It's clear to everyone that the sorts of drug policies that we've had over the
last fifty years or so have been woefully unsuccessful in their outcomes. They
have been hugely expensive, have failed to prevent steady, year on year
increases in illicit drug consumption, and send thousands of people to prison,
whose only real crime is the desire to change their consciousness.
In order to evaluate the success of any policy, we first have to identify the
goals. What are we trying to achieve here? In the past, the goal of drug policy
has been muddied and confused. We pretend that the goal is the health and well
being of the population, when in truth there were ooften very different agendas at
For example, the reason why some drugs are illegal, while other
substances, often more harmful than those that are completely prohibited, is due
to the racist origins of much of our drug policy. These laws were passed as a
result of various racially-focused moral panics. Moral entrepeneurs created
campaigns that played to society's prejudices about various races, and the
possibility that they might use the drugs that they preferred but most white people were unfamiliar with to sexually
defile our pure and innocent women. Such prejudice led to the original legislation against marijuana, one
of the most harmless substances known to man, on the grounds that it incited
insanity in black people and gave them the strength of ten men. Similarly, laws
were passed against the smoking of opium, predominantly a chinese practice,
while it was still legal to buy opium based patent medicines and even heroin
over the counter of through the post. However, these forms of administration
were preferred by the white majority, and as such, were not regarded as being
Nevertheless, it's unarguable that there are many negative health consequences
associated with illicit drug use, and any drug policy worth its salt has to
seek to address these deficits as a primary goal. The question then becomes to
what extent do our existing policies really promote health improvement among drug
It is my contention that rather than promoting health, many existing drug
policies actually works against it. Anti-drug propaganda propagates information
that is so patently false that any serious attempts at drug education and
information are seriously undermined. The stories that the prevention lobby
tells about drugs and drug use simply don't fit with the widespread experience
that people now have of illicit drugs. By stigmatizing and criminalizing those
people who prefer one particular type of intoxicant rather than another, we
place obstacles in the development of a culture of moderate and safer
recreational drug use, and positively dissuade people from seeking expert help
for their drug problems. Furthermore, the ideology of drug prohibition has, in
some countries, skewed treatment and rehabilitation services, many of which are based
upon a quasi-religious ideology and are militantly opposed to scientific enquiry
and a rational approach to the problem.
The extent to which this quasi-religious ideology skews the discourse on drugs,
and drug use, and consequently has a powerful negative effect on both advances
in treatment modalities and on drug policy as a whole, is well illustrated by
the story of Dr. Alex DeLuca.
DeLuca was a clinician at one of the most celebrated facilities in the USA --
Smithers, in New York City. Smithers has traditionally been associated with the
12 step fellowships, and the 'Minnesota Method' of drug treatment, which
effectively elevates the self-help philosophy of the fellowship to a full blown
treatment system. There can be little argument about the fact that many, many
people feel that their involvement in programmes of this nature have saved their
lives, and that they derive a great deal of help from participating in such
programmes. However, there is a large core of people associated with the 12 step
fellowship that believes this should be the sole form of treatment available -- despite
the fact that only a very small proportion of the people who actually need help
for drug and alcohol problems feel that this would be a helpful or appropriate
route for them to take. DeLuca made the terrible mistake of speaking publicly
about the fact that Smithers was now offering a wider range of options,
including making space available for Moderation Management, another self help
group with a similar form to Alcoholics Anonymous, only the people who join that
particular programme have no desire to stop drinking and simply seek to
moderate their alcohol intake. When the article was published, a cabal of rich and
influential 12 steppers kicked off a 'Get DeLuca' campaign, and he was fired
from his position within days.
The approach to drug treatment that DeLuca was espousing, was one that has been
winning increasing support all over the world during the last fifteen years.
Harm Reduction is a theory that outlines certain principles for responding to drug problems that was first
articulated in a coherent fashion in Liverpool, England in 1986, in a Regional Health Authority strategy document titled 'The Mersey Model of Harm Reduction'. Prior to this
point there were a whole range of practices that we would today
describe as Harm Reductionist that the authors drew on for inspiration. Examples included the old
'British System' of prescribing heroin and cocaine to addicts, the Dutch Coffee
Shop policy and the junkiebond (addicts union) and prevention programmes aimed at trying to teach young solvent misusers how to reduce the most serious risks associated with the practice.
The thing that gave Harm Reduction its greatest impetus though, was the spread
of HIV and AIDS in the injecting drug use population. In the mid-80's,
epidemiologists working on HIV and AIDS had identified the fact that AIDS was
spread by the tendency to share injecting equipment. The cheapest, swiftest and
easiest way to do this would be to provide injecting drug users with clean,
sterile equipment. In 1986, the World Health Organisation suggested that all
countries should start doing this immediately as a matter of priority.
Here in the UK, we had our own evidence of how this disease was being spread and how to prevent it. In Edinburgh,
local pharmacists had gotten together of their own volition, and agreed not to
supply sterile injecting equipment to anyone who they suspected of being an
addict. Back in Liverpool though, there had been a consistent policy of maintenance
prescribing for the previous ten years or so, a policy that included the prescribing of injectable preparations like methadone
and diamorphine. When a comparison of the HIV rates in the two cities was
performed, half of Edinburgh's iv drug using population were found to be infected with HIV.
In Liverpool, in contrast, the infection was completely absent. Even when
infected iv drug users moved back home to the city from places with a high rate of HIV
like Amsterdam and Edinburgh, infection rates stayed below .001 percent because the city's drug users had an established culture of buying and using sterile equipment.
One might think that this sort of data might be evidence enough to persuade
people that needle exchange was the right thing to do. Unfortunately,
prohibitionist ideology is grounded in moralistic and quasi-religious
underpinnings, and so the people who buy into this sort of world view weren't
going to give up without a struggle. It was a struggle that saw some very peculiar
alliances forming. Liberal drugs workers, feared for their jobs because their
identity was tied to the old way of thinking. Trotskyists objected on the
grounds that it was a plot by the Thatcher government to sap the revolutionary
will of our youth through state sponsored addiction. Black groups objected,
arguing that this was yet another form of genocide, another Tuskeegee
experiment. And of course, the US government opposed it, saying that the data
It was, of course. And pretty well every other country in the world had needle
exchange schemes, while the Federal government passed laws that pull the funding
from any US program found to be involved in Syringe Exchange Schemes.
Nevertheless, there were those who saw the light. Stout hearted Americans who
were determined to do the right thing, whether the state approved or not.
Guerrilla Exchange programs sprang up across the USA, and the people who worked
for them went out and talked to the rest of the world, and today they are
carrying Harm Reduction theory into the belly of the beast.
So, what is Harm Reduction?
Basically, it's a theory that insists that the core of any drug policy or
treatment philosophy isn't the desire for a drug free society. As the
psychopharmacologist Ronald Siegal has pointed out, human use of intoxicants is
so ubiquitous, that it may actually constitute a fourth innate drive. Human beings
need food, shelter, sex and then we need to get high. Harm Reduction theory
accepts that this is the case, and doesn't make any judgements about it one way
or the other. It isn't good, it isn't bad, it just is. Now how do we best deal
So firstly, Harm Reduction is non-judgemental. Unlike other approaches, we
aren't interested in saying that drug users are bad people, or even that drug
use is bad, per se. Which is not to say that many criminals don't use drugs, or
that many people don't suffer severe drug problems. But we insist on separating
out our judgements about people's behaviour, rather than condemning people
because they happen to use drugs.
Secondly, it's pragmatic. Harm Reduction recognizes that Rome wasn't built in a
day. Even people with the most severe problems aren't necessarily going to stop
using immediately. Are there any other, positive changes that we can encourage
that improve health and well-being? If so, let's deal with that.
Thirdly, Harm Reduction is evidence based. Any intervention, whether it be at
the treatment level or at the grand policy level, should be based on the
available research into what works and what doesn't, and this process of
evaluation should be ongoing. I know that to those of you who have no experience
outside the drug treatment field, this won't sound particularly radical.
However, you should ask yourself why so many US addiction facilities have closed
since the move to Managed Care and HMO's. The old 28 day rehab, once a
flourishing industry in the US, has now been decimated.
Fourth, and finally, Harm Reduction says that any treatment service should be
user friendly rather than confrontational. This is *not* an insistence that
individual workers should never be able to challenge somebody when they are
talking bullshit, but rather it seeks to address the fact that the vast majority
of people who are hired by treatment services tend to think that the people they
are hired to help are the lowest form of scum, and so rather than treatment
being a collaborative project between the drug user, who has the desire, and the
clinician, who has the information and the skills to impart, you have a
relationship characterised by mutual antagonism. In the past, the idea that all
addicts are liars was a fundamental tenet amongst people working in addictions
treatment. Today, we recognize that people don't lie for no reason. People lie
to avoid punitive sanctions. Remove the punitive sanctions, and what you start
to see is an open, honest relationship emerging. Can any talk therapy really be based on anything else?
Harm reduction recognizes that some people will always want to continue to take
drugs. So what? Nobody has ever managed to find a way to stop them from doing
that yet. If we're honest about these things, we can work on the issues that
really do concern them, rather than having to pretend that we're pursuing the
goal of abstinence. This frees up much more time to help those who genuinely do
want to become drug free, but are having some difficulty doing it on their own.
People try to categorize Harm Reduction as being on the left or right,
politically. The truth is, it's neither of those things. In the UK, the initial
support for needle exchange and services based upon Harm Reduction principles
came from the Thatcher government. Their thinking in this area was diametrically
opposed to that of their opposites in the USA, where you had Nancy Reagan and
'Just say no'. When the Conservatives were defeated, and Labour gained power,
they thought it would be politically popular to 'try to do something about
Britain's growing drug problem', and so like other governments in the past, they
made the mistake of looking to the USA, perhaps on the basis that more
experience gives you more knowledge. They hired a liberal police chief as Drug
Czar, who immediately recanted his previous positions on the need for a re-
examination of UK drug policy, and took to parroting Nancy Reagan's 'Just Say
Fortunately, this u-turn in British drug policy didn't go unremarked, and after
several years of widespread criticism, by the media, the public and the drug
treatment field in the UK, the New Labour government has finally had the scales
removed from it's eyes and sees Harm Reduction as the only sensible basis for
their drug policy. Over the last twelve months, it has established the National
Treatment Agency -- a special health authority whose role is to try to ensure
that UK drug service provision is consistent, coherent and of high quality, and
the Home Secretary has indicated his intent to reduce Cannabis from being a
Class B drug, to a Class C -- rendering possession as a non-arrestable offence
(and thus effectively decriminalizing it.) He has also announced his intention to
increase the amount of heroin prescribing to heroin addicts.
At last, the UK has a government that is seeking to provide a rational basis for
drug policy. Of course, just as with drug treatment, there's no magic bullet,
but if we agree that our goals are to improve health and reduce crime, at long
last we will have objectives that are measurable and attainable, and the basis
for a consensual policy that all members of British society can sign up to.
How long must we wait before the USA follows us down this same route?