With the limited exception of HIV/ AIDS prevention, harm minimisation in the UK has focused on the harm that drug users may do to themselves. Jacob Veale examines how harm minimisation within Hammersmith and Fulham (part of inner London) has now begun to address wider issues.
Hammersmith and Fulham Drugs and Crime Forum (the Forum) is a coalition of agencies from one area of London. The forum includes the Metropolitan Police, the Inner London Probation Service, Riverside Substance Misuse Service, the London Borough of Hammersmith and Fulham, the Family Health Services Authority, and Hammersmith and Fulham based voluntary sector drugs agencies. Appendix I shows the Terms of Reference of the Forum.
Its aim is the minimisation of drug-related harm. It focuses primarily on the harm that widespread drug use can do to the wider drug-free community. However, it does not disregard the needs of drug users them selves. Indeed, the Forum believes that the policies and practices that protect the wider community from drug related harm also protect drug users themselves from harm. The main drugs responsible for this wider harm in this area of London are opiates, cocaine and crack, amphetamines and benzodiazepines. Their use causes high levels of acquisitive or property crime (such as shoplifting, credit card and cheque fraud or burglary), rapid transmission to the drug free community of HIV infection, and a vicious circle of drug taking and trading that rapidly spreads drug taking to new users.
Hammersmith and Fulham is a small, inner London Borough. It lies at the edge of London's 'West End' the capital's centre for theatre, the arts and night life. The population is 152 000. Just over half are between the ages of 15 and 44 years, and around 18% are members of various ethnic minority communities. Male unemployment was 15.4% in 1991 (Borough Profile, LBH&F, 1990), and is now considerably higher. It has the highest level of HIV infection of any local authority area in the UK. According to the Local Authority's Social Services Department, over 1% of all men between the ages of 18 and 54 years are known to be HIV positive, and of course the true proportion will be considerably higher ( 1992 ). The Forum estimates that there are between 2000 and 4000 injecting drug users resident in the area, and that between 5% and 14% (or from a minimum of 100 to a maximum of 560) of these are HIV positive.
Crime levels in Hammersmith and Fulham are typical of inner London. The most reliable local research findings on crime show that slightly over 50% of all households experience at least one serious crime each year, with 17% experiencing multiple victimisation (Painter et al.,1988). About 9000 people, or 6% of the population, experience street robbery each year, and about 8850 dwellings, or 12% of the total, are burgled (Painter et al., 1988). Police in Hammersmith and Fulham estimate that between 30% and 70% of all acquisitive crime in the area is committed by drug users seeking to finance drug purchases. Male and female prostitution are both present, and drug dealing at both retail and wholesale levels is widespread. People are known to come to the area from outside to buy or sell drugs.
This article will not provide a detailed history of the national picture with regard to drugs here. However, there are three very broad points that should be made (although in some respects these do not exactly reflect the picture in Hammersmith and Fulham). First, in the period since the late 1960s prescribing services have tended to be minimalist. They have generally offered rapid methadone detoxification for opiate users, some support to recently stopped users, and very little else. As a result, and predictably, they have only attracted two groups of users. Those who genuinely want to stop using drugs, and those who access the services to tide them over a difficult period, but have no genuine desire to stop using.
Secondly, we have relied almost exclusively on enforcement to control the illicit drug scene. Police and customs services have committed huge resources to the so-called 'war on drugs'. They have, by some measures, been very successful. Seizures have increased year on year in terms of quantity, and many traffickers have been caught. However, despite this effort and apparent success, the drug market seems to have been little affected. For example, over the last 10 years or so the retail price of street heroin has been stable even before taking account of inflation. Over the same period purity has tended to increase steadily. Demand for heroin has, meanwhile, been growing. We have falling real prices in a period of market expansion. To use the language of the market, we have a long term supply side glut. The picture with regard to cocaine is similar, although rapid expansion of the market is a slightly more recent phenomenon.
Thirdly, and in common with other countries, most notably the USA, we have consistently misinformed our communities about drugs. There are examples ranging from warnings that cannabis use leads to heroin addiction, to the persistent implicit message that addiction to heroin happens extremely rapidly after first use. These ideas persist in the public consciousness. Many people, and especially youth people, find out by first hand experience, or through the experience of friends, that these messages are inaccurate. As a result, they reject other messages on similar subjects from the same sources. Sadly, they reject the accurate information along with the nonsense. As a result, many who might have accepted the 'Just say No ! ' message are likely to say 'Yes ! ' to drugs . In the face of such a bleak picture, what can a small area like Hammersmith and Fulham do? There are two elements to the answer: shared understanding and shared policies and procedures.
We have pooled our knowledge of the drug scene to gain a reliable, if subjective, picture of its effects on the wider community, as well as on users themselves. The Forum, which brings together clinical and other drug professionals with criminal justice agencies and key public service providers, has produced a more coherent picture than those developed by clinicians or criminal justice agencies working in effective isolation.
The key elements of this picture are:
Having arrived at this picture, we tried to devise policy options that would alleviate the problems. In doing this we asked not only if the policy reduces the harm a user might be doing to her- or himself but also if it would reduce the harm that the drug user might be doing to the wider community? The main policy themes produced by this process are quite simple. They are:
The Forum believes that we can turn these views into a practical programme on the ground. However, there are some problems. Although our views are both logical, and based on a considerable weight of experience, they are unproved. Furthermore, much of what might be called the 'drug services establishment' is firmly committed to the old enforcement and detoxification model. We have therefore decided that proceeding with our programme must be dependent on the establishment of high quality and long-term evaluation and monitoring . This is of course expensive and final agreements concerning resourcing have not yet been reached.
The drug services must prepare themselves to deal with many more clients. Although drug services in our area are already much more comprehensive and constructive than most in the UK, enhancing their existing services should rapidly increase their client numbers. They must be prepared and resourced to cope efficiently with this increase. The Forum has worked hard to develop a set of Prescribing Policy Guidelines, which will be used by clinicians to inform their prescribing practice and I underwrite the development of new prescribing protocols (Appendix l).
Police referral to drug services of people arrested in possession of any drug is in place, and has recently been widened to include people arrested for non drug crimes which are commonly connected with drug use, such as burglary, shoplifting or soliciting. Referral by the probation service is also in place.
The local authority, which is the local provider of schooling and adult education, housing, social and child care services, and leisure facilities such as libraries and sports grounds, has a major development task to undertake. Drug users, who currently have a largely criminal lifestyle, have tended not to use such services except where they can successfully conceal their drug use. But these services will be vital if users are to helped away from their illicit lifestyle by the provision of free prescribed drugs. A user, whose day is no longer filled by the imperatives of raising funds and buying drugs, needs good access to these services. They are what can fill a newly empty day, and perhaps also provide the beginnings of new interests. These in turn may result in eventual moves towards reduced drug taking or abstinence.
Local authority staff also need to develop the skills to recognise the effects of drug use, and be able confidently to refer clients into drug services. Family doctors, who have tended to refer drug users to the specialist clinics, and in some cases fail to provide even primary health care, must begin to take an active role in treating and supporting maintained users.
We need to move drug use out of the shadows Above all, we need to attack the illicit market by removing its customers. We know we cannot do this by gaoling them all because there are far too many. W could never catch enough at once to have any impact But how many users will buy low-quality street drugs a high prices if they can get high-quality pharmaceutical preparations for nothing?
Change on this scale is bound to take time to achieve. There is a heavy legacy of failed social policies of fear and suspicion on all sides, to overcome. But an illicit market without enough buyers or sellers must inevitably wither. We hope to demonstrate the visibility of the approach I have outlined, and I will not pretend that change in national policy is not also goal, albeit a distant one. It is our hope and belief that in the future, we will be able to report that we are achieving the re-socialisation of illicit drug users; and substantial reductions in drug-related crime, the size of the local illicit drug market, the numbers of new recruits to drug use and the spread of HIV, both with the drug-using community, and from there into the wider community.
details of prescribing practice, including substances prescribed, proportions of patients receiving specific drugs, and periods of time spent on maintenance and detoxification regimens
Jacob Veale, London Borough of Hammersmith and Fulham Community Safety Unit, Town Hall. King Street, London W6 9JU.
Borough Profile (1990). Environment Department, London Borough of Hammersmith and Fulham.
Painter, K., Lea, J. Woodhouse, T. And Young, J. (1988). Hammersmith and Fulham Crime and Policing Survey. Centre for Criminology.
Social Services ( 1992) . HIV. A Local Authority
Response. Middlesex Polytechnic, London Borough of Hammersmith
and Fulham.