhelpfully between the polarity of treatment and the polarity of criminal justice. I think at the moment we are in a position where we have underemphasised certain of these priorities.

A CHOICE OF EVILS: POLICY OPTIONS

IN THE ILLICIT

DRUG MARKET

The choices facing policy makers were examined by Professor Alan Maynard of the University of York. He said they represented choices between different evils: in effect the continuation of current policies which have created a huge crime problem and much attendant misery, or a

move to greater liberalisation and regulation which may reduce crime but create a larger health problem. He questioned why so much public money, attention and effort is currently devoted to a drug problem which constitutes such a small health threat. The 500 drug-related deaths a year

A ROYAL SOCIETY OF EDINBURGH CONFERENCE. 27 M AY 2003

are dwarfed by the 100,000 deaths caused by smoking cigarettes and the 5,000-25,000 related to alcohol use. The main threat at the moment is posed by criminal activity, but liberalisation would take the market in drugs out of the hands of criminals. It could result in a state monopoly in heroin and produce tax revenues for the Treasury, leading to better treatment services. The risk is that such an approach may increase the use of substances that are currently illegal. However, any such moves in this direction may be constrained by United Nations treaties which bind individual countries to restrictive policies favoured by the United States. The key issue highlighted by Professor Maynard was that whatever decisions are taken, they have to be based on evidence. He described his presentation as a tale of frustration due to the lack of evaluation carried out into the effectiveness of drug strategies. We do not know what works, yet we are constantly changing our policy. In all our societies, we are pouring money in. The politicians will tell us it is working but they never evaluate. Our evidence base is very poor and growing very slowly. Every reform is a social experiment on the communities we are trying to help. The problem is very simple why is it we know so little, why is it we continue to adhere to these policies? Why are we not prepared to be more scientific in evaluating what we are doing? It is time to stop squandering taxpayers money on untested schemes based on hope rather than evidence. Professor Maynard said the people who are benefiting from our current ignorance are the drug dealers, who are making fortunes out of the misery of others. The lack of knowledge about what is effective does nothing to improve the help that can be given to addicts and their families. He ended by saying that politicians like to innovate but their innovation tends to be the adoption of untested policies in an attempt to be seen to be doing something about a particular problem. He then quoted a line from the popular television comedy series Yes Minister: Ministers need activity. It is their substitute for achievement.

THE DUTCH EXPERIMENT

Robert Keizer, Senior Drug Policy Advisor of the Dutch Ministry of Health, said that the Netherlands has concluded that achieving a drugs-free society is not a realistic option. Consequently, policy is directed at preventing harm to users, those around them and the wider society. It is focused on restricting demand through care and prevention, restricting supply through tackling organised crime and restricting drug related nuisance. That has resulted in significant liberalisation of drug use in the Netherlands, dating back to the 1970s. Although cannabis use remains technically illegal, coffee shops which sell the drug in quantities of up to 5g per day per client are not prosecuted. This policy has been introduced to prevent people having to buy cannabis from drug dealers and coming into contact with more dangerous drugs. In addition, the Netherlands has an extensive programme of harm reduction, based on methadone programmes, needle exchanges, safe injecting rooms, counselling and medical help. Mr Keizer said that drug use in the Netherlands today is not significantly

SCOTLANDS DRUG PROBLEM

different from surrounding countries, in spite of the fact that cannabis has been freely available for sale for 30 years. There are between 25,000 to 40,000 drug addicts in the Netherlands and the number has been stable for 10 years. There are 2.6 drug addicts per 1000 population in the Netherlands, compared with 6.7 in the UK, 4.3 in France, 4.7 in Sweden and 7.8 in Italy. Mortality is low, with around 80 drugrelated deaths a year. Up to 80% of addicts are in contact with the health system and their average age is 41-42. There are hardly any young people in this group of problem users. However, there are problems. The use of certain drugs, particularly cocaine, is increasing, the health of older drug addicts is deteriorating and nuisance continues to be caused by drug use. There is also concern about the Netherlands being a centre for the production and distribution of drugs and continuing international criticism of its liberal drug policies. Mr Keizer said these problems are all being addressed in various ways. Social hostels, new forms of clinics and experiments with forcible treatment have all been introduced to reduce the nuisance surrounding drug use. The number of coffee shops has also been reduced by 25% since 1997 and new limits introduced on the amount they can sell, which is down from 30g to 5g. In conclusion, he said the cannabis policy in the Netherlands had not led to an increase in hard drug use. Harm reduction also pays off in helping to reduce drug- related mortality and morbidity. A good drugs policy must be consistent, workable and understandable, he said. It must consist of an interplay between practice, science and politics. At the moment, politics are dominating the drugs debate. The only solution is that practice and science must contribute more to develop workable policy models.

AN INTERNATIONAL PERSPECTIVE ON DRUGS POLICY

Dr Peter Reuter, Professor of Public Policy and Criminology at the University of Maryland, examined the diversity of drug policies adopted by advanced western countries. There are liberal policies in the Netherlands and Australia, heroin maintenance in Switzerland and the decriminalisation of possession of drugs in Italy, Portugal and Spain, amongst other countries. On the other hand, the U.S and Sweden remain dedicated to tough use of criminal sanctions against drug use as well as against small-scale trafficking. However, there is no correlation between rates of drug use and national policies. There is also discontent with policies that are harsh, intrusive, expensive and inhumane, but great resistance in some countries,

particularly the United States, to experimentation. Countries are trying to learn from each other, but the lessons that are drawn from experience elsewhere are usually extremely crude. Dr Reuter used the experience in Switzerland with heroin prescription as an example. The Swiss responded to a growing heroin problem by creating a no crime zone in Zurich, where small amounts of any illicit drug could be bought and sold without fear of prosecution. This led eventually to a political decision to experiment with heroin prescription. The trial was deemed by Switzerland to be a success and heroin maintenance was introduced for addicts who meet certain criteria. They can self-inject up

A ROYAL SOCIETY OF EDINBURGH CONFERENCE. 27 M AY 2003

to three times a day in a doctors surgery and there is no limit on the dose they can receive. Dr Reuter questioned whether this was medical practice rather than social control designed to reduce the nuisance of drug use. It has managed to keep people in treatment and has had a surprising additional effect. Most of the people who have left the programme have gone on to other forms of treatment, either methadone maintenance or abstinence. Dr Reuter questioned why people who had easy access to all the heroin they could ever want would end up leaving such a programme. This is a population that has spent all their adult lives in pursuit of heroin. Once they are given what they have always wanted, they find it does not make them happy and they are forced to confront other aspects of their lives. Providing them with heroin may, in fact, be the most effective way of getting them to do something about their drug habit. The International Narcotics Control Board have condemned what has been done in Switzerland, but trials of heroin prescription are now running in the Netherlands and Germany and are being considered elsewhere. However, Dr Reuter added that it does not follow that success in one country can be replicated in another. There are difficulties in drawing conclusions based on national experience and much more evaluation is needed if countries are to learn from the experience of others.

THE ROLE

OF THE

POLICE
through. This is a cast iron, rock solid social security system for organised criminals. This cannot be a sensible policy, argued Chief Constable Brunstrom. The choice is between continuing with the international regime of proscription or regulating the supply and use of drugs. I think the evidence is increasingly strong that proscription will not and cannot work. I believe it is a sterile policy. We have got to take the criminality out of this and focus on the social causes, said Chief Constable Brunstrom. Tobacco is a more dangerous and addictive drug and we have managed to reduce tobacco dependency over time. We may be able to do the same with these illicit substances. He called for drug users to be treated as victims rather than criminals and for them to be given treatment rather than imprisonment. Heroin prescription is supported by the Association of Chief Police Officers and Chief Constable Brunstrom described it

Richard Brunstrom, the Chief Constable of North Wales Police, presented an argument for radical change that would take drugs out of the hands of criminals and reduce the appalling social consequences of current drug use. He said he wanted to see a policy based on principle, not on expediency, and called for better leadership from politicians. He described current legislation as illogical, unethical, counterproductive and untenable. It has managed to create an 8 billion a year trade in illegal drugs in the UK, with all this money going into the pockets of criminals. The global trade in drugs is estimated to be worth $400 billion, which is more than the total worldwide trade in petroleum. Almost half of all crime in the UK is drugsrelated and the cost to society has been put at 18.8 billion - 850 a year for every household in England and Wales. Although drug seizures have increased, 90% of drugs still get

SCOTLANDS DRUG PROBLEM

as an absolute must to help stem the tidal wave of crime affecting our communities. He also said that policies have to be logical. Solvents kill more people than ecstasy but can be bought over the counter. Equally, he said the risk from taking ecstasy is minimal compared with that of alcohol which is widely available. Chief Constable Brunstrom called for a mature debate to be conducted in Britain about drugs policy. There is no doubt that there is a significant groundswell of opinion that believes the current policy is untenable. Politicians need encouragement and support. They need people like us to stand up and be counted. I think there is a readiness in our society to have a mature debate on this issue.

THE EUROPEAN SCENE

Figures presented by Richard Hartnoll, a European Drugs Consultant, show considerable diversity in rates of prevalence across Europe, but there is no clear relationship between policy initiatives and prevalence levels. Prevalence is high in some countries with liberal policies and low in others and the same is true for countries that take a harder anti-drugs approach. When you map policies with levels of use you are left with a rather arbitrary pattern, said Mr Hartnoll. I really cannot find any consistent pattern of policy affecting drug use. However, patterns do emerge when differences within countries rather than between countries are studied. Then it becomes clear that drug use is more common in urban rather than rural areas and among particular groups of people. Unmarried males under 25 with no children are 80% more likely to have taken cannabis than married men with children. He said there are very clear demographic trends that can explain increased drug use. Amsterdam, for instance, has a high proportion of single people with high

disposable incomes who provide a ready market for drugs. These trends together with other factors such as geographical location of drug supply routes, explain more about drug use prevalence than any policy or intervention, added Mr Hartnoll. Last year up to 20 million people in Europe used an illegal drug, but 5% of these people accounted for 90% of the health costs. This sub-group of problem injectors is also likely to have been responsible for most of the drug related crime. Mr Hartnoll said it is a waste of time to develop policies to try to reduce prevalence. Where they can have an effect is in reducing the adverse consequences of drug use. That has been borne out by action taken in the UK in the 1980s, when drug users were supplied with clean needles in an attempt to prevent the spread of HIV. That policy has proved to be effective and the UK has the lowest rate of HIVinfected drug users in Europe, despite having some of the highest rates of drug use.

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A ROYAL SOCIETY OF EDINBURGH CONFERENCE. 27 M AY 2003

DEMONISING DRUGS THE ATTITUDE
OF THE

MEDIA

The media has played a central role in demonising drugs and drug users, said Magnus Linklater, one of Scotlands leading journalists and a former editor of The Scotsman newspaper. The broadsheet papers and the middle market tabloids have made drugs the middle class scare story of our time, he said. The cumulative effect of this kind of coverage has made it harder to tackle the drugs problem at its roots. People who advocate treatment rather than punishment are seen by sections of the media as encouraging drug use and undermining society. It was not always like this. Mr Linklater reflected on his time at The Scotsman when the paper supported the liberal and pragmatic policy of supplying clean injecting equipment to drug users to stem the spread of HIV. However since then, more and more English-based newspapers have introduced Scottish editions, bringing with them a different set of political views and a much more critical stance

on many issues. The media is influential in shaping policy largely because politicians want to have the media on their side. Mr Linklater said that treatment at every level is the right approach and tackling the problem of drugs also means tackling deprivation. Success will not be achieved easily or quickly and that is a hard message for both politicians and the media to grasp. We in the media tend to deal in simplicities so, I think, do Ministers. There are grounds for optimism, however. Complex messages about drugs can be accepted by the public if they are clearly stated and if Ministers unite behind them. It requires qualities of clarity and leadership. The media does not like running behind public opinion and if politicians are clear about the policy they want to follow the media may become not the enemy of drug control but the protagonists of it.

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SCOTLANDS DRUG PROBLEM

CONCLUSION

The conference expressed clear dissatisfaction with and frustration at the current position, which has left society paying a heavy price for its decision to declare certain substances to be illegal. It leaves too many drug users without help or support, creates havoc in our communities, drains resources and powers a crime wave that profits only the criminals who have caused it. There are powerful arguments in favour of considering some alternatives. But what alternatives? There appears to be no relationship between policy interventions and prevalence. There is a clear need for more evaluation to gather firm evidence about what works. What should be done in the meantime? Chief Constable Brunstrom believes Britain may be ready to have a mature debate on what it should do about drugs. Professor McKeganey, in his summing up of the days proceed-

ings, echoed that view. He also said there needs to be a greater willingness to experiment. The importance of treatment was emphasised throughout the conference, but Professor McKeganey said that has to mean more than methadone. It should include a trial in Scotland of heroin prescription and other initiatives such as the establishment of safe injecting rooms. He said recovery from drug addiction is not impossible. There is a way out of drug addiction. We must do all we can to help people find that way out. That may also be true for society at large. The conference was clear that there must be a better way than the one we have at the moment. The best choice for the future may be greater regulation. We need our politicians to be brave enough to examine the options. That can start with an open and honest debate.

This report reflects opinions expressed by participants in a specific event. It does not, however, necessarily represent the views of the RSE Council, nor the Societys Fellowship.

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A ROYAL SOCIETY OF EDINBURGH SYMPOSIUM . 27 M AY 2003

THE ROYAL SOCIETY OF EDINBURGH

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Scotlands Drug Problem The Royal Society of Edinburgh ISBN 0902198 73 4 May 2003
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