9th July 2021
The publication of the second phase of Dame Carol Black’s Independent Review of Drugs will, hopefully, mark a sea-change in approaches to treatment in this country. The report pulls no punches in describing the extent to which funding has been slashed in recent years, and it makes a call for an additional £550 million to be allocated to treatment over the next five years - bringing spending back to 2012 levels. Though even if the UK Government does agree to this additional funding - and we sincerely hope they do - it is worth comparing with the Scottish Government’s commitment to an additional £250 million over the same time period, for a much smaller population.
The report also calls for an overhaul of quality oversight, commissioning models and workforce development. All of which are urgently needed. The drug (and alcohol) treatment sector has been shamefully neglected in recent years, contributing to the appalling increases in drug-related deaths that we have witnessed over the same period. Carol Black is clearly committed to addressing the problems in the sector, and to improving the lives and prospects of those who need support for drug-related problems.
However, the report is disappointing in other respects. Unlike the Phase 1 review, which laid out in forensic detail the scale and impact of drug markets, this review is light on the evidence it brings to bear. It notes that key, evidence-based approaches such as Housing First are vital to holistic treatment approaches, but while calling for expansion of this model the body of the report, Housing First doesn’t make it into the actual recommendations.
The report makes a strong call for the expansion of police drug diversions schemes, which are increasingly accepted as the right approach across Government. A more detailed discussion on how best to integrate such schemes with treatment would have been helpful. The passing mention of mandated treatment programmes (which Dame Black herself criticised in detail previously) feels like a missed opportunity to highlight the real challenge of how to divert from criminal justice while not exchanging prison for ineffective and enforced treatment. The discussion of prevention programmes also lacks depth – correctly noting that the evidence for effective schools prevention is weak but adding little detail on what we know works, and what doesn’t. The risk of calling for an evidence-based campaign of behaviour change without clearly describing the evidence-base is that Governments may well be tempted to fall back into ineffective ‘Just say no’ type programmes, which amount to little more than shallow, and stigmatising, moral signalling.
The report avoids any discussion of key harm reduction interventions such as heroin assisted treatment, overdose prevention centres or drug checking. While these are not core elements of the drug treatment system, they do address the needs of some of the most vulnerable and hard-to-treat populations. It reflects the limitations of the report that it doesn’t touch on these options, even to acknowledge them as important areas of inquiry or as examples of the kinds of innovation that the report elsewhere demands.
Of course, the elephant in the room for both this and the first review is that Dame Carol was prevented from considering the role of the legal framework in creating, exacerbating or mitigating the harms her reports address. So, while discussing the huge costs of policing and imprisonment in Phase 1, she was not able to consider how criminalisation caused those harms. Similarly, in Phase 2, there is no mention of the extent to which criminalisation exacerbates mental health harms and undermines life chances (the word ‘criminalisation’ does not feature even once). There is no consideration of how illegal markets lead to the widespread promotion of the strongest and most addictive forms of drugs; or how many of the deaths due to adulteration or unknown potency are a consequence of the market being entirely unregulated.
The report does go beyond a focus on treatment to briefly discuss ‘recreational’ drug use, and the need for Government action to tackle this. In doing so, it strongly asserts that ‘most people who use recreational drugs don’t think they have a problem’. However, the reason for this is simple, and very well-evidenced: most people who use recreational drugs don’t have a problem - in the sense of a substance use disorder that requires treatment. Of course, many do experience addiction, at similar rates to those who become dependent on alcohol, and their needs are the proper focus of the report. As the report says, without any use there would be no dependency - but the same is true for alcohol. For the rest, the problem they face is – specifically – the fact that the drugs involved are (unlike alcohol) illegal. That many substance use problems arise from polydrug consumption (very often including alcohol) is also not discussed in depth; nor is the important challenge of how to most effectively align alcohol and other drug treatment services.
Dame Carol’s hands were tied in regard to the scope of this review. The remit was explicitly to discuss drug markets, treatment and prevention … but without mentioning the law. As we have said before, this is like reviewing climate change without being allowed to discuss carbon emissions. To this degree, it is inevitable that the report – while containing much that is vital, humane and compassionate in regards to the urgent need for better treatment funding and infrastructure – is rendered somewhat absurd when touching on wider drivers of harm.
The Government response to the call for a cross departmental unit to reduce drug harms has been swift. Unfortunately, naming it the ‘Joint Combating Drugs Unit’ and housing it in the Home Office, points to a continuing belief that a ‘war on drugs’ style approach will achieve what it has signally failed to achieve previously. It is, by any measure, peculiar to respond to a report on the best treatment of a health problem by establishing a unit led by a Minister for Policing. Can anyone imagine a ‘Joint Combating Alcohol Unit’ – despite the fact that alcohol (legal status aside) carries far more risks than many of the substances this unit will focus on. We are also left to wonder how this new unit will differ in practice from its predecessor - the cross-departmental Drug Strategy Board - which similarly oversaw an enforcement, not health, led approach.
The absurdity of all this has only been highlighted further by the publication of a review which, by necessity, has to swerve awkwardly around a fundamental dimension of the problem it seeks to address. It makes it even harder for heads to remain buried in the sand.
If we are serious about reducing drug harms in the long run, we need a root and branch review of the law: a Phase 3 of this series of studies which finally, seriously, and without blinkers looks at the evidence on the impact of prohibition on harm, the innovations in policy and law that are emerging across the globe, and the real options for alternative legal approaches.
This is what we at Transform have been calling for to mark the 50th anniversary of the Misuse of Drugs Act. If you agree, and want to help push this issue forward, please get involved and encourage your MP to join the many Parliamentarians already backing the growing call for reform.