The Lure and the Loss of Harm Reduction in UK Drug Policy and Practice
Neil McKegancy, BA, MSc, PhD, FRSA

Centre for Drug Misuse Research, University of Glasgow, Glasgow, UK

Abstract:

Since the late 1980s drug policy and practice within UK has been heavily influenced by the idea of reducing drug related harm. The paradigm of harm reduction, which has shaped drug treatment services grew out of the fear that HIV may spread rapidly and widely amongst injecting drug users. This article looks at the extent to which drug use or HIV have had the greater impact on individual and public health within UK and the extent to which it has been possible to reduce drug related harm in the face of continuing drug use. The article concludes that in the face of the growth in the prevalence of problem drug use over the last 10 years and the persistence of an array of drug related harms including: the extent of Hepatitis-C amongst injecting drug users, the extent of drug related crime and the impact of drugs on communities and families that it may be appropriate now to make drug prevention, rather than harm reduction, the key aim of drug policy and practice.

Introduction
In 1988, the Advisory Council on the Misuse of Drugs published the results of its enquiry into the growing problem of AIDS and HIV in the UK. Contained within the council’s ‘‘AIDS and Drug Misuse: Pt 1’’ report (1988), was a sentence which proved to be more influential than any other in the history of UK drug policy. That sentence identified the need for a fundamental shift in drug policy and provision as a result of the belief that the ‘‘spread of HIV is a greater danger to individual and public health than drug misuse’’ (ACMD 1988: 17). In the wake of that statement, the principal priority for services working in the drugs field, as well as for drug policy more broadly, became one of reducing drug users’ risks of acquiring and spreading HIV infection.

Whilst the ACMD’s report was not the first to articulate the need for a ‘‘harm reduction’’ focus on the part of those working in the drug field, the report was a key step along the road to the development of harm reduction as a distinct area of professional practice. Stimson, writing in 1990, outlined what he saw as the development of a new paradigm on the part of those working within the drugs field. At the centre of the new paradigm was the focus on HIV:

A key issue in shaping drug policies is the choice that has been posed between two targets, between the prevention of HIV transmission and the prevention of drug abuse. Preventing the physical disease of AIDS has now been given priority over concern with drug problems. In this paradigm prevention takes on a new meaning – the key prevention task is not the prevention of drug use, but the prevention of HIV infection and transmission. (Stimson 1990: 333–334)

Further aspects of this new paradigm involved the concentration on injectors and injecting drug use as opposed to those using illegal drugs by other means; a recognition that given the means (sterile injecting equipment, condoms) injecting drug users would seek to reduce their chances of becoming HIV positive; and the importance of ensuring that drug treatment services were as accessible and as user friendly as possible. This latter element contrasted markedly with the previous paradigm of drug abuse treatment in which the focus had been on addressing client’s drug dependency needs. Challenging drug users about the impact of their drug use as well as testing individuals motivation for recovery (which were aspects of the prior paradigm focussed on meeting individuals drug dependency needs) was now seen as antithetical to the view that services should be doing all they could to attract clients and retain contact with clients as a way of reducing their HIV related risk behaviour.

It is difficult to overstate the impact of these ideas on the world of drug abuse treatment within the UK. In the period following the publication of the ACMD report there was the growth of an entirely new form of drug agency in the form of needle and syringe exchange clinics. There was also, at this time, a substantial growth in the use of methadone prescribed on a maintenance basis as a method of engaging and retaining drug users in contact with drug treatment services and reducing their HIV related risk behaviour.

Some 10 years, after the publication of the ACMD report the ideas and practices of harm reduction have become a key part of the ‘‘drug treatment establishment’’ within the UK. The UK drug strategy ‘‘Tackling Drugs to Build a Better Britain,’’ published in 1998, identified the importance of harm reduction within the treatment pillar of the strategy:

There is growing evidence that treatment works. In particular, harm reduction work over the last 15 years has had a major impact on the rate of HIV and other drug related infections. (Tackling Drugs to Build a Better Britain 1998: Aim, iii)

Similarly, David Blunkett, the then Home Secretary, further endorsed the importance of harm minimization initiatives in his introduction to the Updated Drug Strategy published in 2002:

All problematic users must have access to treatment and harm minimization services both within the community and through the criminal justice system. (Updated Drug Strategy 2002: 3)

So, central were the ideas of harm minimization to policy that the updated drug strategy even re-named the fourth pillar of the strategy ‘‘Treatment and Harm Minimization’’ in contrast to its previous designation simply as ‘‘Treatment’’. The updated strategy summarized how widespread the ideas and practices of harm reduction had become by 2002:

Nearly all DAT area (97%) have harm reduction services and 87% provide access to drug prescribing services. (Updated Drug Strategy 2002: 52)

Within these terms, there can be little doubt that the ideas of harm reduction/harm minimization have had an enormous impact on the world of drug abuse policy and treatment within the UK. What I would like to do in the remainder of this article is to ask three related questions. First, was the ACMD right in asserting that AIDS and HIV represented a greater threat to individual and public health than drug misuse? Second, how successful have we been in reducing HIV and other drug related harms within the UK? Third, whether the time is right to shift the direction of policy and provision within the drugs field in the UK from reducing the harm of continued drug use to reducing the incidence and prevalence of drug use itself?

AIDS and HIV a greater threat than drug misuse?
At the time that the Advisory Council on the Misuse of Drugs ‘‘AIDS and Drug Misuse’’ report was produced, the thinking within the UK around the issue of drug users and HIV was influenced by one study more than any other, namely the results of research involving drug users attending a general practice surgery in Edinburgh. This research, carried out by Roy Robertson and colleagues, showed that a staggering 63% of injecting drug users attending the practice were HIV positive (Robertson et al. 1986). The results of this research sent a shock wave through those planning and delivering drug services in the UK as well as those working within the public health field more broadly. For the first time, there was real evidence that the UK might experience an epidemic of HIV amongst injecting drug users that was equal to, if not greater than, that experienced by sections of the gay community within parts of the USA. Moreover, the Edinburgh results opened up the possibility of widespread heterosexual transmission of HIV, first to the sexual partners of injecting drug users and then on to the wider heterosexual non-drug injecting population.

In the wake of these fears, research was rapidly commissioned to assess the extent of HIV infection amongst drug injectors across a broader range of locations. For example, on the basis of research carried out with drug injectors drawn from across Edinburgh (as opposed to the clients of a single general practice sample as was the case with the Robertson research) the prevalence of HIV infection amongst injecting drug users was found to be 19.7% (Davies et al. 1995). In Glasgow, similar research involving interviewing and drug testing citywide samples of drug users found that only 1.8% of injecting drug users were HIV positive (Rhodes et al. 1993). In London, research using the same methods identified 12.8% of injectors to be HIV positive (Rhodes et al. 1993). Finally, Haw and Higgins reported that 26.8% of injecting drug users in Dundee were HIV positive compared to 3.7% in the surrounding rural area (Haw and Higgins 1998). Further, research in Glasgow and London with female drug-using prostitutes – a group who at that time were seen as key in terms of spreading HIV beyond the injecting drug using population to the wider heterosexual non drug injecting population – identified low levels of HIV infection and high levels of condom use with commercial partners (McKeganey et al. 1992; Ward et al. 1993). Cumulatively, this research lowered the fears of an impending public health crisis involving drug users and HIV within the UK.

By December 2005, there were thought to be 21,898 AIDS cases in the UK. (of whom 1234 are thought to be as a result of injecting drug use) and 76,765 cases of HIV infection (of whom 4381 are thought to have acquired infection as a result of injecting drug use). The prevalence of HIV infection among injecting drug users attending drug treatment agencies and taking part in the Unlinked Anonymous Prevalence Monitoring Programme was 2.3% in London and 0.5% elsewhere in England (Health Protection Agency 2004). Despite these low levels of infection, very recent research has indicated that there may have been a small increase in the prevalence of HIV infections amongst injecting drug users in London, although the possible increase is still well short of the level of infection feared in the late 1980s (Hope et al. 2005).

The figures on the prevalence of HIV infection and AIDS amongst injecting drug users contrast markedly with the prevalence estimates for problematic drug use within the UK. Within England, Frischer and colleagues used the multiple indicator method to estimate a total problem and drug injecting population in 2001 of 287,670 (Frischer et al. 2004). From Scotland, Hay and colleagues used capture recapture statistical methods to estimate the prevalence of problem drug use (defined as heroin and benzodiazepine use) in 2003 to be around 51,582 (Hay et al. 2004). From Northern Ireland McElrath estimated the prevalence of problem drug use to be of the order of 828 (McElrath 2002). On the assumption that the prevalence of problem drug use in Wales (where there is no current or recently equivalent estimate) is on a par with that in England, the overall prevalence of problem drug use in the UK as a whole may be in the region of 356,000, i.e. some 80 times greater than the number of HIV positive injecting drug users within the UK. On the basis of these figures alone it is difficult to avoid the conclusion that it is problematic drug use, not AIDS and HIV, which is having the greater impact on individual and public health within the UK.

In the next section I look at the degree to which it can be said that we have been successful in reducing drug related harm including that related to HIV amongst drug users in the UK.

Reducing drug related harm

There are a number of areas in which it is possible to consider how successful we have been in reducing drug related harm, some of these pertain to the individual whilst others relate more to the impact of drug use on families and communities.

HIV infection

It is evident from the foregoing that the UK has not witnessed anything like the rapid rise in HIV infection rates amongst injecting drug users that was feared in the initial ‘‘AIDS and Drug Misuse’’ report from the Advisory Council on the Misuse of Drugs. One reason for this may well have been the success of the very harm reduction measures (needle and syringe exchange, methadone maintenance programmes, and advice on safer injecting), which that report gave impetus to. This is the thrust of the submission from the UK Harm Reduction Alliance to the Home Affairs Select Committee’s enquiry into drug policy:

Between 1987 and 1997 Britain led the world in developing a harm reduction approach to drug use. The clearest achievement was in the prevention of HIV infection among people who inject drugs (by heeding the advice outlined in the report of Advisory Council on the Misuse of Drugs). UK has thus averted an epidemic of HIV infection associated with drug injecting and there is evidence that harm reduction has resulted in lower rates of Hepatitis-C virus (HCV) infection than found in comparable countries. (UKHRA 2001: 2)

Whilst HIV has certainly not spread to anything like the extent feared in the ACMD’s report it should not be assumed that this was due solely to the development of a harm reduction approach on the part of drug services within the UK. It may have been the case, for example, that the number of cases of HIV infection amongst injecting drug users simply did not reach the critical threshold or ‘‘tipping point’’ to generate widespread transmission of HIV. However, having said this, it is unlikely that the development of such harm reduction initiatives as needle and syringe exchange had no impact on reducing the spread of HIV infection amongst injecting drug users. Setting this issue aside though, the claim that harm reduction initiatives within the UK have been effective in preventing the spread of Hepatitis-C is a good deal less convincing.

Hepatitis-C

By the end of 2003, there had been a total of 38,352 cases of Hepatitis-C diagnosed in England, over 90% of which are thought to have been acquired as a result of injecting drug use (HPA 2004). In Scotland, in 2003, there were a total of 18,109 cases of HCV infection; amongst the 12,166 cases where information was available on route of transmission 90% were known to have injected drugs (HPA 2004).

In 2003, 41% of injecting drug users taking part in the Unlinked Anonymous Prevalence Monitoring Programme of drug users in contact with drug treatment agencies were known to be HCV positive (HPA 2004). High, as these percentages are the extent of HCV infection amongst injecting drug users may be even higher in some cities. Bloor and colleagues, for example, have recently reported that as many as 60% of injecting drug users in contact with drug treatment services in Glasgow may be HCV positive (Bloor et al. 2006). The high prevalence of Hepatitis-C amongst injecting drug users within Glasgow is all the more striking when one considers that for much of the 1990s to the present day, Glasgow has had a well supported, city-wide network of needle and syringe exchange schemes (EIU 2003). It is difficult to see how the level of Hepatitis-C in Glasgow could be any higher even in the near total absence of such harm reduction measures or indeed how the provision of such services over many years have in any way reduced the spread of infection amongst injecting drug users.

Deaths

Data on drug related deaths in the UK are collated by the Office for National Statistics. In 2001, there were a total of 235 AIDS deaths in UK and 1192 deaths amongst drug users involving heroin, cocaine or methadone (Health Statistics Quarterly 13). Between 2000 and 2004 there were a total of 5551 deaths of drug users involving heroin, cocaine or methadone (Health Statistics Quarterly 29). On the basis of these figures there is little doubt that the level of drug related mortality within the UK attributable to HIV/AIDS is only a fraction of that associated with drug misuse more broadly. Whilst there has been a decline in the number of drug related deaths in England and Wales, with the number of heroin and morphine related deaths falling from 926 in 2000 to 744 in 2004, that reduction is hardly commensurate with a successful harm reduction campaign that still leaves hundreds of drug users dying prematurely each year (ONS: 2006). Indeed, for the period 1993 to 2000 (a key period in the impact of harm reduction ideas within the UK) deaths from heroin and morphine in England and Wales actually increased from 187 in 1993 to 926 in 2000 (ONS: 2002).

Overdose and life problems

Over the last few years there has been a growing interest in the extent and the factors associated with non-fatal overdoses amongst drug users. This research has been initiated in part in an attempt to reduce drug related deaths amongst injecting drug users although the work itself has identified the extent of the problems which in many ways are characteristic of the life circumstances of long term drug users within the UK and elsewhere. The National Treatment Outcome Research Study found that 15% of respondents had overdosed in the three months before accessing treatment (Stewart et al. 2002). From Scotland, Neale and Robertson (2005), reporting on the results of the Drug Outcome Research in Scotland study, found that 11.5% of drug users initiating treatment had experienced an overdose in the last three months and 2.4% had experienced more than one overdose during that period (Neale and Robertson 2005). Within this Scottish study 32.9% of drug users had experienced a recent relationship breakdown, 34.4% had financial problems, 34.5% had accommodation problems, and 30.3% had experienced the death of a close relative or friend. This array of life problems was significantly associated with an increased risk of overdose on the part of drug users included in the DORIS research.

Homelessness

Whilst the extent of homelessness amongst those using illegal drugs has not been widely studied within the UK, previous research has shown that in many instances those who have developed a significant drug problem are also often living in very unstable conditions. For example, a study of 1000 homeless young people in London found that 88% were taking at least one drug and 35% were using heroin (Flemen 1997). Also, Downing-Orr found that 85% of homeless young people in London were using illegal drugs (Downing-Orr 1996). In a study of 200 drug users admitted to hospital following a non-fatal drug overdose Neale (2001) found that 32% were currently homeless and 68% had been homeless in the past. Of the 136 individuals in this study who had been homeless in the past, 82% had experienced a non-fatal drug overdose compared to 66% amongst those who had never been homeless. As Neale points out these findings suggest that the ‘‘combined experience of homelessness and drug use increased life threatening behaviour (Neale 2001: 363).

Dual diagnosis

Within the last few years there has been increasing attention focussed on the nature and extent of mental health problems experienced by dependent drug users. Marsden and colleagues, reporting on the sample of 1075 drug users included within the National Treatment Outcome Research Study, found that 32.3% of females and 17.5% of males had experienced anxiety symptoms, whilst 29.7% of females and 14.9% of males had experienced depression. Fully 26.9% of females had experienced paranoia compared to 17.1% of males (Marsden et al. 2000). From Scotland, McKeganey and colleagues have reported that 61% of female drug users contacting drug treatment services had experienced physical abuse and 35% reported having been sexually abused. In the case of male drug users contacting drug treatment services, 22% had experienced physical abuse and 7% had been sexually abused (McKeganey et al. 2005). On the basis of these figures, it is evident that a substantial proportion of drug users are experiencing serious mental health problems associated with past, and in some cases continuing abuse.

Prevalence of problem drug use

There has never been a series of drug misuse prevalence studies carried out within UK that would enable an assessment to be made of the increase in problem drug use over the period in which the ideas of HIV prevention and the reduction of drug related harm have been influential. Nevertheless, De-Angelis and colleagues have sought to analyse data on drug related deaths over the period 1968–2000 to estimate the possible growth in the incidence and the prevalence of problem drug use over that period. On the basis of this work De-Angelis and colleagues suggest that with regard to the incidence of opiate use/drug injecting there may have been a ‘‘threefold increase in the incidence between 1975 and 1979 and a five- to six-fold increase between 1987 and 1995’’. With regard to the prevalence of opiate use/drug injecting over this period De-Angelis and colleagues suggest that this has ‘‘continued to rise since the early 1970s doubling between 1977 and 1982 and rising more than fourfold from 1987 to 1996’’ (De-Angelis et al. 2004).

Identifying possible changes in the prevalence and the incidence of problem drug use in the absence of successive prevalence estimation studies is a complex and inexact science. However, the research from De-Angelis and colleagues does at least illustrate the very real possibility that during the period in which, in Stimson’s words, attention was shifting from the prevention of drug abuse to the prevention of HIV that in fact problem drug use increased substantially within the UK.

Children of dependent drug users

Whilst the impact of problem drug use is most evident in terms of the individual drug user the harms of dependent drug use often extend well beyond the individual user to other members of his or her family. The ‘‘Hidden Harm’’ report from the Advisory Council on the Misuse of Drugs estimates that there may be between 205,300 and 298,900 dependent children in England and Wales with a parent using illegal drugs. The figure for Scotland is thought to be between 40,800 and 58,700. Large as these figures are, the authors of the Hidden Harm report add the caveat that ‘‘in the light of the assumptions we have made we believe these are very conservative estimates and the true figure may well be higher’’ (ACMD: 2003: 25). The Hidden Harm report notes further that amongst 77,928 drug using parents on whom information was available, only 46% of parents were actually living with their dependent children. 54% of drug using parents had children living elsewhere most often with other family members. These figures give an indication of the continuing destructive impact of parental drug dependence upon families and of the harm to both adults and children associated with parental drug use.

Although not all of the children with drug dependent parents are likely to suffer serious adverse effects research has indicated that many of these children will experience a range of short-term and long-term problems arising from amongst other things: neglect, exposure to their parents drug use and associated criminality, disruption to their household routines (Hawley et al. 1995; Forrester 2000; Hogan and Higgins 2001; McKeganey et al. 2002; Kroll and Taylor 2003; Barnard 2007). To a large extent it is only with the publication of the Hidden Harm report in 2003 that drug treatment agencies have become aware of the importance of meeting the needs of children within drug dependent households.

Whilst communities represent one of the four key pillars of UK drug strategy there has been remarkably little research that has charted the evolving impact of drug abuse on communities within the UK. Where research has been carried out, the picture that emerges is one of communities that have been profoundly influenced by their local drug problems. Qualitative research in one such community in Scotland identified that drug abuse had become a major fault line amongst local residents with many of those interviewed and surveyed identifying drug abuse as one of the worst aspects of their local area (McKeganey et al. 2004). Similar qualitative research carried out for the Joseph Rowntree Foundation in England has explored the development of drug dealing markets within local communities and has identified something of the complex relationships that exist between local drug markets and their surrounding community. In some instances the drug markets studied arose within a context of widespread social dissolution, in others the local drug market was sustained within the context of socially cohesive local relationships. Both types of drug markets though were to be found in circumstances of widespread local poverty and deprivation. One of the shocking findings of the research team undertaking this work was the involvement of young people within local drug markets:

Young people’s involvement in drug market activity caused concern among professionals in all our sites. In Byrne Valley, the market relied on young people to connect seller and buyers. In Sidwell Rise and Etherington young people actively tried to be part of the drug market but found it hard to gain acceptance from the more established sellers. It was reported to us that young people in these two sites often offered to work for free in an attempt to gain a foothold in the market. Just under a third of our professional interviewees and just under half of four police officers thought that young people were more likely to work as runners than any other position. (May et al. 2005: 23).

The researchers in this study sought to identify the views of local residents as to how their local drug problems should be tackled. Over a quarter of respondents stated that there needed to be more of a police presence on the streets with only 10% feeling that the police were doing all they could. However, three quarters of respondents felt that tackling the local drug problem was a responsibility that needed to be shared by the whole community. There are though likely to be certain requirements for communities to be able to tackle their local drug problem: for this to occur a local community needs to be cohesive and to have mutual trust and shared expectations. In short there needs to be a collective sense of efficacy if residents are to be able to exercise any form of informal social control over the areas in which they live. (May et al. 2005: 29). Other research carried out for the Joseph Rowntree Foundation is rather more pessimistic about what it sees as the prospects for successfully tackling local drug problems. On the basis of their own qualitative study of the impact of local drug problems on communities Shiner and colleagues concluded, for example, that:

Widespread drug use has given rise to a seemingly intractable set of problems dating back to the middle of the last century and there is little sign that these problems are abating. Despite the best efforts of the police, and the medical establishment, illegal drugs continue to be readily available and widely used. Even when the police are able to identify and arrest major drug dealing operations this has little if any discernible impact on price and availability. (Shiner et al. 2004: 48)

On the basis of these studies one would have to conclude that we have had only limited success within UK over the last 10 to 15 years in tackling the impact of drug abuse on local communities.

Drug Related Crime

Information on the nature and the extent of drug related offending has been provided in the UK through a range of studies including work involving interviewing and drug testing arrestees. The ADAM and the New ADAM (Arrestee Drug Abuse Monitoring) programme in the UK has provided a means of systematically measuring the proportion of arrestees using illegal drugs and the extent of the link between drug use and offending (at least that element which involves a police arrest). Holloway and colleagues have produced an overview of the results of having interviewed and drug tested over 3000 arrestees in England between 1999 and 2002. In year 1 of their research 25% of arrestees tested positive for opiates (n¼1434), by year 3 this figure had increased to 28%. Similarly in year 1 15% of arrestees tested positive for cocaine, whilst by 2002 this figure had increased to 23%. In terms of the link between drugs and crime the New ADAM research team were able to report a number of significant reductions in drug related offending over the study period. For example, the proportion of cocaine users reporting one or more property crimes in the last 12 months fell from 59% in year 1 to 51% in year 3, overall the proportion of arrestees reporting property crime in the last 12 months fell from 53% in year 1 to 48% in year 3. The link between drugs and crime was very evident in this research with, for example, 17% of non-drug using arrestees in year three reporting one or more property crime in the last 12 months compared to 85% of those who had used crack cocaine or heroin.

Similar research carried out in Scotland in 2000 found that fully 71% of arrestees tested positive for at least one controlled drug, 31% tested positive for opiates and 33% tested positive for benzodiazepines (McKeganey et al. 2000). Within this Scottish research 43% of injectors had shared needles within the last three days, 25% reported that they had been in receipt of an illegal income in the last 30 days. Amongst current injectors 61% reported having been in receipt of an illegal income in the last 30 days whilst amongst those arrestees who had not used any illegal drugs over the last 12 months only 5% reported having been in receipt of illegal income over the last 30 days. These figures confirm the close association between illegal drug use and crime and of the challenge, which we still face within UK of breaking the link between problematic drug use and offending. Crucially, within the Scottish research only 44% of female drug using arrestees and 19% of male drug using arrestees had prior contact with a drug treatment agency. These findings indicate the shortfall in access to treatment of a significant proportion of drug using arrestees at that time within Scotland (McKeganey et al. 2000).

Discussion

In the light of the previous section one would have to say that the harm reduction approach within the UK appears to have had only modest success in reducing the breadth of drug related harms. With approaching 15 years experience of harm reduction initiatives we have a situation in which around 40% of drug injectors within the UK are Hepatitis-C positive, in which thousands of drug users are dying from drug related causes, in which the number of problem drug users appears to have increased substantially; in which drug use continues to fuel high levels of offending and to undermine communities and families throughout the UK. It is worth considering in this section why we have not had more success in reducing these various drug related harms.

The level of harm reduced in the face of continuing drug use is less than it needs to be

The principle of reducing drug related harm has an immediate and almost unquestioned appeal. However, whilst the notion of reducing harm is very appealing this is not the same thing as saying that it is possible to reduce drug related harm to a sufficient degree, in the face of continuing drug use, to enable drug users and those around them to avoid a range of adverse outcomes. The effectiveness of harm reduction initiatives in this sphere then may lie not with the question of whether it is possible to reduce drug related risk behaviours per se, but by how much such behaviours can be reduced. Within the UK Unlinked, Anonymous Prevalence Monitoring Programme, 29% of a total of 1677 drug injectors studied in 2003 reported sharing injecting equipment within the last month. In Scotland in 2003/4, 34% of injecting drug users on the Drug Misuse Database reported sharing needles and syringes in the previous month. This figure compares to 32% to 36% during the period 1998 to 2002 (HPA 2004). These figures indicate that despite a plethora of initiatives aimed at increasing drug injector’s awareness of the risks of needle and syringe sharing, and of providing drug users with access to sterile injecting equipment, that around a third of injectors are still sharing injecting equipment. Whilst the level of sharing identified in these studies may not be sufficient to generate epidemic spread of HIV infection the level of sharing identified may well be sufficient to generate further spread of Hepatitis-C infection given that it is already more prevalent than HIV amongst injecting drug users within the UK.

Existing initiatives aimed at reducing drug related risk behaviour are not able to exert sufficient control over injectors risk behaviour

Another reason why existing harm reduction measures may have had only modest success in reducing the level of drug related harm may have to do with the degree to which these initiatives have been able to exert control over individuals’ injecting behaviour. A good illustration here may well be the provision of sterile injecting equipment to injecting drug users. This is an initiative, which, on the face of it, should reduce the risk of drug injectors acquiring HIV and other blood borne infections. However, if a sterile needle and syringe is used in a highly un-sterile environment (for example a toilet or derelict building) to inject highly toxic substances the drug user is likely to experience serious adverse health effects irrespective of the cleanliness of the injecting equipment used. For services to be successful in further reducing the risks of continued drug injecting it may be necessary to intervene much more directly in the injecting event, for example by providing advice on injecting technique, by supervising or administering injections to naive users, by providing drug users with a setting where they can use their street drugs under some level of medical supervision and ultimately by providing drug users with the drugs which they are injecting or using by some other means. At the moment, there are no services within the UK that are developing such an intensive array of harm reduction measures although in fact anything short of such an array may well leave considerable areas of injecting risk behaviour intact and leave substantial numbers of injecting drug users experiencing a range of harms associated with their continued drug use.

Shortcomings in the quality of harm reduction work

There have been surprisingly few attempts to assess the quality of harm reduction initiatives within the UK. Recently, however, the National Treatment Agency has undertaken an assessment of needle and syringe exchange services. Whilst the results of this research have not yet been published, an early report provided by Abduldrahim and colleagues (Abduldrahim et al. 2005) gives considerable cause for concern at the quality of harm reduction work within at least some needle and syringe exchange schemes. On the basis of this survey of needle and syringe exchange clinics across the UK, the authors found that 16% of needle and syringe exchange clinics did not discuss issues to do with needle and syringe sharing in their assessments of clients, 30% did not discuss issues to do with safer injecting techniques, 35% did not discuss injecting hygiene, and 61% did not discuss issues to do with the clients possible registration with a general practitioner. These are all areas, which bear directly upon improving drug users health. The fact that substantial numbers of needle and syringe exchange clinics were not discussing these areas gives an indication that the quality of professional work within a significant number of clinics is falling below the level that would be needed to significantly reduce the array of drug related harms.

A lack in the quantity of harm reduction work

Another possible explanation for the persistence of serious adverse harms associated with illegal drug use may be the fact the level of investment in harm reduction initiatives is itself less than it would need to be for those initiatives to be successful in reducing drug related harm. It is difficult to weigh this explanation because of the lack of detailed information on the funding of harm reduction initiatives within the UK. However, on the basis of some of the statements made about harm reduction on the part of both advocates and commentators as well as official government policy it is difficult to accept that the level of investment within harm reduction has been so modest as to fall well short of that which would be required to bring about a major reduction in drug related harm. The updated UK drug strategy, for example, refers to the fact that ‘‘nearly all DAT area (97%) have harm reduction services and 87% provide access to drug prescribing services’’ (Updated Drug Strategy 2002: 52). With regard to substitute prescribing, although there is a lack of clear costing data with which to assess the level of funding for substitute prescribing services, Peter Martin has reported that approaching half of the total UK drug abuse treatment budget (itself estimated to be in the region of £500 m a year) is now being spent on providing substitute medication to dependent drug users (Martin 2004). Within Scotland, whilst there are no accurate data on the number of drug users being prescribed methadone, recent research undertaken by the Scottish Executive has estimated that as many as 19,000 drug users (more than a third of the total estimated addict population within Scotland) are now receiving methadone (ISD 2004). On the basis of these sorts of proportions it cannot be said that there has been a lack of support for harm reduction initiatives within England or Scotland.

The focus on reducing drug related harm has been directed too much at the individual drug user

Another possible reason why there has been the persistence of drug related harm within the UK may be that the harms which have been targeted in policy and practice have been too closely associated with the individual drug user. Again it is difficult to judge the degree to which this is the case. However, if one focuses on the children of drug dependent parents there are relatively few drug services oriented towards supporting the children within drug dependent households. Indeed it was not until the publication of the Hidden Harm report in 2003 that there was even significant official recognition that children living within drug dependent households were even in need of support. Further, whilst within the last few years there has been a growing awareness of the impact of parental drug use on children there remains hardly any official awareness of, or provision for, children affected by their siblings drug use despite the findings of recent research which has shown that the lives of children can be seriously adversely affected by their siblings’ drug use (Barnard 2005). It may well be the case that in relation to reducing the harms experienced by family members our efforts have been impeded by the concentration within much harm reduction work on the individual drug user (Barnard 2007).

The impossibility of eliminating drug related harm

Finally, our limited success in reducing drug related harms might arise from the fact that illegal drug use, drug dependence, etc., are intrinsically harmful in and of themselves. Whilst one may reduce some of the harms of dependent drug use, it may well be the case that so long as the drug use itself continues that there will be a continuing element of harm arising as a consequence. For example, whilst it is possible through judicious prescribing of methadone to reduce individuals’ needs to turn to crime to support their drug use, nevertheless, to the extent that some level of illegal drug use persists there may be a continuing involvement in criminal activities to support that drug use. Indeed it may only be with the complete cessation of illegal drug use that the harms of such drug use can themselves be eliminated.

Conclusions

Whilst in the late 1980s there were good grounds for fearing that AIDS and HIV might become a national epidemic amongst injecting drug users in the UK and for suggesting that HIV and AIDS represented a greater threat to individual and public health than drug use itself, in fact the reverse has been the case. HIV/AIDS has remained a relative rarity amongst injecting drug users whilst problematic drug use has become widespread in communities across the UK. Further, on the basis of the evidence assembled within this article, one would have to conclude that in the face of substantial support for harm reduction policies and practices within the UK nevertheless substantial drug related harms remain.

Writing in 1990 Gerry Stimson recognized that over time the shifts in policy and practice heralded by the AIDS and Drug Misuse Report from the Advisory Council on the Misuse of Drugs might themselves be vulnerable to challenge in the face of escalating levels of HIV infection and continuing drug related harm:

For how long will agencies and their staff be able to sustain this new image of the drug user, when (to be realistically pessimistic) they will be faced with recalcitrant injectors many of who will not change their behaviour? How long will the doors remain open to all comers, and for how long will staff cope with the stress of such working conditions. For how will drug workers agree to give up on dependence and other chronic drug problems? How acceptable will these policies and practices appear when there are substantial numbers of HIV positive sick injectors? How much concern will there be for the injector when the epidemic becomes established in heterosexual populations?

Stimson further observed that in relation to the shift in drug policies and practices within the UK that ‘‘the stakes are high, if the paradigm turns out to be wrong or ineffectual, the consequences will be disastrous’’ (Stimson 1990: 338). Whilst for Stimson the key challenge to the harm reduction approach appeared to be the possible failure to curb the further spread of HIV infection, in fact it could be said that a greater challenge has come from the limited spread of HIV amongst injecting drug users combined with the persistence and escalation in drug related harms and prevalence. In the light of this it is possible to conclude that it is the prevention of drug use rather than the reduction of drug related harm, which now needs to become the central direction of policy and provision within the drugs field in the UK.

Given the current extent of problem drug use within the UK it would be inappropriate to entirely switch attention from reducing the harms of continuing drug use to preventing drug abuse itself – such a policy would seem to be a classic case of locking the stable door long after the horse has bolted. Nevertheless, high as drug user prevalence is within the UK the potential for further increases in prevalence remain. At the present time the estimated 350,000 problem drug users within the UK still only represents around one percent of the UK population aged 15–55. On this basis one would have to say that the potential for further spread of illegal drug use remains and the need for effective means of drug prevention is greater now than in the past. Within these terms, there needs to be a renewed focus upon drug prevention within the UK. In addition, however, there will be a need to continue our efforts directed at reducing the harms of continued drug use. Crucially though the notion of the harms that need to be reduced have to be extended well beyond the individual drug user.

Such an extension will present a substantial challenge to the harm reduction movement since it cannot be assumed that a commitment to reduce the harms experienced by those continuing to use illegal drugs will be equally applicable to those who are affected by others’ drug use. The clearest example of this challenge lies in relation to the children affected by their parent’s drug use/dependency where agencies may increasingly have to identify whose needs are paramount (those of the child or those of the parent) in seeking to reduce the impact of parental drug use on children. There is though a further reason why prevention rather than harm reduction may need now to become the major concern of drug policy and practice. At the current level of drug prevalence many of the drug related harms that we have become aware of over the last few years are already beyond the capacity of our existing services. Again the best example of this has to be children within addict households. It is currently estimated that there may be in excess of 350,000 children with one or both parents dependent upon illegal drugs (Hidden Harm 2003). If only a quarter of those children are in need of support then that is already well beyond the capacity of social work services within the UK. For many of these children then the only prospect of reducing the harm associated with parental drug use may actually be the reduction of parental drug use itself. Much the same case can be made in relation to many of the other drug related harms (Hepatitis-C, overdose, dual diagnosis etc.) such that it may well be only by reducing the extent of problem drug use that one can bring about a substantial reduction in the array of drug related harms within the UK.

Acknowledgements

This article, and the ideas within it, have profited from discussions with numerous colleagues and friends. I am grateful to Jim McIntosh, Joanne Neale, Marina Barnard, Lochy MacLean, Charlie Lloyd, Mick Bloor, Neil Hunt, Bill Nelles and dozens of others. None of these individuals would necessarily agree with all or in some cases any of the ideas set out in this article. The article was written whilst I was attached to the Criminal Justice Research Centre at the University of Wellington. I acknowledge my debt to Pat Mayhew, the Director of the Centre.

Neil McKeganey and the editors of The Journal of Global Drug Policy and Practice would like to thank the editors of Addiction Research and Theory for permission to reprint this article, which originally appeared in Addiction Research and Theory, December 2006.

Professor Neil McKeganey is the founding director of the Centre for Drug Misuse Research which opened at the University of Glasgow in 1994. A sociologist by training, Neil McKeganey has carried out research on such topics as prostitution and HIV, drug injectors HIV related risk behaviour, young people and illegal drugs, the impact of parental drug use on children, the evaluation of drug treatment services and the recovery from dependent drug use.

Neil McKeganey has written widely on issues to do with drug policy and provision and is committed to stimulating public and professional debate on the nature, impact, and response to the problem of illegal drug use. In 2005 Professor McKeganey was asked by the UK Government Department of Trade and Industry to undertake an assessment of the likely impact of the UK drug problem in 20 years time. The report which Professor McKeganey produced raised fundamental questions about the direction of drug policy and the importance of successfully tackling the drug problem. Neil McKeganey is the author of over 150 articles on aspects of illegal drug use and is the author with James McIntosh of “Beating the Dragon:  The Recovery from Dependent Drug Use.”

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