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Harm Reduction and Injection Drug Use:
an international comparative study of contextual factors influencing the development and implementation of relevant policies and programs

Harm reduction in the United Kingdom

Overview

In the area of harm reduction and injection drug use, the United Kingdom is best known for its policies and practices regarding the prescription of drugs for the treatment of drug dependence, its needle exchange and outreach initiatives, and for some well coordinated multi-agency community-based services. All these initiatives, as well as initiatives to educate drug users about ways to reduce risks associated with drug use and related behaviours, are directly or indirectly supported by a national drug strategy that involves partnerships with the police, health and social service providers, educators and other major stakeholders.

Except for one program established in the late 1960s, the UK has not had supervised injection sites. Most addicts in treatment receive methadone and this is increasingly seen as a harm reduction measure and valued as a means to reduce drug-related crime. Oral amphetamine is sometimes prescribed to heavily dependent amphetamine users and one ongoing study is looking at the effects of making naloxone available to injection drug user to manage overdoses. There is growing support for the use of arrest-referral and other justice system mechanisms and incentives to increase the number of addicts in treatment.

The policy context for harm reduction

In 1998, the new labour government under Tony Blair appointed Keith Halliwell as the first Anti-Drugs Coordinator for the UK. This appointment signified the government's concern about drug problems and especially about drug-related crime. At the same time, the government announced a 10-year strategy for tackling drugs. This strategy built on and extended a strategy developed by the previous conservative government and envisioned a society that was healthy and confident and increasingly free from the harms caused by the misuse of drugs. The strategy also signified a commitment to tackling the social inequalities that contribute to drug abuse through reforms to the welfare state, education, health, criminal justice and the economy.

The strategy includes both legal and illegal drugs, but the greatest emphasis is on illegal drugs, especially heroin and cocaine. In his first report to the government, the new anti-drugs coordinator indicated that he was especially concerned with 100,000 to 200,000 illegal drug users. "It is this group which causes the greatest problems for society and for themselves. They are responsible for a substantial amount of crime, many are victims of abuse from drug dealers and pimps: they are often disruptive and make disproportionate demands on law enforcement and on medical, counselling and social services." It can be assumed that many of these are people who use illegal drugs by injection. .

The UK strategy has four main elements: (1) education, health promotion and related initiatives to help young people to resist drug misuse; (2) law enforcement and community action initiatives to protect communities from drug-related, anti-social and criminal behaviour; (3) primary, secondary and tertiary treatment, and harm reduction initiatives to enable people with drug problems to live healthy and crime-free lives; and (4) supply reduction initiatives.

Coordinator Halliwell's first report to parliament included a number of statements that indicated support for some elements of harm reduction. For example, the report pointed to the need to provide methadone and other substitute medications according to guidelines developed by the Department of Health. It also indicated the need to provide problem drug users with accurate information, advice and practical help to avoid infections and other health problems related to their use of drugs. Further, one statement in the report touched on the need to support problem drug users in reviewing and changing their behaviour toward more positive lifestyles and in linking them to accommodation, education and employment services. Statements concerning treatment seemed to recognize that abstinence was not necessarily a principal outcome. However, it is otherwise clear that abstinence is considered preferable.

"...the government acknowledges that there will be those who, through ignorance or other reasons, will misuse drugs whatever the consequences. For these people, information and facilities aimed at reducing the risks should be provided because this may save lives. However, such information must be coupled with the unambiguous message that abstinence is the only risk-free option."

The coordinator's report makes only one direct reference to harm reduction per se and this is in connection with efforts that had been made to prevent the spread of HIV among injection drug users. This statement did not, however, specifically mention that this was accomplished through needle exchange and no other references to needle exchanges are made.

Comments from those interviewed in connection with this project indicated that the intent of the current national drug strategy has been interpreted in different ways. Some saw the strategy as reaffirming the government's commitment to treatment and harm reduction, but otherss saw a shift away from harm reduction at the government level. One prominent observer saw nothing in the strategy that recognized drug dependence as a public health issue, and nothing that clearly endorsed harm reduction. Another well-placed observer regretted that UK was "becoming like America" in its approach to drugs. Several of those interviewed noted the strategy's emphasis on drug-related crime and the use of legal means to increase participation in treatment.

The coordinator's report lists a variety of sectors involved in implementing the goals and objectives of the national drug strategy, including high-level strategy support groups from the Home Office, regional advisory services, regional Drug Action Teams, and local Drug Response Teams comprising core agencies concerned with health, education, social services, housing and law enforcement. Key roles are also identified for other major national organizations, including the Home Office, the Standing Conference on Drug Abuse, the Institute for the Study of Drug Dependence, Customs and Excise, the National Crime Squad, and the National Criminal Intelligence Services. The strategy also identifies opportunities for the private sector, the voluntary sector, the media, parents, young people and community representatives. The strategy does not mention drug users or user/ex-user groups as contributing to its implementation. The key groups and agencies variously involved in the delivery of harm reduction services (needle distribution and exchange, user education, outreach and/or drug prescription) include general practitioners, social service agencies, public health units, street-level counselling and advisory services ¹⁷ , drug dependency clinics, residential rehabilitation units, and private rehabilitation units. Hospitals provide both inpatient detoxification services and outpatient services. Specialist drug dependency clinics also offer inpatient and outpatient services, day centres and self-help groups. Community Drug Teams (CDT) play an important role in service delivery. These are multi-disciplinary teams that include a social worker, a community psychiatric nurse, administrative staff, and a consulting psychiatrist or physician, or close links to local physicians. The teams are sometimes based in a hospital or clinic, but many are based in the community. The teams provide assessment, counselling, detoxification, and aftercare. They also provide or arrange for prescription services. The teams refer clients to relevant services which they themselves do not provide such as child protection, and mental health or medical services. The teams work closely with the local HIV/AIDS teams. Most areas now have active CDTs. One informant who was familiar with methadone services in Canada said the CDTs ensure that methadone treatment in the UK is more closely linked with other services than in Canada.

Funding for harm reduction under the national drugs strategy

The coordinator's report indicates that the UK government spends the equivalent of $2.3 billion a year on tackling drugs. Some new funds have become available under the new national strategy, including new funds for treatment and for a national hepatitis B vaccination program for injection drug users. Otherwise, the strategy aims to ensure that existing resources are aligned with the strategy's goals and objectives. Under the strategy all stakeholders have been asked to realign their priorities, resources and operations in line with the government strategy and to develop corporate and individual performance targets and measures.

At the local level, funds for harm reduction may be specially earmarked (e.g., for HIV initiatives, including needle exchanges) or negotiated from the pool of funds devolved from the Department of Health to local health authorities. This process involves members of the Drug Action Teams (DATs) that encompass multiple local agencies. DATs are given support and advice by the Drugs Prevention Advisory Service of the Home Office centrally and through nine regional teams.

There are plans for a National Treatment Centre that will provide funds to local treatment services and the intention is to tie funding to results. However, details have yet to be worked out.

About 50% of all treatment agencies are part of the voluntary (non-government) sector and funded by charitable trusts. However, many also receive some funds from statutory authorities. Hospital and general practitioners and other essential health services are funded under the National Health Service.

Some key informants felt that new resources for crime reduction initiatives were more readily available than those for treatment or harm reduction. One indicated that resources for needle exchanges were under threat because HIV/AIDS was no longer seen as a major concern among injection drug users. However, others felt that efforts were being made to ensure a balance across all elements of the strategy.

The current status of specific harm reduction initiatives

Needle and syringe distribution and exchange

Possession or purchase of sterile needles and syringes has never been illegal in the UK. Needle distribution and exchange schemes run by health and social agencies were first set up on a pilot basis in 1987 and are now widespread and accepted as an integral part of a comprehensive drug service. However, they developed more rapidly in some areas (e.g., Liverpool) than in others (e.g., Scotland). They currently operate from a variety of sources, including drug agencies, retail pharmacies and outreach workers. Needle exchanges also provide condoms, bleach, education and advice. There are more than 2,000 needle exchange outlets and they give out more than 27 million needles a year. Many outlets are in pharmacies and more than 90% of local health authorities have needle exchange schemes.

Needle exchanges sometimes give out large numbers of needles - 50-100 plus at any one time. This has not apparently lead to widespread concerns about the increasing availability of needles or to a large number of needles being found on the streets, in parks or other public places. There are, however, some areas where needles are often found in public or semi-private places. These tend to be multi-problem areas characterized by high rates of unemployment, social disorganization, very poor housing and high rates of drug-related and other types of crime.

One person interviewed for this study said that very little is known about the actual functioning of needle distribution/exchanges or relationships between the clients and the workers. The expectations of the workers, and their capacities and skills have not been studied, but seem to be quite variable. This interviewee was concerned that some needle /distribution/exchange providers had a restricted vision and saw themselves as only responsible for giving out needles rather than capitalizing on the opportunity to bring about some changes in drug-use behaviour. This interviewee also felt that UK needle exchanges needed to be more integrated with other services and to offer a wider range of services.

Some variability in the acceptance and functioning of needle distribution/exchanges is evidenced by a study of the introduction and development of agency-and community-based syringe exchange schemes by community pharmacists in Wales (Keene and Stimson, 1997). Drug agencies with an abstinence policy rejected syringe exchange, while those with a pre-existing harm reduction model easily integrated syringe exchange into their work and played a major part in establishing the services.

Drug substitution treatment

The UK's drug current drug strategy endorses the prescription of substitute medication and this reflects long-established policies and traditions that make this possible. British physicians have always been permitted to prescribe both heroin and methadone to addicts, although the right to prescribe heroin has been limited to specially licensed psychiatrists since the late 1960s. General practitioners do, however, have the authority to prescribe methadone to narcotic addicts and, at present, this includes methadone for self-injection. A few general practitioners and some consultant psychiatrists also prescribe amphetamines to people who are heavily amphetamine-dependent. Cocaine is not approved for the treatment of addiction.

Clinical Guidelines for physicians involved in treating drug misuse and drug dependence have been published by the UK Department of Health (www.doh.gov.uk). The Guidelines specifically addressed the issue of harm reduction, which is used to refer to the reduction of various forms of harm related to drug misuse, including social, health, legal and financial problems, until the drug user is ready and able to come off drugs. Physicians are also advised to give their patients advice on harm reduction, including, where appropriate, access to sterile needles and syringes, testing for
HIV/AIDS and immunization against hepatitis B.

The Guidelines also encompass issues concerning the prescription of drugs. Preference is urged for the use of longer-acting opiate agonists (e.g., methadone) for the treatment of opiate dependence and long-acting benzodiazepines. The prescription of injectable formulations is seen as having a very limited place and as requiring special knowledge. Some observers view the practice of prescribing injectable methadone in the absence of guidelines or policy as having serious practical, ethical and legal implications for physicians (Sarfraz and Alcorn, 1999). The aim of prescribing drugs is regarded to be the prevention of withdrawal symptoms and the reduction or elimination of non-prescribed drug use. Preference is given to the prescription of drugs that are used under supervision on a daily basis.

A consultant psychiatrist interviewed in connection with this project emphasized that the aim of prescribing methadone or other drugs was not to attract addicts into treatment, but rather to treat addiction among those who sought treatment for any reason. With respect to heroin, the Guidelines indicate that this may be used as part of a maintenance regime for a minority of patients: "With the availability of injectable methadone there is very little clinical indication for prescribing diamorphine." A Home Office license is required and this is the preserve of specialists. Heroin is only to be prescribed in situations involving rigorous monitoring and where use in the initial stages can be supervised. The guidelines also indicate that there is no recognized indication for prescribing injectable amphetamines, cocaine or benzodiazepines. Buprenorphine is acknowledged as a potentially useful drug for maintenance especially for those with lower levels of opiate dependence. Naltrexone is acknowledged as blocking the effects of opiates, but its use for this purpose is not addressed in any detail. The guidelines indicate that codeine, LAAM, dexamphetamine and cocaine are not authorized for the treatment of drug dependency.

In practice, heroin is prescribed to less than 1% of addicts in treatment and its use is questioned in the Department of Health Guidelines. Despite international attention, heroin prescription was never a dominant feature of harm reduction or treatment in Merseyside (Eaton, Seymour and Mahmood, 1998), and very few people were ever prescribed heroin-impregnated cigarettes as is commonly believed; no key informant was able to confirm if this practice continues. Several of those interviewed for this study questioned the degree of outside interest in heroin prescription in the UK and one said that he considered reports of heroin prescription in the UK to have reached "mythic proportions".

The infrequent use of heroin is a function of the evidence in favour of methadone, a lack of evidence for the value of prescribed heroin, and the reluctance of most physicians to prescribe drugs for self-injection. One physician interviewed for this study said that this leads to all kinds of difficulties, including overdoses and collapsed veins.

Methadone is the treatment of choice and this is currently prescribed to more than 98% of addicts in non-abstinence treatment. Until quite recently methadone was mainly prescribed for the purpose of withdrawal with the ultimate goal of abstinence (Spears, 1997). Thus, in 1994, there were no methadone maintenance programs under the National Health Service and methadone was prescribed in an arbitrary and ad hoc fashion - predominantly in low dosages and for short terms (WHO, 1994).

The need to enhance methadone maintenance services was recently supported by the Effectiveness Review Task Force in their 1996 report to the cabinet ministers. Most of the recommendations in the report were directed at health and social services. In response to the recommendations of the Task Force the Department of Health issued the following directions to health and social service purchasers:

• the need to encourage greater involvement of primary care professionals, such as general practitioners and community pharmacists, in the care of more stable drug misusers;
• the need to develop accessible and appropriate services for young people who misuse drugs;
• improving the delivery of care for drug misusers in contact with the criminal justice system; and
• supporting well managed methadone administration programs and associated counselling programmes for opiate users (ISDD, 1998, p.1).

The Department of Health Guidelines address these issues, recognizing that some addicts may need long-term methadone maintenance, but encouraging physicians to also consider other options. Maintenance doses of 60-120mg/day are mentioned. One consultant interviewed for this study indicated that maintenance may be "for life" for many of his patients and that that was a widely shared view. This was confirmed by another informant who expressed the concern that that harm reduction had become an end in itself. This informant felt that more attention needs to be paid to getting people off drugs altogether.

As noted above, the Guidelines do recognize that methadone might be prescribed for self-injection in some cases, but this is an issue for specialists:

"There is a small section of the treatment population who, despite continued treatment with oral preparations, fail to make adequate progress and continue to be involved in high levels of injecting drug misuse and other risk-taking behaviour. These patients may benefit from specialist assessment: in some instances clinical benefit can be improved by correcting sub-optimum dosing. Although for others specialists could decide to initiate a prescription for a drug taken by injection."

Plans to restrict the prescription of injectable methadone to specialists are being developed.

Although general practitioners can prescribe methadone, most addicts initially receive this drug from specialized clinics. Patients may be referred back to GPs once they become stabilized but GPs are still encouraged to provide care in collaboration with specialists. There are, however, regional differences in the degree of support available to GPs and many GPs are reluctant to take on addicts as patients. One informant indicated that GPs in his area have wanted more money to treat addicts because they are seen as difficult patients. Some GPs are also reportedly reluctant to become involved in addiction treatment because they do not understand the shift in policy from abstinence to maintenance and are concerned that this may change again. The DHS guidelines include the following statements with respect to supervised methadone consumption:

• Most new patients being prescribed methadone should be required to take their daily dose under the direct supervision of a professional for a period of time that may, depending on the individual patient, be at least three months, subject to compliance.
• Similarly, when the patient restarts methadone after a break, or receives a significant increase in the methadone dose, daily dispensing, ideally with supervised consumption, should be re-instated for a period of time stipulated in local guidelines and protocols.
• These arrangements should only be relaxed to allow take-home doses if the doctor can be satisfied that compliance will he maintained. The relaxation of supervision can be seen as an important component of rehabilitation and re-establishing responsible behaviour.
• Arrangements for daily dispensing through instalment prescribing and, where appropriate, supervised consumption of other drugs, should also be made.

The Guidelines also state that take-home doses should not be prescribed where

• the patient shows a continued and unstable, or unauthorized pattern of drug misuse, including a significant increase in alcohol intake, the use of illicit drugs, benzodiazepines or other tranquillisers;
• the patient has a significant unstable psychiatric illness;
• there is continuing concern that the prescribed drug is being diverted or used inappropriately.

The nature of the Guidelines and the degrees of discretion awarded individual practitioners most certainly result in considerable variation in methadone prescribing practices across the country. Variations in the availability and quality of ancillary services also contribute to differences in methadone-based services. The literature also notes that in the UK "the consultant is King" and that this results in considerable variations in the implementation of drug policy in the UK (Strang and Gossop, 1994). Some physicians who are not part of the National Health Service are involved in the prescription of drugs for addicts, but the number of such physicians and addicts is not known. The Royal College of Psychiatrist has expressed concerns about "prescription buying" and the lack control on non-NHS service providers, and two interviewees expressed concerns about the quality of some non-NHS physician services and "rogue" practitioners.

No reliable statistics are available to indicate the proportion of opiate addicts receiving methadone or any other kinds of treatment. Estimates provided by various key informants suggested that 30-50% of heavily dependent opiate addicts might be receiving methadone and that 70% may be involved with services of some kind (including needle exchanges). The main barrier to increasing the coverage of methadone services was reported to be a lack of resources. This has limited the capacity of services and contributed to long waiting lists in some cases.

A few specialists prescribe oral amphetamine to heavily dependent amphetamine users and there is some ongoing research concerning the effectiveness of this treatment (Fleming and Roberts, 1994).

Supervised injection sites

The Department of Health Guidelines for the treatment of drug dependence recommend that, if used at all, drugs for self-injection should be used under supervision in a clinic setting. Some clinics have always permitted this, but drugs for self-injection can also be prescribed for home use. When clinics were first established, some addicts were found injecting prescribed drugs in public toilets. This led to the establishment of a day program with an injection room for addicts attending a local clinic in South London. This was in the late 1960s. This program is still operating, but the injection room has closed. The circumstances have not been documented and no accounts of this injection room could be located.

No key informant indicated that injection sites are currently being considered. One reason may be that the drug scene is generally not highly visible except in some high-problem areas. Even there the addicts tend to have places to inject and few are truly homeless. Homelessness is less of a problem in the UK than Canada due to the availability of social housing. Squatting (living in abandoned houses and other buildings) also occurs in some cities. One interviewee attributed the low visibility of drug use in his area to the availability of housing, the geographic dispersion of dealers and home delivery services offered by some dealers. Another felt that rigorous police work had prevented the development of open drug scenes.

One informant described the use of blue lighting in public toilets and railway stations to discourage drug injection in such places. Blue lighting makes it very difficult to see veins and thus inhibits intravenous self-injection.

Drug user education and outreach

Outreach has been a key component of efforts to address injection drug use in the UK. Outreach work is carried out in all public domains. Outreach workers provide much needed contact and information explaining the risks associated with needle sharing and sexual behaviour.

One informant said that outreach is now focused on the hard-to-reach population that includes prostitutes and amphetamine users. He felt that most other drug users had already been contacted and were aware of services. He did, however, indicate that outreach workers from his clinic were based in police stations and went through the cells every day searching for newly arrested drug users and link them with treatment services.

Harm reduction in the justice system

In 1998, an all-party parliamentary group recommended the introduction of needle exchange schemes in prison as a public health measure. The prison service has since ruled out prison-based needle exchanges, but acknowledges that developments in other countries are being monitored. However, at present, the service considers "the arguments in favour are outweighed by the risk of increasing the numbers of needles in circulation and undermine the need to deter and prevent drug misuse".

Disinfecting tablets are increasingly being made available in prisons and these are seen to have worked well in Scotland for some years. However, where they are used, information leaflets and other materials are given out to make it clear that the use of these tablets is a harm reduction initiative, but only abstinence will completely eliminate the risk. Prison medical officers can prescribe condoms if, in their judgment, there is a risk of infection. However, it is not known how often this occurs.

Other recommendation by the parliamentary committee included better training for judges, new national guidelines for treatment of drug users in prisons, provision of rapid drug testing facilities, increasing the number of drug-free wings in prison (wings where the prisoners would agree to voluntary drug testing), a new emphasis on helping short-term or remand prisoners, and substantial improvements in care and aftercare. These recommendations are reflected in a policy statement from the UK Prison Service. This statement is presented as part of the national strategy and aims to offer support and treatment to any prisoner with a drug problem. It includes the following components:

• Improving the availability and quality of treatment,
• Improving the availability of voluntary testing,
• Continuing the mandatory drug testing program,
• Reducing the supply of drugs in prison,
• Improving the training of staff,
• Using research to measure effectiveness and the needs of specific groups of offenders,
• Establishing management information systems to monitor performance, and
• Integrating the work of various departments within prisons and the various agencies involved in working with prisoners.

It is not known how often methadone is prescribed to addicts in prison. This is at the discretion of individual prison medical officers who were reported by several of those interviewed as having traditionally supported rather harsh treatments for addicts.

Factors influencing harm reduction policies and practice

Trends in injection drug use

Until the 1960s, dependence on opiates was uncommon. Opiate users were typically middle-aged and middle-class, and acquired their dependence as a consequence of medical treatment or though self-medication. In the 1960's narcotic use patterns changed rapidly and use was increasingly prevalent among young people. In the late 1970s, use of opiates increased significantly, particularly among males in areas of high unemployment and social deprivation. Since that time, it has continued to grow, fed by an international drug trade, rather than by leakage of drugs from legitimate sources. The use of cocaine and amphetamines also increased in some areas. Increased drug use was associated with rising crime rates and the issue of drug-related crime has since become a significant political issue, contributing to the development of national strategies, increased attention to treatment as a crime reduction strategy, and increased use of legal measures to boost participation in treatment.

Studies and debates about drug problems led to new perspectives and it came to be recognized that if drug misusers were to remain drug-free, it was not sufficient to offer medical help with withdrawal. Addicts needed counselling and help to make more permanent changes in lifestyle, including employment and housing. This lead to a significant expansion of abstinence-oriented treatment and counselling services. However, goals other than complete abstinence also become more widely accepted.

The use of cocaine has increased in some parts of the UK and all key informants considered that cocaine users pose special problems for harm reduction and treatment. Many cocaine users are also heroin addicts. Some inject cocaine many times a day, but others only inject cocaine with heroin (speedballs) three to four times daily. None of those interviewed felt that the UK had anything unique to offer regarding the treatment of heavy cocaine users.

Trends in the rates of HIV and other infections among injection drug users

Support for needle exchanges and the ongoing funding of needle exchanges reflect policies adopted in the late 1980s in response to justifiable concerns about the spread of HIV among injection drug users and to the general population. In 1988, the statutory Advisory Council on the Misuse of Drugs (ACMD) convinced the government to support needle exchanges because it saw the threat of AIDS as being greater than the misuse of drugs. The Council also recommended that drug services modify their policies to make contact with and change the behaviour of the maximum number of drug users, including those still actively using drugs. The ACMD also advised that drug services establish a hierarchy of objectives for behaviour change, starting with the cessation of sharing of injection equipment, followed by a switch to non-injecting drug use, a reduction in drug use, and ultimately, cessation of drug use. The success of the UK needle exchanges and related user education initiatives in preventing the spread if HIV among injection drug users is widely recognized.

Hepatitis C rates among samples of injection drug users in the UK have been around 35-50%. These rates are lower than those reported in Canada and this may also reflect the success of the UK's needle exchanges and related harm reduction strategies. However, these rates are viewed with concern and have stimulated a hepatitis B vaccination program for injection drug users, partly to increase awareness of all types of infection risks. Education materials on hepatitis that target intravenous drug users have also been developed. Some drug treatment providers carry out testing for HCV, but not all have the resources for this.

One key informant indicated that the government has not provided much leadership with respect to hepatitis C and injection drug use. However, new management guidelines that address issues of hepatitis C were reportedly being developed at the time of this project. It is also possible that new funds for hepatitis C prevention may be made available.

Attitudes of service providers

Key informants indicated that most groups and individuals working closely with injection drug users have supported needle exchange schemes and the use of methadone as a maintenance drug. These intervention strategies are seen as evidence in favour of a public health approach to addiction. The evidence in favour of the positive effects of methadone on crime has also been used to champion the cause of treatment - at least at the funding level. One key informant said that some treatment providers have cited reduced crime levels as the primary goal of treatment, and he was concerned that this could limit expectations for treatment services and restrict their activities.

Treatment providers were also reportedly quite willing to serve clients referred from the criminal justice system. The main concerns have been resource-related, but justice referrals are a source of funds in some cases. One key informant indicated that the growing use of arrest-referrals and treatment orders has not led to much debate about matters such as inappropriately motivated clients or confidentiality.

Attitudes of police

Police attitudes to needle distribution/exchanges were described as "iffy" by one respondent but as "very positive" by another. This latter respondent said the police were early champions of needle exchanges in his community and had never put them under surveillance. Another well-placed observer confirmed that this was generally the case, noting that "the police recognize that they (needle exchanges) have an important role and let them get on with it". Several others indicated that the UK police have been very positive about harm reduction and treatment and that this was a consequence of police involvement in policy-making at all levels. However, one key informant with knowledge of police work felt that uniformed police officers were not always comfortable with needle exchanges and that there were ongoing efforts to develop and provide more police education.

One indicator of success for police work under the national drug strategy is the number of drug users linked to treatment through arrest-referral programs. Some police units, therefore, stake out areas suspected as being frequented by drug users (e.g., abandoned buildings where syringes have been found) and arrest those hanging around on drug-related and other charges. These are then introduced to arrest-referral workers, but not necessarily charged if they go for treatment and no serious offence is involved.

The availability of general health and social services

The UK has a National Health Service and its social services, including public welfare, generally function well. Although there are regional differences in the availability and quality of the services, they are generally accessible even to intravenous drug users. As noted, housing is not a major concern among the injection drug use population, although the quality of housing is, in some case, very poor.

Health and social services are severely stretched in some regions and communities. There are areas of very high unemployment and communities with high rates of mutually compounding problems (unemployment, low education, poor housing, dysfunctional families, alcohol and drug abuse, and drug-related and other types of crime). The government is on record as intending to address these issues and as seeing drug use in the context of social inequalities.

User groups

As noted previously, drug users are not identified as part of the solution to drug problems in the national strategy, but as the problem itself. Some user groups have developed, including a group that aims to represent people who receive methadone. However, their influence is uncertain. There has been some discussion at a high level of providing funding to hire coordinators of user groups, but no funds are available at the time of writing. One respondent closely involved with treatment planning and delivery indicated that efforts were made to involve users and ex-users, but that they were not well organized as a group.

Europe

It does not appear that the UK's involvement in the European community has had a direct impact on risk management initiatives. European involvement may influence the priority and resources given to treatment and harm reduction if substantial resources are given to cross-national supply reduction initiatives.

Research and evaluation

The new national strategy includes many statements about the importance of evaluation and performance measurement. The coordinator has indicated an expectation that all key players will develop business plans and will submit annual reports indicating the cost-effectiveness of their programs. One well placed observer felt that this signified a key role for research and evaluation in shaping future risk management and other initiatives in the UK. However, it was not possible to find out what resources were available for research or evaluation.

Some researchers were less certain that research has had or will have an influence on UK policy, and two other respondents suggested that drug misuse has always been a political issue largely uninformed by research. It does, however, appear that research had influenced the level of support for methadone and needle exchanges. Research seems likely to inform future practices with respect to the prescription of amphetamines, and some ongoing research on the prescription of heroin could influence future prescribing practices. The lack of experimental research on the prescription of injectable drugs is, however, noteworthy given the many years during which experimentation has been possible in the UK (Strang and Gossop, 1994).

Public opinion and the media

No studies of UK public opinion or media reporting of drug-related issues could be found. Key informants indicated that the general public was generally indifferent and largely unaware of how this was being handled except from media reports of drug busts. Another felt that drugs were probably among the top 10 issues of concern in some areas and that opinions about what to do were very divided. However, the public seems to accept that drug abuse is in the hands of professionals. One informant said that public discussion of drug policy could limit options for policies based on research or sound reasoning. He also felt that professionals should try to ensure that drug abuse does not become too political because this tends to reduce opportunities to implement evidence-based programs and to use the results from evaluations of new initiatives.

Key informants indicated that the media have not noticeably favoured or opposed needle exchanges or the use of methadone. None could recall any media reports of problems associated with either of these initiatives. Rather, the media were see as principally concerned with drugs and crime, and drug use by celebrities and those in high places.

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17 The neighbourhood services were reported as being quite common and prominent in some areas.

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