Introduction

The Mersey Drug Training and Information Centre was established in 1986 by Mersey Regional Health Authority with the aim of providing information and training to a wide variety of groups and organizations throughout the region. Initially the center's aim was solely to be an information resource and provide training service, but circumstances dictated that the service develop a wider role than its initial aim. The Center has been a central point in the development of the Mersey Harm Reduction Model. There are many others whose contribution to this strategy has been equal to, and in some cases, greater than my own. Any consideration of this agency must primarily recognize the contribution of Allan Parry who founded the agency and was responsible for many of the developments that have made the service what it is. Allan's radical initiatives and his tenacious advocacy have resulted in the establishment of a unique program that has made Mersey Region a model of radically sensible drug policy.

Establishing and Developing the Service

The Mersey Drug Training and Information Centre was established by people who understood drug users and their needs. Its establishment also coincided with that of Liverpool's first specialist Drug Dependency Clinic. The two units happened to be located next door to each other and so a close relationship between the two agencies was forged and their policies evolved symbiotically.

It might be well to mention another important historical factor in the emergence of Merseyside's strategy for dealing with drug use. Although the new prescribing clinics that followed the second Brain report on dealing with drug use initially continued with the policy of maintaining users on injectables, this policy had begun to fall into disfavor and in most parts of the country. Drug Dependency Clinics no longer offered maintenance or injectable drugs. Liverpool, as a provincial backwater, had failed to move with the times and Consultant Psychiatrists, usually the doctor in charge of a clinic, were still maintaining addicts on injectable drugs. Experience had convinced many working in the field that although abstinence may be a desirable goal, it was not immediately attainable for many, but real, positive improvements in the lives of many drug users were attainable by the provision of a pure, legal, controlled dose of methadone or heroin.

It was during this period that the connection between HIV/AIDS and intravenous drug use first came to light. In an effort to combat this, Allan Parry, then manager of the agency, initiated one of the country's first syringe exchange schemes, based upon the low-threshold model of service delivery established in Amsterdam on the effort to combat the spread of Hepatitis B. Though established on a shoestring and run from a converted bathroom, the success of the scheme provided a lead and a model for syringe exchange schemes nationally.

HIV and AIDS were responsible for much of the agency's subsequent development. If the syringe exchange was to be successful, it was important to gain the cooperation of the local police force. If treatment policies had a role to play, it was necessary to educate local doctors. As a consequence, the agency began to play a role in training local police officers, doctors, medical students, drugs workers and other groups. The content of that training was harm-reduction, rather than abstinence-oriented. A result of this work was that a consensus slowly emerged around how we should deal with drug problems in the area.

Given the imperatives of HIV and AIDS however, training was a relatively slow method of transmitting information. The Mersey Drugs Journal was established in order to educate and inform local workers of developments in the field. However, it was recognized by those responsible for the journal that treatment policies were constrained by other factors and so the jour-nal began to look at drugs and drug use in a wider context.

As the syringe exchange scheme was highly successful, and new HIV/AIDS prevention initiatives such as outreach work with male and female prostitutes and injecting drug users began to take off, this side of the agency's work outgrew its origins and so became a separate agency, The Maryland Centre.

Mersey Drug Training and Information Centre Today

With the hiving off of the HIV/AIDS prevention aspects of the service, Mersey Drug Training and Information Centre has returned to its original role, the provision of training and dissemination of information on drugs and drug-related issues. The Mersey Harm Reduction Model is dependent upon the cooperation of a number of agencies: drug dependency clinics, local police, social services, syringe exchange schemes, and outreach workers. The agency continues to recognize the need to service these various bodies with accurate information and training at a local level. However, the demand for the services that we offer has grown, at both national and international levels.

Growing international interest in what was going on in the drugs field on Merseyside and in the views expressed in the Mersey Drugs Journal was eventually to lead to its rebirth as The International Journal on Drug Policy. The IJDP has become one of the major journals for the increasingly influential debate on drug policy, being committed to publishing articles in many fields, from treatrnent policies to governmental policy and international policy. While it publishes articles on both sides of the debate, it is firmly committed to looking at radical initiatives aimed at facilitating the emergence of rational and humane drug policies.

The agency also facilitates the transmission of information through the organization of conferences. One-day seminars have been run on matters such as Drug Education, Harm Reduction and Maintenance Prescribing. This year MDTIC established the First International Conference on the Reduction of Drug Related Harm. Held in Liverpool, it attracted many of the most prominent thinkers in this field from all over the world and was highly successful in drawing together like-minded people to share their knowledge and experience of harm reduction strategies. Many of the papers are to be published in book form next autumn. Subsequent conferences are curently being planned, to be held on an annual basis, the next scheduled for Barcelona in May 1991, and the third in Australia in 1992.

The Role of Information and Education in Harm Reduction

British criminologist Jock Young, in his book The Drugtakers (1971), spelled out 10 rules that inform the development of a path toward a sane and just drug policy. While all of these rules have a bearing upon the philosophy of the agency, two in particular inform the work that we do.

Young's first rule is to "Combat Absolutist Dogma." Those with a commitment to our existing drug policies have tended to present them as the only means by which we can deal with drug problems. Underlying presuppositions are taken for granted by advocates for the status quo or increasingly repressive drug laws. Furthermore, their arguments are bolstered by reference to somewhat "scientific" evidence. Rule eight identifies the need for "Positive Propoganda." As he points out, "The majority of information fed to the public as to the nature and effects of psychotropic drugs is misleading and inaccurate. This results in widespread scepticism." Young goes on to argue that information aimed at controlling drug use must take into account the life experiences of drug users and supplement and correct this by the use of authoritative outside sources.

Part of the success of the agency may result from the fact that it has always had close contact with, and taken account of, the views of active drug users. As a consequence, information about drugs has always been informed by the experience and cultural values of users. This does not necessarily imply information is presented in glowing terms. What we seek to offer is factual information, presented in non-judgmental fashion, on the matters that have real importance for drug users in their everyday lives. For example, the possibility that cannabis may affect the reproductive capacities of mice is of no consequence to committed smokers. Reports on whether the crop has been sprayed with paraquat is.

Drug Education for Young People

One area in which I believe the work in our area is not as effective as I would wish is in the provision of drug education for young people. In the United States, much drug education appears to be based upon a primary prevention model: explicit messages about the negative aspects of drug use aimed at deterring experimentation There are a number of difficulties associated with this model, not the least of which is that there appears to be no evidence that demonstrates its efficacy. In short, it doesn't work. Some young people will never take drugs. There is no evidence that indicates this is a result of drug education. Others go on to use drugs regardless of exposure to drugs education. Information may actually be inaccurate, deliberately so, as "prophylatic lies" are used to attempt to dissuade young people from using drugs, according to The Great Drug War by Arnold Trebach.

In the United Kingdom today, there is a consensus that education about drugs should be intergrated into a school program of personal and social education (PSE). I would contend that PSE is part of an educational philosophy aimed at empowering students and expanding their personal choice. This style of education does not sit easily with a "Just Say No" approach to drugs education. In fact, such courses devolve very little power to young people and it is paradoxical to attempt to empower or expand personal choice in an institution where only a very limited and prescribed range of attitudes and behaviors are acceptable.

Despite the intrinsic flaws in these models, I would like to see drug education for young pegple make far more use of secondary prevention and harm minimization models. Such approaches will attempt to offer both information on the relative harms associated with drug use, and specific skills such as first aid, counseling and helping skills. Such education should be offered to all young people, rather than targeting "at risk" individuals in order to avoid stigmatizing or bestowing status upon the recipients, and avoid a potential "self-fulfilling" prophecy. In the final analysis, young people need education about drugs as opposed to education against drugs.
 

Conclusions and Recommendations

While there was a degree of specificity about the emergence of this model on Merseyside, I believe that there are a number of levels at which education and information must be directed in order to create a coherent and cohesive harm reduction-oriented drug service.

It is essential to gain the cooperation of other services in the area. Such services are unlikely to cooperate willingly unless they understand the reasons for policy changes. Training and information must be directed at managers and staff of drug program, medical personnel, social workers, police officers and others working in the criminal justice system.

An important component of harm reduction strategy is an emphasis upon empowering drug users. The failure of previous education strategies has been due to their tendency to regard drug users and potential dug users as empty vessels, waiting to be filled with the wisdom of experts. Drug education must recognize the ways in which the drug using subculture transmits information, and the role that an individuals experience of drug use plays in shaping that information. Accurate and nonjudgmental information must also be aimed at the people close to drug users, family, friends etc. The uninformed reactions of such people can make a situation far worse than it already is.

Harm reduction strategies do not occur in a vacuum. Their potential for success or failure is to some degree determined by the wider context. Policies that criminalize or socially marginalize drug users, rather that seeking their social intergration also serve to make the problem worse. Information must be aimed at the level of the policymakers if we are to maximize the potential success of a harm reduction strategy.

Outside the information and education field, I am aware of a number of initiatives that could usefully promote the value of our existing harm reduction model. In Liverpool, the police have a policy of non-prosecution of first-time offenders for possession of all drugs. Instead, users are cautioned, and referred to appropriate services. This has the effect of preventing use escalation as the sanction of a criminal record for drug use still exists.

It is also part of the Merseyside police policy not to devote a high proportion of their resources to pursuing individuals for possession of small quantities of any drug for personal use. However, such a policy is at the discretion of individual police forces and such an enlightened policy may not operate in other areas. I believe that there are insufficient reasons for maintaining criminal sanctions for possession of cannabis and they should be removed at the soonest opportunity. This would have the effect of removing the major problem associated with what is otherwise a relatively unproblematic form of drug use. As an experiment, it could also act as a pilot for reevaluating the existing legal controls over other forms of drug use.

Despite the large numbers of drug users receiving prescribed drugs in the region, there is still a sizeable demand for injectable maintenance and syringe exchange that is not being met. There are also parts of this country, and of many others, where such treatment options are unavailable. These areas often coincide with the areas where rates of HIV infection and AIDS are highest. I believe that there is a need for the expansion of programmes based upon the controlled availability of such drugs, not only locally and nationally, but also internationally.

Finally, as a society, we should recognize the ad-hoc, reactive nature of our existing drugs policies, and commit ourselves to a thorough reevaluation of policy upon rational and humane grounds. Before HIV and AIDS, such a reevaluation was necessary for the protection of our civil liberties and our human rights. Today, it is a matter for our moral consciences. How much longer can we afford to let people die because we disapprove of the substances they choose to put into their bodies? How much longer can we allow the toll of casualties to rise in this unending civil war?

Pat O'Hare, Director, Mersey Drug Training and Information Centre, Liverpool, England.