5. What principles should
underpin the national alcohol harm reduction
strategy?
The main principle must be to integrate the
alcohol misuse strategy within a fully integrated
drugs misuse policy. The recreational drugs (i.e.
social not medical) adopted by a society are a matter
of historical accident rather than based upon
evidence of safety. 1920s US prohibitionist policy
banned all intoxicants (all drugs other than tobacco).
Alcohol prohibition failed through lack of public
support but the remaining prohibitions against other
intoxicants became embedded in international law.
Evidence suggests that the distinction between legal
and illegal drugs is purely arbitrary when viewed
from a harm perspective. The distinction seems more
based on an economic assessment rather than a health
assessment. The UK Government receives £20 billion a
year from the trade in legal drugs that a quarter of
the adult population are addicted to and which kill
one in five citizens. Government has a conflict of
interest between economic and health policies. Recent
evidence (University of York report) suggests the
economic costs of prohibiting illegal drugs may
approach £20 billion a year indicating little
overall economic benefit from prohibition.
Government still refers to 'tobacco, alcohol and
drugs', misleading people into thinking that alcohol
and tobacco are not really drugs. Indeed this issue
is raised by the DPAS booklet 'Let's Get Real -
communicating with the public about drugs', p.40,
where they say "in the interests of encouraging
a rational debate and combating knee-jerk prejudice,
we need to continue referring to alcohol, tobacco and
caffeine as drugs". This guidance is routinely
ignored as with the recent 'Drugs Policy Update 2002'
which says "We will maintain our focus on Class
A drugs as they cause the most harm." This
statement is untrue: class A drugs do not cause the
most harm. The Advisory Council on the Misuse of
Drugs (ACMD) has stated that "legal drugs, such
as tobacco and alcohol, are responsible for far
greater damage both to individual health and to the
social fabric in general than illegal ones".
Much of our nation is in denial about the dangers of
legal drugs, projecting all concern for drug dangers
onto those classed as illegal.
All drugs can be dangerous if misused - used
excessively, for example. Indeed it seems bizarre
that excessive tobacco use is never classified as
misuse though it is more addictive than heroin, has a
death rate for addicts several times higher than
street-quality heroin and kills hundreds of innocent
people every year through passive smoking. The World
Health Organisation's Fact Sheet 222 states that
"No amount of tobacco use is safe." The
Scientific Committee on Tobacco and Health report
1998 stated that "smoking … accounts for
one fifth of deaths in the UK: some 120,000 deaths a
year". Conversely even moderate cannabis use is
always classified as misuse in spite of the statement
by the ACMD in their report 'The classification of
cannabis under the Misuse of Drugs Act 1971' that
"the high use of cannabis is not associated with
major health problems for the individual or society."
Alcohol seems to be the only drug where realistic
policies are being adopted: moderate use is
acceptable, even beneficial, while misuse can become
very harmful (to both individual & society). The
alcohol misuse strategy should become a template for
an integrated drugs misuse policy that clearly
defines use and misuse for each drug.
The ACMD has acted as a bridge between the
opposing views of the prohibitionist Home office and
the more evidence-based Department of Health. The
time is right for integration, especially in light of
'The 10 Year Strategy for Tackling Drugs' that states
"legally obtainable substances such as alcohol,
tobacco … should … be addressed within the
strategy" and that "drugs misuse is a
national problem requiring fairness and consistency
in our response." Sadly integration seems
limited to services, ignoring policy.
"Integration requires: Services to be
considered from a user's perspective (integration of
alcohol, tobacco and all drugs)" (p.59, 'The
Substance of Young Needs - review 2001', Health
Advisory Service).
"The Substance Misuse Guidance (2001)
identified the importance of a joined-up approach to
integrated service provision. The report recorded the
ministers' wishes for this fully integrated approach"
(p.66, 'The Substance of Young Needs - review 2001',
Health Advisory Service).
As a health education voluntary group publicising
government quotes about drug dangers we find
ourselves effectively informing parents and children
that cannabis is safer than legal drugs. Drug policy
and implementation must become aligned with health
evidence for it to be respected by citizens,
especially the young who are very sensitive to adult
hypocrisy. "Increasingly, young people feel that
authority is hypocritical rather than ignorant about
drugs" (p.12, 'Talking about Drugs', DoH/DfES/Home
Office).
An integrated drugs policy conforms with other
Government policies:
1. Informed choice: the Health Advisory Service's
'Substance of Young Needs' Review 2001 states "the
specific aims of drug education [including alcohol
& tobacco] are to make informed choices, to take
responsibility in drug related situations, develop
assertiveness and gain skills in decision-making".
Government does not present comparisons of the danger
posed by different drugs in terms of death rate,
addictiveness, illness and link with crime. For
example, how long does it take to become addicted to
tobacco or heroin? Vital information like this is not
made available. This is what people need to know to
make an informed choice concerning which drugs are
safest to use and at what point use becomes misuse
for each drug. Only then can they take responsibility.
Such comparisons do, however, highlight our unjust
drug laws. Legal choice is limited to two of the most
lethal addictive drugs with safer drugs being
prohibited.
2. Evidence-based policy and risk management: the
Strategy Unit's 'Risk and Uncertainty' states that
"successful risk handling rests on good
judgement supported by sound processes and systems.
Action is recommended in these areas: (a) systematic,
explicit consideration of risk should be firmly
embedded in government’s core decision-making
processes (covering policy making, planning and
delivery); (b) risk handling should be supported by
best practice, guidance and skills development –
organised around a risk "standard"; (c)
Departments and agencies should make earning and
maintaining public trust a priority in order to help
them advise the public about risks they may face.
There should be more openness and transparency, wider
engagement of stakeholders and the public, wider
availability of choice and more use of "arm’s-length"
bodies such as the Food Standards Agency to provide
advice on risk decisions". These recommendations
need to be applied to drugs misuse policy, applying a
standard cost-benefit or use-misuse assessment to
each drug. Only then can policy claim to be 'evidence-based'.
3. Harm reduction: an integrated drug misuse
policy would discourage the use of the most dangerous
drugs, the most addictive and harmful drugs, while
encouraging the use of safer alternatives. Currently
the law prohibits even relatively safe use of some
drugs (e.g. cannabis) while permitting misuse of
other more dangerous drugs (e.g. tobacco).
4. Anti-discrimination and human rights:
minorities that choose the safer illegal drugs are
persecuted and imprisoned; majorities that comply
with the law are denied access to these safer drugs.
Citizens' human rights are infringed by such
Government discrimination.
5. Social exclusion & Neighbourhood Renewal:
The Government's report '10 year strategy for
tackling drugs' says "research suggests that
there are all kinds of reasons for misuse; that key
factors include unemployment, low self esteem,
educational failure, boredom and physical,
psychological or family problems. And many people
misuse drugs because they don't have the opportunity
to lead fulfilling lives." Why then do we punish
this most socially excluded sector of society? The
most deprived spend up to 10% of their income on
recreational drugs when cannabis can be grown at home
by anyone at no cost. Many young people experiment
with drugs, both legal and illegal - risk-taking
seems to be natural for teenagers; the majority give
up drugs in their early 20s after adapting to an
adult lifestyle. For alcohol this often means a
transition from misuse (e.g. binge drinking) to
healthy use. This timing of giving up drug use is
also shown in cannabis. Compare this with tobacco use
which is strongly associated with social exclusion;
social exclusion causes a sense of powerlessness
which makes the likelihood of being able to break an
addiction much lower - especially for tobacco, the
most addictive drug.
6. Integration & cross-cutting approaches:
Alcohol misuse might be drastically reduced if
cannabis was legalised. Cannabis is a safer stress-relieving
drug with intoxicant properties that do not cause a
reduction in inhibitions or increase in risk taking
as alcohol does. The ACMD's report 'The
classification of cannabis under the Misuse of Drugs
Act 1971' states that "Cannabis intoxication
tends to produce relaxation and social withdrawal
rather than the aggressive and disinhibited behaviour
commonly found under the influence of alcohol. This
means that cannabis rarely contributes to violence
either to others or to oneself, whereas alcohol use
is a major factor in deliberate self-harm, domestic
accidents and violence." Advice could be given
to switch to using cannabis after moderate use of
alcohol rather than consume more alcohol to become
more intoxicated. Currently the Strategy Unit is the
only part of Government able to assess this harm
reduction strategy while there is no integrated drug
misuse strategy. The Strategy Unit's 'Adding It Up'
concluded that action was required in these areas of
integration strategy: (a) "Leadership from
Ministers and senior officials. Departments should
redress any bias against quantification and analysis;
(b) Openness from analysts and policy makers; (c)
Better planning to match policy needs and analytical
provision".
7. Trade: on what grounds can the restriction of
trade in illegal drugs be justified if not on health
grounds? Nationally and internationally there is no
free trade in lethal addictive recreational drugs.
Internally we allow tobacconists to profit from their
drug supply while imprisoning those supplying other
lethal addictive drugs or safer alternatives that are
neither lethal nor addictive. Externally we pay the
Afghan government to stop opiate production and
export while tobacco is the most heavily subsidised
non-food crop in Europe. The West has an effective
monopoly on these drugs. The World Trade Organisation
seems unconcerned about the barriers to free trade
created by international law. Developing countries
that threaten to encourage export of their drugs are
threatened with reduced aid. The Strategy Unit's
'Rights of Exchange' states: "A rules-based
international trading system is important, in order
to avoid the dangers of protectionism, which may be
disguised as raising SHE [Social, Health &
Environmental welfare] standards; there are ‘win-win’
policies available, which both liberalise trade and
improve SHE outcomes, for example reducing subsidies
that encourage unsustainable agriculture;" and
"Action to influence foreign production methods,
including measures targeted at trade, should be
avoided, where the motive is to achieve a competitive
advantage, through the protection of domestic
industry. This includes protectionism disguised as
action in pursuit of SHE objectives."
Integrated policy development:
Illegal drugs policy must be integrated with
alcohol as the Welsh Assembly have done, then with
tobacco. Further policy development would integrate
this drugs policy with food misuse (which leads to
obesity etc) under an integrated 'Substance Misuse'
policy (dealing with all potentially dangerous
substances individuals wilfully put into their body).
Every year in the UK obesity causes 30,000 deaths, 18
million days of sick leave and costs of around £2
billion. Regulatory authorities are considering the
need for health warnings to be placed on high-fat,
high-sugar and high-salt foods. Like tobacco, food is
certainly a 'substance' that can be overused or used
unhealthily. This integrated 'Substance Misuse'
policy should later be integrated into a
'Recreational Activities' policy which would cover
all unnecessary potentially dangerous activities that
people wilfully choose to follow (sport, dangerous
sports, DIY, substance use, etc). "Drug-related
deaths get enormous publicity, but totals are rarely
given and almost never compared with the number of
deaths from other leisure-related causes (such as
skiing accidents, for example)" [p.11, Talking
about Drugs - Home Office/DoH/DfES]. This wider group
of recreational activities all have costs and
benefits. Hillwalkers may pursue an essentially
healthy activity but more die from it than ecstasy
and rescues may endanger emergency services - yet
society does not assess the cost-benefit nor compare
such assessment with that of other activities such as
drug use. Strategies developed for dealing with food
misuse and sport are relevant to drug policy
formulation: eating disorders have highlighted the
motivation of 'control' as well as stress-relief (comfort
eating) while dangerous sports strategies recognise
that danger is itself an attractor and education
should be practical, not dwelling on exaggerated
safety risks. Holistic 'systems' thinking requires a
common policy for all these activities which people
have free choice over, however far in the future
their implementation might lie.
Recommendations:
Our legal system can compensate for unjust laws
but the mechanisms have been rendered powerless
through poor information and misguidance from above.
Chief Constables can use their discretion not to
enforce drug laws. Cannabis cafes could be allowed in
the same way that brothels are. The problems are 'off
the streets'.
The CPS has a duty to prosecute only when in the
public interest. They could decide it is not in the
public interest to prosecute illegal drug offenders,
the most socially excluded, when legal drug misuse is
not prohibited (waste of resources, discrimination
etc).
Ultimately the final democratic responsibility for
altering the law lies with juries. Juries have the
right to decide a person is guilty of breaking the
law but innocent of doing any harm and so find that
person innocent. This ensures that unjust laws are
not upheld. Juries are not informed of their legal
duty to judge the law and judges direct them against
doing so. Juries need proper information and
empowerment.
The Government itself can not yet be expected to
act unanimously and impartially in creating fair
drugs law due to inaccurate past perceptions about
social drugs.
However we suggest that the Strategy Unit, as
recommended by their report 'Wired Up', approaches
"the centre (No. 10, the Cabinet Office and the
Treasury) to lead the drive to more effective cross-cutting
approaches wherever they are needed". To enable
a fair evidence-based drug policy, the Misuse of
Drugs Act must be fully reformed to include all drugs
that are misused with clear definitions of the
boundary between use and misuse. While the degree of
prejudice within Government is unknown, it is evident
that years of Government propaganda against illegal
drugs have instilled prejudice in many voters. This
obstacle to reform can only be addressed by a
campaign of public education comparing the risks of
all substances and, perhaps, other recreational
activities. Once prejudice has been replaced by
evidence-based information, reform should be able to
proceed unchallenged. Current public confusion over
the relative safety of cannabis will only increase as
drug health education becomes inevitably more
effective. The present balancing act - reclassifying
cannabis balanced by clamping down on supply and
'hard drugs' - is unsustainable. More information
about European campaigns for drug policy reform,
especially in relation to the UN's drug policy review
in April 2003, can be provided by the Transnational
Institute, European
Cities on Drug Policy and the group of 108 MEPs
supporting these changes.
Links:
National Alcohol Strategy: www.strategy.gov.uk/2002/alcohol/main.shtml
or www.doh.gov.uk/alcohol/alcoholstrategy.htm
Alcohol Concern: www.alcoholconcern.org.uk
The Medical Council on Alcohol: www.medicalcouncilalcohol.demon.co.uk
Institute of Alcohol Studies: www.ias.org.uk
National Association for Children of Alcoholics: www.nacoa.org.uk
Health Development Agency: www.hda-online.org.uk
