The time was long overdue for looking at alternatives to a criminal justice-based approach to drugs, heard delegates at the Royal College of GPs and Addiction Professionals online conference.
‘We’d all much prefer to be wise before the event,’ chair of the Independent Advisory Panel on Deaths in Custody (IAPDC), Juliet Lyon, told the Managing drug and alcohol problems in primary care conference. When it came to reducing drug-related deaths in custody settings there ‘could be a much greater use of harm reduction initiatives, and a much better dissemination of recommendations’ following a death – ‘to learn what could have been done and apply that’.
Her panel – which advises the Home Office, DHSC and the Ministry of Justice – had recently produced a report concluding that it was vital to take a whole-systems approach to deaths in custody (www.drinkanddrugsnews.com/whole-system-approach-needed-to-tackle-prison-drug-deaths). There needed to be a better database for understanding the extent of the problem, as well as improved court-based liaison and diversion services when it came to sentencing. While community sentences with treatment requirements had been on the statute book for decades they remained ‘spectacularly under-used’, she said. There was a problem in terms of both magistrates’ confidence around them and availability. Magistrates ‘would say these things aren’t available in our area or we simply don’t have enough information. It’s a terrifically wasted opportunity.’
A letter from a prisoner had pointed out that any attempt to tackle alcohol and drug-related deaths in custody would need to address ‘many aspects’ of prison life. ‘It’s the overall context in which people are living, and of course this has been exacerbated massively by COVID. The kind of desperation we’ve been seeing, the crushing boredom, living 23 hours a day in a six-by-nine cell often shared with a stranger.’ It was clear why people would turn to ‘any substance’ to try to block this out, she said. Unless someone had gone through it they could ‘never comprehend’ it, the letter had stressed.
‘We haven’t yet created a safe environment, that’s responsive to the often very vulnerable people who live within it,’ she said. ‘If we focus too narrowly then we’ll miss something that’s hugely important and we won’t reach our aim of reducing the level of deaths in custody.’
More than Treatment
‘It’s much wider than just a treatment need,’ agreed chair of the RCGP’s secure environments group, Caroline Watson. ‘It’s that holistic health, housing and employment need that will stop the cycle of people coming in and out of custody related to their substance misuse.’ Short sentences for drug-related acquisitive crime meant there was very little time for meaningful rehabilitation work, and in the prison where she worked prisoners were released into a number of counties, she said. ‘Multiple locations, multiple services, short times in prison, a transient population and multiple providers.’
Coordinated communication between services was vital, she stressed. ‘We need to build trust and connections not only between people in treatment and providers, but also between the staff of different providers.’ Group work had been badly affected by a prison regime that had locked down for far longer than the wider community, and lack of meaningful activity remained a key driver of prison drug use. Pilots of long-acting buprenorphine – either weekly or monthly injections – were helping to give people an opportunity to connect with community services on release and lessening the risk of dropping out.
When it came to reducing demand, many prisons had enhanced airport-like security and trained drug dogs, partly to address the issue of staff bringing in drugs. ‘But people are ingenious and prisons are being targeted as institutions where serious money can be made,’ said Lyon. ‘The x-ray scanners have proved useful but engaging people in something that provides a bit of hope and sense of future is much more important. I think too often people think that because you’ve got someone detained it’s a brilliant treatment opportunity, and it can be. But the mistake is when the courts see it as a potential treatment centre.’
This was ‘frankly disastrous’, she said, given the pressures on the prison service, very low levels of staffing, overcrowding and extension of remand. ‘It’s the last place one would see as a treatment centre, either for substance misuse or mental health. It’s really important that the courts get a sense that there are real options in the community that work very much better for people who are just getting pulled into the criminal justice system.’
Public Health Approach
Although the Scottish Drugs Deaths Taskforce’s role was to focus on the recommendations it could make within the current law, said Dr Catriona Matheson, its chair and professor of substance use at the University of Stirling, it was clear that ‘we need to move towards a public health approach and away from this crime and punishment angle’. That would ‘allow us to treat people with dignity and respect and help them to thrive. We need to talk about changing the culture around the law and asking the fundamental question – why are we criminalising people with complex needs who experience serious disadvantage?’
The arguments for decriminalisation were based on looking at the failings of criminalisation, senior policy analyst at Transform, Steve Rolles, told the conference. ‘The concept of the deterrent sits at the heart of UK policy, but criminalisation is not an effective deterrent. The evidence is simply not there.’ Criminalisation was, however, actively harmful, with the burden falling most on marginalised and vulnerable communities. It could also increase health harms as people were reluctant to approach treatment or emergency services, and it pushed drug use into higher risk, unhygienic environments.
‘We’ve issued 3m criminal records since the Misuse of Drugs Act was brought into force in 1971,’ said Release executive director, Niamh Eastwood. ‘Criminalisation undermines health, creates further harms and contributes to further inequalities.’ Those targeted by drug law enforcement were mainly young people, people of colour – particularly black people – and those living on the margins, such as people who were street homeless and didn’t have private spaces to use drugs. ‘So while drug use is ubiquitous, drug law enforcement is not. This really matters when it comes to policing,’ with the vast majority of stop and searches carried out on the street related to drugs – primarily possession offences for personal use.
The stigma linked to criminalisation was also hugely powerful. More than half of people who died a drug-related death in England and Wales hadn’t been in contact with treatment services for the last five years, she said. ‘You have to ask why. When you are first and foremost seen as a criminal you are less likely to access the treatment services you may need.’
In the past five years, almost 6,500 people in England and Wales had been sent to prison for possession of a controlled drug, with nearly 80 per cent never convicted of drug possession before. When decriminalisation models were done well, with investment in treatment and harm reduction, then ‘we can see really positive outcomes. An environment where you don’t treat people like criminals means it’s much more likely they’ll access the support they need.’
Drug diversion schemes were now in place in some form across around 12 police authorities in the UK, however, said Rolles. ‘It’s in the new drug strategy, it’s one of the Ds in the government’s flagship ADDER scheme, it was recommended in the Carol Black review. The government doesn’t particularly like to talk about it, certainly as a form of decriminalisation, but it does seem to be edging towards becoming national policy, and the better schemes can be seen as a form of de facto decriminalisation. The good ones are largely indistinguishable from the experience you’d have if you were caught in possession in Portugal.’
So what were the obstacles to wider change? ‘Why are we only limping towards decriminalisation when so many other countries support it?’ he said. Simplistic drug war narratives were still persuasive in the public domain and needed to be challenged, and there was also lack of engagement from key professional groups. ‘Doctors, GPs, medical professionals have an authority in the public and political debate. Unlike politicians or journalists, they’re trusted voices, and when they speak out for change people listen.’
They needed to use their voice to advocate for change, he urged, and while some of the royal colleges supported decriminalisation, other organisations had no public position on it. ‘It’s just not good enough. If you don’t have a position on decriminalisation by default you tacitly support criminalisation of a key vulnerable population.’