Drug Abuse

As argued in the introduction and chapter 2, drug policy is a notoriously difficult area in which to have rational and dispassionate policy debates. There are fundamental conflicts of value and the stakes involved are perceived to be very high. Politicians engage with the issue at their peril, and often rely on a risk averse stance that entails an extension of the precautionary principle. A not inconsiderable proportion of crime in the UK is linked to drugs of different kinds and there are regular reports of young people dying or becoming mentally ill following drug use (although there may be debate about the extent of causal links between these events). Despite some shifts in public opinion noted in the previous chapter, most public opinion polls suggest more people are in favour than against a tough enforcement approach to drug use. This is particularly true when polls are carried out after a high profile ‘overdose’, such as the case with Leah Betts in 1995. Politicians are thus (perhaps rightly) fearful of media and political reactions to any appearance of being ‘soft on drugs’. With so much potential for loss, and little obvious gain, it is little wonder that there is very little political appetite for changing drug legislation.

Meanwhile, reformers argue that moralising and scaremongering among the media have wrongly shaped public opinion. The result, they argue, is support for a policy that actually causes harm to many people on top of the harms caused by drugs themselves. While the prevailing cultural value is that ‘drugs are bad’ and ‘drug users are irresponsible’ it should come as no surprise that few professionals are willing to make public statements challenging the current legislation. There are calls for change, but only from retired leading professionals, whether they are judges, chief constables122 or medical experts.123 Even an ex-Home Office minister has called for change, but only when out of office .124 There appears to be little support from current professionals for change.

While both drug reformers and drug enforcers argue for their respective proposals and arguments, there is little actual data on what is or is not effective, as demonstrated in a recent comprehensive review of evidence.125

This chapter presents a different approach to drug policy based on a soft systems methodology and the conceptualisation of the drugs problem as a ‘wicked issue’. Much of the perceived current impasse on drug control policy is in large part due to the polarised nature of the debate. This debate tends to reinforce the view that there are only two options available to policy makers: controlling drugs through the Misuse of Drugs Act (MDA) and criminal enforcement, or decriminalisation. Those on each side of the debate present their view as offering the only solution to drugs and drug policy. We argue that this is unhelpful, and that there is no silver-bullet solution to the drugs problem. However, there are things that can be done to progress a more informed analysis of different control options for new substances and make improvements to the current policy framework that are based on broad areas of consensus.

Our soft system workshops, described in more detail below, sought to encourage people to reconsider their perspectives, give greater recognition to other viewpoints, focus on the goals of drug control rather than competing means, and find consensus on ways forward. We did this by structuring the discussions around outcomes on which there was universal consensus, and avoiding discussion about whether the use of psychoactive substances is an inherently bad thing. For example, the first workshop addressed the question: what is the best approach to protect young people from the harms of new emerging psychoactive substances?

Framing the question in this way and focusing on outcomes, rather than asking whether classifying a substance through the MDA minimised harms, allowed for a more fruitful discussion.

Drugs: a ‘wicked issue’

Drug use in society and drug policy are ‘wicked issues’: social problems characterised by resistance to resolution over long periods of time, being fractured by different deeply held values and by being connected to other similarly complex and unresolved issues .126

The ‘war on drugs’ was launched in the USA in 1970 and has been viewed as one important stimulus for the MDA introduced in the UK in 1971. Yet, despite this rhetoric and significant increases in expenditure on enforcement, drug use in the USA and UK has increased until recently while the street price of most drugs has steadily declined. Numerous commentators have claimed that if it really were a ‘war’ then governments have been roundly defeated. This formulation of the issue is widely contested and few today would argue that a drug-free world is achievable.

There is significant disagreement about whether drug policy over the last 50 years has been a complete failure, or just the least worst option. While the supply of drugs and drugs harms remain persistent, many argue that the levels of prevalence of use and problematic use could be even worse if illicit drugs were available in the same way as alcohol and tobacco.

The disagreements around drug policy have two contrasting roots, both of which are significant. The first lies in the fundamental values around drug use. For some, drugs are ‘evil’ and their use has to be prohibited and discouraged as much as possible. For others, government has no right to interfere with what citizens ingest for their pleasure. And for pragmatists, the core value is reducing the various associated harms, both to individuals and society in general.

The second root of disagreement is about how the world is understood to be operating, and how drug use fits into the fabric of modern society. Here the issue is one of causation. Problematic drug use is often intertwined with a range of other social issues, including family breakdown, poverty, worklessness and family history of substance abuse. It is difficult to identify which of these issues is the cause of the others. For example, many young people who have problematic drug use come from deprived backgrounds; is the source of their problems the drug use or the deprivation?

Traditional policy making starts from the assumption that the issue to be addressed can be identified and defined. However in the face of the type of profound disagreements outlined above, dispute starts at the definitional stage and continues into what constitutes evidence, what should be the goals and what means should be used. What appears to be a ‘solution’ from one perspective is likely to make matters worse from other perspectives. Wicked problems do not have simple ‘solutions’, no matter how much the media and politicians would wish otherwise. Rather, we argue that a more fruitful way of framing the issue is to seek ‘improvements’ to policy that are supported by all stakeholders. One of the fundamental problems with policy making on ‘wicked issues’ is that a huge amount of time and energy is spent arguing among stakeholders about which is the right solution. Focusing on improvements to policy which are backed by consensus can help contribute to more efficient and less fractious policy making.

A soft systems approach to drug policy

A key feature of this project was to use a soft systems approach to explore the different perspectives or world views operating within the drug policy debates in order to identify areas of consensus. The soft systems method, pioneered by Peter Checkland in the 1970s,127 emerged from systems engineering in recognition of the complexity in managerial problems resulting from different views on what the system was, what its goals should be and what needed to be done to improve the situation. The process aims to identify these differences in perspective with the aim of gaining a bigger picture and thereby generating system improvements that are not in opposition to any of the existing perspectives. To achieve this, participants in the process are encouraged to voice their perspective strongly, but with the aim of being understood, not with the aim of trying to change other people’s minds.

Each workshop for this project focused on a specific question, though the aim was not to arrive at a definitive answer to the question. Rather the question served to limit the scope of the debate and provide a vehicle for exploring improvement options.

The first workshop considered the question:

What is the best policy approach to protect young people from emerging new synthetic drugs?

The second considered the question:

What steps can we take to control the availability of new emerging psychoactive substances?

The participants

Each one day workshop had about a dozen participants.

Participants agreed to participate on the basis of anonymity. For each workshop, we chose participants carefully in order to try to ensure that every type of stakeholder in the drugs debate, and represent a wide range of perspectives.

We aimed to have representatives of all the government departments and agencies responsible for some aspect of UK drug policy, including areas of enforcement, health, education, medicines legislation and trading standards. In addition to these participants, we sought to have a representative of the police at both workshops, representatives of different frontline drugs charities with on-the-ground knowledge, a young person with experience of drugs, advocates representing the parent or carer perspective, and expert pharmacologists. We also sought out individuals and academics with specific knowledge of ‘legal highs’ and new psychoactive substances. Crucially, we also invited two well-known individuals in the drug policy debate who represented the more extreme views on drug policy: each workshop had both a committed and passionate enforcer and reformer.

The process

The systems workshops began by participants being invited to draw a ‘rich picture’ of how they perceived the issue. Using images in this way enables each person to focus on what exactly they wish to communicate, and to give expression to emotions by their choice of images and colour. Then each person introduced themselves to the group, including their job title and role, and briefly described the elements of their picture. The picture and short debate that followed gave rise to a number of issues that were captured on flipcharts by the workshop facilitator. Once all the pictures had been presented, the group debated the topics that seemed most significant, either because they generated most debate or because they recurred a few times. As these discussions proceeded further, issues were captured on flipcharts after which they were grouped by issues into themes.

The groups then chose to work on one of the general themes that had emerged from their discussions by defining an ideal system that, if it existed, would address the theme. For example, in the first workshop one of the themes that emerged was providing information to young people and the ideal system was defined as:

A system to enable young people to make informed and responsible choices regarding substance use before they risk becoming regular users, in order to enable young people to realise their full potential as adults, by providing accurate, accessible and relevant information, combined with education and skills, to both young people, parents and communities while recognising that different groups will require the information presented differently.

Arriving at the definition of an ideal system requires debate about what exactly the system is seeking to achieve (its purpose), why this is important and how it is to achieve its purpose. This is an iterative process in the sense that the formulation of a
definition usually illuminates something that has, to date, been overlooked or perhaps simplified. Once an adequate definition is achieved the group then considers the sequence of activities that would be required for this ideal system to fulfil its purpose. In the example given above, key activities would include gathering and assembling relevant information, assessing its accuracy and relevance, identifying the key audiences, and for each audience devising appropriate messages, media and methods of transmission.

Once the set of activities for the ideal system have been assembled they are then compared with what is happening in the real world. This then leads to a debate about what steps could be taken to improve the existing system in the direction of the ideal. In the example illustrated above, it was agreed that the most important step was the collection and collation of accurate information on new psychoactive substances since without the completion of this activity no other part of the system could operate effectively. By focusing on concrete purposes and using the rigour of systemic thinking, the group could come to an agreement about an improvement without becoming bogged down in their different perspectives.

Workshop questionnaire

One of the aims of the workshops was to enable the participants to enlarge their own view of the issues. It is normal for participants in this type of workshop to be influenced by increasing their understanding of each other’s perspective. In order to explore whether such changes took place, participants were invited to complete a short questionnaire (see Appendix II) before and after the workshop. The results confirmed the expectation that people did not move their positions much, presumably because they had previously understood each others’ positions. However there were some changes and these are summarised below:

·    In both workshops, there were slight shifts from positions of certainty to uncertainty: participants became less certain of their views. General comments also reflect that they had broadened their perspectives and considered wider options for control.
·    Of all the questions asked in the survey, both workshop groups were most unsure about whether the temporary ban will be the most effective approach, suggesting they were unclear about the implications of such a policy.
·    Both groups agreed that the emergence of new substances requires a new approach to drug control, and that providing education is an essential prerequisite for deterring use.

Different perspectives

As mentioned, a key reason for using the systems workshops was to identify the different perspectives that were operating within the drug policy debate. The workshops succeeded in this respect and a number of the different perspectives are summarised below. The aim of this summary is not to pigeonhole people, but to provide composites designed to convey a flavour of the differences that emerged. It is important to recognise the variation within categories of participants so individual participant’s views often differ from those in a particular category. For example, not all members of the police will concur with the description attributed to the police below. It should also be recognised that individual participants are quite likely to hold conflicting views and beliefs about the issues. Nevertheless, for developing a bigger picture of the drug policy domain the following summaries capture something of the extent and nature of the different perspectives to be found.

The police’s perspective

Box 6    The police’s perspective

The young people the police come into contact with who are in trouble with drugs are in a high-risk group from broken or chaotic homes. It does not help to criminalise them, or other young people, for their involvement with using drugs:

How people choose to get off their heads is really none of our business – provided that they do not engage in risky or illegal activities (other than possessing illegal drugs).

The risky activities are things such as driving, getting into fights and so on. Our job is to catch the villains who are making a lot of money by importing, distributing and selling drugs.

The police saw the paradox posed by the current prohibition system quite clearly. They wanted drugs to be illegal so that they could catch the villains who make money from drugs, while at the same time not wanting to wreck young people’s careers by giving them a criminal record.

Reformers’ perspective

Box 7    Reformers’ perspective

Reformers think the current system simply does not work. Drugs are cheaper and more widely available than ever before; this after almost 40 years of control under the MDA.

Thousands of young people have their lives wrecked by being given a criminal record as a result of recreational drug use.

Banning a substance does not have much impact on its availability, but it does make drug use more hazardous due to lower purity, unknown dosage and unknown contaminants. A regulated system is both possible and preferable and, as the example of cigarette smoking demonstrates, need not lead to uncontrolled use.

Reformers tend to be advocates working for charities and/or campaigning organisations with well-known views on drug policy. Reformers often do not fully address the fact that making something legal and regulated might lead to an increase in its use, which could lead to an increase in harms associated with addiction.

Drug workers’ perspective

Box 8    Drug workers’ perspective

Officialdom has no idea what’s happening on the street. The problem with new substances is the lack of accurate and reliable information. No one, not the young people using them, nor the drug workers trying to give advice about them, nor the doctors in A&E units treating users, knows enough about these substances, and there seems to be a continual supply of new ones. The lack of information is about dosage, toxicity, side effects and issues associated with mixing different drugs. There is a growing body of data available among young people and drug workers, but no one is collecting and collating this, and it could be the basis for giving advice. Messages about extreme dangers of drugs are negated by peer experience, so the whole drug advice and education system is brought into disrepute. The young people who get into trouble with drugs are usually ‘at risk’ for other reasons and fall foul of mixing different drugs (including alcohol).

Frontline charity workers tended to have a very pragmatic perspective based on aiming to reduce harm at the street level. Legality is seen as less of an issue than accurate information. The best advice given to youngsters is, ‘If you are having fun that’s OK, but if you are using any drugs to get out of it then stop, you are overdoing it.’

Civil servants’ perspective

Box 9    Civil servants’ perspective

Civil servants are involved in delivering a harm reduction agenda while perceiving that radical changes to drug legislation are unlikely any time soon, so they accept the constraints of the existing system. This leaves them with a dilemma because they recognise the drawbacks of the current policy, but are not convinced that decriminalisation is the answer. They recognise different groups of users (teenagers, clubbers, old hippies) but these differences are not represented in policies or campaigns. They are puzzled by many aspects of drug use including the changes in fashion that determine drugs of choice and the steady decline of teenage use of both drugs and alcohol since 2001. They recognise that the young people at greatest risk are those from disadvantaged backgrounds, and these can be targeted independently of drug use. For this group the most effective assistance is helping them make less risky decisions in all aspects of life.

Civil servants tended to adopt a very intellectual approach, largely because they do not see it as part of their role to challenge the moral or value judgements involved. They are also aware of potential paradoxes, eg demands for classification of substances on the basis of harms quickly before any evidence of harms can be obtained, which then makes obtaining such evidence extremely difficult.

Professionals’ perspective

Box 10    Professionals’ perspective

Professionals (pharmacologists, academics, clinicians) believe the MDA is no longer fit for purpose. The classification system is crude and not related to harm: and does not appear to have any effect on users’ decisions. Banning substances changes the sellers, not the users, and means that what is used might be less pure and the users less certain of what they are ingesting. The mephedrone issue brought the Advisory Council on the Misuse of Drugs (ACMD) into disrepute and illustrated that policy was driven more by the media than by scientific evidence. They recognise that there is a moral judgement driving prohibition, and that this is a valid role of government. However they also see that pursuing a harm reduction agenda might well lead to some substances being regulated rather than banned. They are also concerned by the anomalies in the current system (eg around poppers, GBL, nitrous oxide).

This is quite similar to the civil servants’ perspective, but less bound by politics, as well as the reformers’ perspective. It is an open perspective that requires clear evidence to determine the way forward that would actually reduce harms.

Enforcers’ perspective

Box 11    Enforcers’ perspective

Enforcers believe that any relaxation in the legal position will lead to a dramatic increase in use of drugs, with a concomitant increase in the harms due to addiction, mental illness, overdoses and other accidents. Drugs are bad and we have to do all that we can to stop young (and older) people using them. We have to be much tougher using border controls to prevent the importation of drugs of all kinds. We have to be tougher on the criminals who import and distribute drugs and we have to combat the pervasive pro-drug culture in the UK. The sake of our children’s future depends on maintaining an approach to drugs backed by the threat of criminal sanction to send the right message of deterrence.

At the workshop this perspective was presented as being entirely based on a desire for harm reduction. Nevertheless the implicit value judgements that drugs are bad, that being intoxicated is not good and that the moral fibre of our culture is at risk was always visible beneath the surface. This appeared to be the most ‘closed’ perspective at the workshop; there was very little scope for any shift.

Young people’s perspective

The significant perspective not represented at either workshop was that of young people. The first workshop included a young person below the age of 25 years old who had previously had problems with drugs and was working as a peer drug mentor for a local charity.

At the workshop it was recognised that there were several sub-groups of young people of relevance, characterised during the workshops as:

A Young people who do not use drugs, or have tried drugs a couple of times but ultimately do not use. According to available surveys, this applies to the majority of young people.
Participants at the first workshop raised the question of why the majority did not use drugs. Was it as a result of personal inclination, lack of opportunity or because drugs were illegal?

B Pupils still at school who use drugs occasionally. The interesting question that arose regarding this group was why the consumption of all types of drugs and alcohol in this group has steadily declined since 2001.

C Clubbers and other young adults in the age range 18–30 who used drugs recreationally as part of a dance culture in which drugs enhance the experience and facilitate the ‘all night’ participation that is a feature of this scene. This is the group that adopted mephedrone enthusiastically in 2008/09 and towards whom the ‘legal highs’ marketing is targeted.

D Young people of any age for whom drug use becomes problematic. This is a small proportion of the total number of young people using drugs. It was also recognised that in most cases drug use was a symptom of more general problems for this group who were at risk for other reasons.

In order to ensure representation of young people in the research, we conducted a separate focus group with eight young people between the ages of 17 and 25. The focus group was arranged with help from the Foyer Federation, and included young people who were living in one of their supported accommodation centres. While young people in Foyer Federation housing often come from chaotic households, and would fall into category D above, those who participated in this focus group appeared to fall into group A or B of those outlined above.

Box 12    A young person’s perspective on drugs

Alcohol and tobacco are just as harmful as drugs like cannabis and ecstasy, though ultimately it’s very difficult to say which is more harmful (there was little consensus on the relative harms among the group of young people we spoke to). They suggested people use drugs for a range of reasons, but mainly through curiosity, boredom, because everyone else is doing it, the media, and popular music and culture. Legality of a substance doesn’t matter as much as the effect. Young people will take things that make them feel good, and try things that their friends recommend. For some, even, the illegality of something makes it more cool and more desirable:

They don’t really care whether it’s legal or not... if people give them something they’re like ‘what’s this’, not ‘is this legal’, they don’t care if it’s legal. If it gives them a buzz, the higher they feel, the better they think it is. They don’t care if it’s legal or not. Most of the time, if it’s with the people they trust, they don’t care if it’s legal anyway.

The media plays a huge role, with lots of young people using drugs because they see other people (singers, rappers) doing it.

Most of the young people in the focus group had heard of mephedrone but were not necessarily familiar with the term ‘legal highs’. Their knowledge of mephedrone mainly came through the media, though a few had friends who used it; no one at the focus group admitted to trying mephedrone, or other drugs. Although they described friends getting it from other friends, motivations for using mephedrone were thought to be curiosity, legality (‘they don’t get done for it if they get caught’) and availability. One participant noted their friends had tried Spice, mainly because it was legal, but didn’t like the effect so went back to smoking cannabis. In general, the young people were very aware of the harms of drugs, tobacco and alcohol. There was lively debate about whether alcohol, cannabis or tobacco was more harmful, but almost all the participants thought that ecstasy and mephedrone were very harmful. Opinions were again divided over whether drugs should be controlled: many felt that the harms caused by alcohol were the result of its easy accessibility. Nevertheless, most felt that legalising cannabis ‘wouldn’t make much of a difference’ because it was already widely available. No one thought that all drugs should be legalised. Interestingly, one participant spoke about being surrounded by drugs, including from his parents, but ‘got a thrill’ from saying no:

But I’ve chilled with these people my entire life, and I’ve never taken these things. My dad is the biggest smoker you’ll ever know. All my friends. I’m always in the circle. If I’m going to die it’ll be of passive smoking, because I take it every day, I’m always around him. He’s like do you want some, and I’m like no, I’m alright. My thrill is saying no. I get a thrill out of it – like yeah, I can say no. That’s why I’m so independent today.

One of the surprising features of both workshops was that the debates between the participants were extremely constructive with a great deal of acknowledgement involved in the exchanges. This was in sharp contrast to the way drug issues are presented in the media. All the participants had considerable experience of working with and around drug policy and the discussions were rich in ideas and challenges, some of which are included in the description of perspectives above. The next two chapters summarise the issues on which the participants in each workshop were able to form a consensus. This should be instructive to policy makers in seeking to make improvements to drug policy that would enjoy wider support.

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