The original aim of this study was to look at the drug-using careers of a group of heroin users in a fairly small south coast town. However, very early in the study it became obvious that the group's drug use was dependent on the supply or distribution systems or heroin- oi.Crating m the town, and that these supply networks were themselves affected or changed through police action. The study therefore focused on the effects of police interventions into supply networks on the harmfulness of users' behaviour.
The Health District studied was a mixture of urban and rural communities, predominantly white and middle class, and had a population of just under a quarter of a million (of whom half live in the main town of the district: Worthing). As a result of its reputation 'as a retirement centre the population distribution shows a disproportionate number of elderly residents. However, in spite of this, or perhaps because of this, the district has had a significant heroin problem since the late 1960s, until recently largely ignored by authority and unnoticed by residents.
The heroin users in this study were not of course a homogeneous group, but some common characteristics could be identified: they were mostly male, in their late twenties to early forties (peaking around the rnid-thirties), had worked their way through the spectrum of drugs, finishing up with heroin, were all injectors and had been using heroin for a number of years. They were a group that was born and bred in Worthing, went to school together, started using drugs together and finished up using opiates together. As a consequence of this there were, as one might suspect, strong social and friendship bonds between the cohort members.
The overlapping catchment areas of the two treatment agencies — DAIS and Options — has meant that the heroin users present to either agency; the two agencies have developed long-term helping or therapeutic relationships with the cohort members based on trust, understanding and mutual respect. Pooling of data between the two agencies and snowballing allowed the construction of comprehensive accurate 'networks' of the heroin users and dealers. At the beginning of this study 101 heroin users were identified. In the following three and a half years only a further seventeen members were added to the original chart, of whom five were new to the area; nine were returning to the area, sometimes after a custodial sentence; while only three were 'missing' from the original head count or were not using heroin at that time. In Worthing it is almost as if someone had shut all the doors and allowed the natural course of evolution to take place, with relatively few individuaLs either leaving the system or entering from outside.
DRUG DISTRIBUTION NETWORKS AND THE POLICE
Using the nomenclature developed by Lewis et al. (1985) and Dom and South (1987) the drug distribution networks for heroin have been identified and reported in detail elsewhere (Fraser and George, 1988; George and Fraser, 1989). Table 17.1 summarizes the types of heroin distribution networks operating in Worthing over a ten-year period, police action against the networlcs and the corresponding network response.
Focusing on the 'cops and robbers' aspects of heroin distribution in Worthing it was seen that police action against dealing networks usually led to a corresponding reaction. Dealing networks usually 'self-healed' minor darnage, but where major damage was done to a dealing structure it mutated into a different forrn. For example, police action against the 'traditional' social centre for the pyramid structure of dealers and users successfiilly destroyed the pyramid; however it then, over time, reformed hydra-like as a house-dealing system, a more difficult challenge to policing.
It was seen in Worthing and has been reported from several other studies, that policing of heroin distribution networlcs can rarely eliminate heroin from an area on a long-term basis. While policing is ineffectual in this respect, it is however of interest to look at the effects of policing on the drug-using behaviour of the heroin cohort.
The street scene, as it presented in the heyday of heroin availability, had a stable and identified hierarchy of distribution with a universally recognized and accepted market place/social centre, a seafront pub widely frequented by the heroin-using cohort. Continuous monitoring of the cohort gave much detail about the way in which the street scene and problems encountered by users varied as a result of the disruption of this network and the costs and benefits of upsetting this particular apple cart (Table 17.2).
Neither of the treatment agencies existed during the first phase, but current clients still reminisce wistfully about the mid-1980s when 'the sun always shone' and the 'gear' was cheap and pure. Those who ran into difficulties were referred to the Brighton Drug Dependency Unit where medium-term methadone detoxification provided temporary relief from the complexities of the user/dealer network. Briefly the situation was stable and contained.
Following the two police actions in 1986 (Operations Mauritius and Anthill) which disrupted both the dealing network and the central distribution/social centre, Worthing moved into a second and different street scene. As described in earlier papers (Fraser and George,1988; George and Fraser, 1989), a series of unstable mutual societies sprang up and withered as the drug-using and dealing network attempted to re-establish itself in a series of town centre public houses and cafés. Since by this time both the treatment agencies had thrived and achieved wide acceptance, it was possible to observe much more closely the displacement activities which grew up over the next three years. Initially there were many reports of bad deals, rip-offi and increasing numbers of identified primary opiate users who tumed to benzodiaze-pines, alcohol and other problematic combinations in ill-fated attempts to satisfy their addiction.
Similarly there was a 22 per cent increase in thefts from pharmacies and general practitioner or veterinary surgeries from forty-five in 1986 to fifty-five in 1987. The figure for 1988 was identical at fifty-five.
These points can be fluffier illustrated by analyzing the fatal overdoses which have occurred in the town over this time. Of eleven identified fatal overdoses for which there are Coroner's post-mortem details, a large variety of substances have been identified both in isolation and in combination, notably Diconal and alcohol, also tranquillizers and prescription opiates.
The most important outcome of this investigation is that heroin and its metabolites are conspicuous by their absence. It can therefore be justifiably argued that chaotic displacement-type drug use is significantly dangerous and has accounted for a number of deaths in the Worthing area.
However, the news has not been all bad.
The disruption of 1986 led to a steady increase in opiate users presenting for treatment. In autumn 1987 the Options project was treating thirty-six of the 101 identified cohort membeis (36 per cent); by autumn 1988, Options was seeing sixty-three of the cohort of
For many, the disruption of the stable network and the stepping up of police action provided the impetus which led them to present. The data, however, reflect pessimistically on the association betvveen contact with treatment agencies and reduction in risk-laden drug use. The majority (eight out of eleven) of the overdoses and. all of ffie natural cause deaths were among clients in contact with the treatrnent agency. The three overdose subjects who were not in contact with the treatment agency all met their deaths as a result of a Diconal overdose in isolation, although in one case small quantities of Dihydrocodeine were also identified.
The available data for 1989 point to a gradual re-emergence of stability. A house dealer network has evolved, which in combination with a larger number of users benefiting from a more liberal prescribing policy, appears to have stabilized the situation. Clients presenting or representing for treatment do so more as a planned, internally motivated action rather than as a crisis response. There have been no known overdoses for the last six. months and the number of crimes involving the theft of drugs has reduced from fifty-five in 1988 to thirty in 1989.
Could all this be an indication that the clear waters muddied by police action in 1986 are gradually re-stabilizing? The tentative conclusion is that police action aimed at disrupting the distribution and social network of drug use has had a negative impact on the harmfulness of drug use. Increased harm may be associated with more chaotic drug use, increased theft of drugs and a dispersion of drug use and drug users which gives the (possibly erroneous) impression of an increase in prevalence, reflecting the observation of Power (1987) describing the 'Pool Hall' phenomenon in London's West End.
THE ATTITUDES OF LOCAL POLICE TO HARM REDUCTION
Measures taken by local police appear to have had major direct and indirect effects on the type and extent of drug use in the local population and this has had knock-on implications for levels of risk-laden behaviour. It is therefore worth investigating the extent of match or mismatch between police attitudes and actions, and effects thereof.
A questionnaire was completed by fourteen members of the local police force and fifteen members of the Sussex Drug Unit. The purpose was to explore any difference in attitude and impression between specialist and non-specialist officers (see Table 17.3). While this study cannot be regarded as anything more than a pilot study of the police force ,in general, it does in fact canvass a sizeable proportion of local police, giving it some authority as a local survey.
Table 17.3 summarizes the results of this survey and shows a remarkable similarity of response between specialist and non-specialist officers. In only one respect do they differ significantly: non-specialist police advocate an increase in counselling and treatment agencies as the most effective way of reducing illicit drug use, while specialist drug unit officers favour more arrests and convictions.
The survey reveals that all specialist and non-specialist local police feel that drug use has increased and become more visible over the last three years in and around Worthing. This may be partly a direct result of fragmenting and disturbing the stable hierarchical structure of the mid-1980s. Few officers feel that the strategy adopted over the last few years has been successful in suppressing or eradicating drug use from the town.
As regards attitudes to effective responses to first-time offenders in comparison with habitual drug-related offenders, few officers surveyed advocate treatment alone. There is a moderate preference for early punishment, presumably as a deterrent strategy. When this has failed (i.e. in the case of a habitual offender) a combination of treatment and punishment, (for example, community service, probation or a fine in combination with counselling and/or detoxification) is more likely to be indicated as the preferred strategy. The low proportion of police officers advocating treatment alone for drug-related offenders is hardly surprising. As one Detective Inspector put it: 'When you start arresting them we'll start counselling them!'
The survey also suggests that a majority of local police officers would be prepared to give information to drug users to encourage treatment and harm reduction strategies. Nineteen respondents (65 per cent) were prepared to give information about local needle and syringe availability.
A larger proportion (79 per cent) were prepared to give information about safe disposal of needles and syringes and virtually all those questioned (93 per cent) were prepared to give information about local advice and treatmmt centres.
The largely positive attitude towards harm reduction is to be welcomed since the pOlice, by virtue of their type of work and hours of duty, are most likely to be the agency present at the moment, or just after, a crisis occurs which may provide a valuable choice point in the decision-making process of a drug user.
Furthermore, an interesting discrepancy arises between the drug unit officers' preference for arrests and convictions as compared with the local police preference for counselling. Various explanations may be posited, including a personal knowledge (almost camaraderie at times) which develops between well-known local faces and police officers. It might also be suggested that the closer the liaison between local drug agencies and the police, the greater the likelihood of counselling being judgecl an effective intervention by the police.
Finally, it is both interesting and significant that virtually none of the respondents felt that a liberal long-term prescribing policy was an effective way of reducing illicit drug use. This important mismatch between treatment and enforcement agency attitudes deserves further study and indicates a need for ongoing combined educational input to update Working philosophy at a local level.
POSSIBLE FUTLTRE DIRECTIONS
The Sussex Police have joined other forces throughout the country in employing a pilot scheme to put young people who get into trouble with drugs, and their parents, in touch with local advice and treatment agencies.
In the Sussex area the telephone number of a local self-help organization is given on a card, offering help and advice. The scheme is called 'The Families Referral Scheme' and was piloted by the Institute for the Study of Drug Dependence (ISDD). A further component of this pilot scheme is to caution first-titne offenders as well as encouraging them to present to treatment agencies. The guidelines to caution rather than to prosecute extend to all drugs and not just, as might be expected, cannabis.
Further possibilities for the police and the courts to become involved in harm reduction arise from the White Paper Crime, Justice and Protecting the Public (February 1990). This influential paper makes no bones about the practical futility of incarceration: 'Nobody now regards imprisorunent, in itself, as an effective means of reform for most prisoners' (Paragraph 2.7).
Furthermore, imprisonment is costly at a minimum of ,C320 weekly. The report gives an example, on the other hand, of a young offender, addicted to heroin, who was put on probation for shoplifting and received treatment at a local drug clinic. He obtained stable accommo-dation, got married and applied for a job. He completed his two-year probation order without re-offending. The implication of the White Paper is to make such therapeutic intervention a condition of the court; effectively the offender is sentenced to treatment. This may provide many possibilities as long as the treatment outlined by the court is not too specific (and therefore liable to being breached), nor is it necessarily abstinence orientated. Either of these measures (Haynes, 1990) would inevitably lead to higher rates of breaching and subsequent imprisonment. Not only are prisons ineffective and expensive but they are also very dangerous by virtue of the high-risk sexual and drug-taking activity which several studies have found to take place within these institutions.
Courts could make better use of residential therapeutic assessment programmes as an alternative to remand in custody where the offence or offences are obviously drug-related in origin. Initial experiments are already being undertaken. Conditions of treatment or attendance at a counselling céntre could also be associated with deferred or suspended sentencing. These measures would enable offenders to demonstrate to the courts a sustained level of stability and cessation of offending.
Finally, and more controversially, the role of harm reduction within the prison system should be urgently reviewed. Since it is unlikely that the use of illicit drugs would ever be condoned by the provision of sterile injecting equipment, the role of an oral opiate substitute such as methadone during periods of imprisonment might be considered. The present system often involves either the use of chlorpromazine hydrochloride or an unmodified withdrawal in the prison hospital. Many clients report illicit drug use within prison at some point during their sentence and the risks involved cannot be underestimated.
To colleagues at Options and DAIS for their encouragement and assistance throughout this study. To members of the Sussex Police Drug Unit and Worthing Police who took part in the questionnaire. To South East Thames Regional Health Authority and the Pompidou Group Fellowship scheme for their funding of this study.
Dorn, N. and South, N. (1987) Some Issues in the Development of Drug Markets and Law Enforcements. 'Workshop, Drugs: Side Effects of Policy Controls', Commission of the European Communities, Luxcmbourg. London: Institute for the Study of Drug Dependence.
Fraser, A. and George, M. (1988) 'Changing trcnds in drug usc: An initial follow-up of a local heroin using cotnniunity', British Journal of Addiction 83: 655-63.
George, M. and Fraser, A. (1989) 'Changing trends in drug use: Thc sccond follow-up of a local hcroin using community', British Journal of Addiction 84: 1461-6.
Haynes, P. (1990) 'Sentenced to gct better', Druglink 5 (1): 8-10.
Lewis, R., Hartnoll, R., Brycrs, S., Daviaud, E. and Mitchcson, M. (1985) 'Scoring smack: Thc illicit heroin market in London 1980-83', BritishJournal of Addiction 80: 281-90.
Power, R. (1987) 'After the Pool Hall — pressure on the streets', Druglink 2 (3): 21-2.
White Paper (1990) Crime, Justice and Protecting the Public, London: HMSO.