Vol 29 | Issue 2 | March/April 2014

l Minority reports DruglinkReporting on drugs since 1975 l Commissioning l Headshops l China High anxiety: Getting perspective on ‘legal highs’

March/April 2014 Druglink | a Helen Joubert Design

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News

2 is there a shortage? 2 Uruguay grapples with pasta base 3 Mystery of super-strong E Druglink 3 NPS seizures – headshops raided 4 New laws on cutting agents 5 News comment: Disunited nations 6 News focus: The emerald experiment NPS: we are not all Features doomed 8 Stress release Rebecca Lees looks at problematic Like ‘The War on Drugs’, the term ‘legal highs’ has become equally unhelpful use in the LGBT and inaccurate with the usual panoply of ‘unintended consequences’. But community. whatever the terminology, the presence of substances, many of which have very similar effects to controlled drugs, but sit outside the law and are easily 10 cultural shifts purchased online, represents a significant new dimension to the global drug Substance use among British-Asian scene. And without doubt, the legal challenge should not be underestimated. people – Max Daly reports. That said, the problem is not necessarily insurmountable; the most visible manifestation of the new situation are high street head shops which, for 12 at your service? example, the Irish government has closed down without too much head Does the commissioning of drug scratching. Whether this is a wise policy or not remains to be seen. The NPS and alcohol services push smaller business may well be driven online, but then nobody seriously believes that agencies out of the market? By Sara you can close down all traditional drug trafficking, so why should the internet McGrail. be any different? If you want to pursue a law enforcement-focused policy, then as ever, you do what you can to tackle the issue, accepting all the limitations. 16 The Druglink Interview In the UK, at least, not that many people are coming forward to services as Tim Sampey of Build on Belief talks yet with a currently still legal NPS as a primary drug problem. And for those to Harry Shapiro about how the workers who are faced with this, the message is ‘deal with what’s in front of service user charity started. you’ – the chances are that the person has taken a drug very similar to what you have been familiar with for years. And as far as education and prevention 18 The X factor is concerned, we have a wealth of evidence of what works and what doesn’t; Mike Power reports on a so no new wheels have to be invented here either. controversial Welsh service that tests For the media, however, NPS is the hot drug story in town right now, which people’s drugs for them. inevitably has political repercussions. So it behoves all of us, whether service providers, clinicians or researchers, not to add fuel to the current firestorm. 20 chinese take away Peter Shadbolt investigates links Harry Shapiro between crystal meth in China, Editor and Director of Communications and Information the pharmaceutical industry and Mexican drug cartels.

Regulars

22 research: should dependent DrugScope DrugScope is the UK’s DRUGLINK STAFF Cover illustration drinkers always try for abstinence? Asra House leading independent centre Editor Harry Shapiro Luke Waller, 1 Long Lane of expertise on drugs and Editorial Assistant www.lukewaller.co.uk London SE1 4PG the national membership Ruth Goldsmith CONTRIBUTIONS 24 reviews Telephone organisation for those Online Jackie Buckle Druglink welcomes letters Blaine Stothard reviews Youthoria, a 020 7234 9730 working to reduce drug Book Reviews Editor and other contributions. Email harms. Our aim is to inform Blaine Stothard Send direct or contact guide to adolescent substance use. [email protected] policy development and Director of Communications Harry Shapiro Victoria Brooks on a collection of Web reduce drug-related risk. and Information Email: new and important topics in drugs www.drugscope.org.uk We provide quality drug Harry Shapiro [email protected] Druglink is for all those information, promote ADVERTISEMENTS Material published in and alcohol. with a professional or effective responses to drug Email: Druglink does not necessarily occupational interest in drug taking, undertake research, [email protected] represent the views or problems and responses advise on policy-making, The inclusion of an policies of DrugScope 26 Factsheet – GBL to them – policymakers encourage informed debate advertisement, flyer or free © DrugScope/the author(s). and researchers, health and speak for our members sample in Druglink does not All rights fully reserved. workers, teachers and other working on the ground. imply any endorsement of a Requests for permission Cover Story educators, social workers SUBSCRIPTIONS particular product or service to reproduce material 28 headspace – A hidden threat and counsellors, probation Subscription for the year by DrugScope or Druglink. from Druglink should be Mike Power on media hype around and police officers, and drug (six issues): £55 Design addressed to the editor. workers. To subscribe call Helen Joubert Design ISSN 0305-4349 ‘legal highs’. 020 7234 9730 www.helenjoubertdesign. com

March/April 2014 Druglink | 1 NEWS

Is there a ketamine shortage?

Drug-oriented internet chat forums such Revenue Intelligence raided an industrial major disruption of supply could impact as Bluelight and Silk Road are buzzing unit near the city of Jalgaon in western else where quite quickly. with queries about what is claimed to India. The drugs were alleged to belong Worryingly, there are also reports be a ketamine ‘drought’ in the UK right to Vikas Puri, who reportedly owns of ‘fake’ ketamine in circulation from now. Several online forum members are pharmaceutical and chemical companies users who have subjected the substance saying that they just cannot get hold of based in a suburb of Mumbai. India is the to a Mandelin reagent and Marquis the drug at all and wondering what is major source country for ketamine into colour testing as well as sampling the going on. the UK. drug themselves. Results have been Some have referenced a seizure of 225 The situation is reminiscent of inconclusive as to what the substance kilos of ketamine on the M6 in February the huge seizure of safrole, the main is, but some of what is being sold as by Titan, the north west’s regional crime precursor for MDMA, in Cambodia ketamine appears to contain none unit. The police estimated the ketamine in 2008, which resulted in an ecstasy of the drug at all, or is extremely haul to be worth just under £7m on the shortage in Europe. The drug in badly prepared ketamine and/or even street. But if drug seizures are at the circulation was of poor quality, allowing 4-Methylethcathinone (4-MEC). Whatever root of the situation, then the seizure much stronger to gain a it is, the warnings have been stark; from of 1.2 tonnes of ketamine by the Indian foothold in the UK, a position now since users lapsing into unconsciousness authorities back in December may consolidated. What comes out of India, through to serious nasal damage. be more germane. The Directorate of however, is the finished product, so any

Uruguay grapples with pasta base

While Uruguay captured the world’s attention by becoming the first country to legalise cannabis, another drug issue remains more hidden. The problem is the growing number of poor people addicted to ‘pasta base’, a by-product of refining into . Crude cocaine preparations such as pasta base (also known as paco or basuco) are marketed as cheap alternatives to cocaine aimed at local markets. As cocaine production has spread beyond Colombia, Peru and Bolivia, so the use of coca paste has also spread to Argentina, Chile and Uruguay. Another coca derivative known as Oxi has become very popular in Brazil over the past decade and overall, while use of cocaine by-products has been reported for years, the more recent world economic downturn is being blamed for exacerbating the problem. It is the hope of the Uruguayan government that a legalised cannabis market whereby users can either grow their own or buy up to 40g a month from a pharmacy, will drive a wedge between the cannabis market and the market for other drugs. Opinions of course, differ; smoke who will then want to try other drug and feel that if cannabis is more some people believe in the gateway drugs. Others, who have been addicted to freely available, more people who have theory of cannabis and that a legalised pasta base, have used cannabis to wean a problem with crude cocaine products market will encourage more people to themselves off the more dangerous will have help finding a way out.

2 | Druglink March/April 2014 NEWS

Mystery of super-strong E New queries over NPS Recent months have seen an increase in a huge amount of the main precursor the availability of pills containing MDMA had been seized in the Far East causing above 180mg, even in excess of 200mg a drought. Mephedrone came in to death claims in some cases, which have resulted in fill the vacuum, but perhaps now the medical emergencies and at least one MDMA chemists (or at least those not In this issue (see page 18) author Mike death. The main culprit identified in also making mephedrone as well) are Power challenges the calculations from the UK is a red pill embossed with a somehow fighting back in an attempt St George’s Hospital Medical School drug dragon logo sold under the name ‘Mortal to recapture some lost ground, before deaths statistics (np-SAD) on the number Kombat’. Why such a product should perhaps reducing the strength back of NPS deaths on the basis that the be in circulation is unknown, however, down towards a more standard dose. figures include substances long banned the presence of high strength MDMA is Time will tell. and others that don’t really qualify as confirmed by the 4th annual report of NPS. Professor David Nutt and former the Trans-European Drug Information Home Office forensic scientist Dr Les project or TEDI, funded by the Health King raised the point in the pages of The Programme of the EU. The latest report Lancet. covering July-November 2013 found that Now a similar issue has arisen with 11% of tablets tested contained 150mg figures published by the government of MDMA or more up to an alarming statistics office for Scotland. However, 271 mg in one sample, although overall, in this case, it is more to do with how tablet purity remained on average the the figures have been interpreted by the same as 2012. media rather than doubts over how the So why would anybody bother to put figures themselves have been presented. out high strength ecstasy pills? It has The Daily Telegraph (25 March) claimed been shown that around 2008/09, the that the figures showed that ‘a total of quality of MDMA was relatively poor as 36 people died in Scotland in 2012 after taking legal drugs…this represents a 300% rise on the 12 people who are reported to have died in Scotland…in 2010’. However, a closer reading of the NPS seizures figures reveals a very different picture. In fact, of those deaths (which the official report cites as 32 not 36), in only five In the continuing cat and mouse game cases could it be said that NPS were between the police and headshops, the only drugs implicated and even for Leeds police raided a branch of Dr three of those, the deaths were ‘drug- Hermans in Leeds city centre. Police related’ rather than necessarily as a said that they seized the products in the direct consequence of drug ingestion. hunt for substances that might already And as the official report admits, ‘the be controlled, but continue to be on definition of a drug-related death is not sale as legal substances. In Bradford, a straightforward’. Drilling down further head shop owner was convicted under still, it appears that in 2012, there were Section 9A of the Misuse of Drugs Act, only two deaths where an NPS was the where it is an offence to supply articles only drug involved. One case revealed (such as bongs, pipes etc) that could be the presence of phenazepam (controlled used to administer or prepare controlled from June 2012), but alcohol was also drugs. It is exceptions to this legislation present. The other death involved APB that allow for the provision of injecting (Benzo Fury). equipment and foil. And in another case, police secured a conviction under the Intoxicating Substances (Supply)

Act 1985. This was originally brought rd Tele graph and A rg us B rad fo in to prosecute shop owners who sold solvents to those under 18 years old inhaled substances. In the context of where they could reasonably know NPS, this would apply only to smoking or assume that the product would be mixtures, but not to pills or powders. The misused. However, the current wording Home Office is currently reviewing the of the legislation restricts its use to UK response to NPS.

March/April 2014 Druglink | 3 NEWS

Cutting out the middlemen

Following a consultation last year, the government is to introduce new legislation to strengthen powers of seizure against those supplying cutting agents for use in the illegal drug trade. For the 2008 Street Drug Survey, Druglink reported that a whole new industry had grown up supplying ‘bash’ as it is known in the street. Some criminals had ditched selling illegal drugs to cash in on the legality of buying and selling cutting agents. Currently there are no laws or regulations that target the domestic trade in cutting agents; up to now any seizures of cutting agents would in theory have to be returned, even if there was suspicion that they were being used in drug production. The new powers would be available to the National Crime Agency, all UK police forces and the Border Force m ai l ly dai enabling enforcement agencies to enter and search premises, seize and destroy While most responses to the suspected chemicals. Originally, the consultation were in favour of the new target chemicals were benzocaine, controls, there were concerns expressed Street lidocaine and phenacetin (used mainly that these relatively benign substances, in cocaine adulteration) but could now could be replaced by more toxic apply to any suspect chemical. substitutes. cannabis dealing angers Dutch locals Catching the worm The citizens of Maastricht are up in arms about open cannabis dealing on their A recent article in Vice magazine revealed producers very little compared with the streets. Nothing very newsworthy there, the degree to which cocaine is cut with profits, with an adulterant that is more except it is the country’s new policy of an anti-worming substance called expensive than alternatives? clamping down on cannabis ‘tourism’ levamisole. In 2005, around 2% of cocaine The article’s author, a chemist and closing down any cafes near seized by the DEA in America contained specialising in drug testing, concluded schools, which has seen an unwelcome levamisole, by 2011 this had jumped to that there were two plausible reasons. return of old ways. Not every city has 75% of all seizures – and that included Firstly, one of the metabolites of fully embraced the new regulations; samples from multi-ton shipments levamisole is a compound called foreigners can still smoke in any of suggesting that cutting of cocaine was which has - Amsterdam’s 200 hundred cafes. But happening at source. like stimulant properties. Secondly, with its 14 ‘coffeeshops’, Maastricht has For those who are regular high dose levamisole increases the amount of gone the whole way, and in consequence, users of cocaine, levamisole is by no released in the brain and locals say that the streets have become means a benign cutting agent. Users so combined with the dopamine more intimidating as dealers hassle run the risk of a condition known as release prompted by cocaine, would tourists and fight over turf.T here are also agranulocytosis, where the immune in theory enhance the euphoric effect. concerns that the dealers are not just system is so compromised that a small Conceivably, this might give traffickers selling cannabis; the original idea of the scratch or infection can develop into a and dealers the opportunity to promote coffeeshops was to put some distance life-threatening disease. their product as being of superior quality between a legalised environment for But the questions remains, why cut and hence more expensive. using cannabis, and the street drug high grade cocaine which is costing the scene.

4 | Druglink March/April 2014 NEWS comment Disunited Nations

Behind the scenes at the UN’s latest drug summit, frantic negotiations took place in order to acknowledge the changing nature of the drug debate. But as Max Daly discovered in Vienna, all the world could do was agree to disagree.

The UN’s High Level meeting in Vienna cheekily described the JMS as a “broad (March 13-14) marked the midway point consensus”. in its 10-year action plan to reduce or He played down talk about Uruguay eradicate the use and production of or the two US states sparking a new illegal drugs by 2019. trend in cannabis legalization. “So far I The aim of the meeting was to track don’t see any other countries, or group progress, acknowledge new challenges of countries, that may follow the route and look to the future before a special which has been taken by Uruguay,” he session of the UN General Assembly in said. 2016. Discussion was to be concluded Fedotov had earlier said legalisation with the publishing of a joint ministerial was not a solution to the world’s statement (JMS), a consensus on what narcotics problem. He said legislation in needs to be done. Uruguay was not compatible with the At first glance the meeting, attended “letter and spirit” of international drug by 1,300 delegates from 137 member control conventions, however the UN has states, simply involved countries But the chasm of opposing views on taken no action against Uruguay for its updating each other in an often robotic international drug policy is widening new drug law. fashion, on how they were doing in and countries stand on either side of Between the lines, there was an terms of tackling their own drug problem the rift; those interested in increased interesting dynamic in Vienna. It became and the latest issues they were facing. harm reduction and legalization, apparent that, because of developments They were all dutifully seizing drugs, such as Ecuador, Uruguay, Mexico, in its own backyard, the US, previously helping users and noted the rise of Portugal, Germany, Czech Republic and a notable sabre rattler in the anti-harm NPS. Alongside this, there were three Switzerland; and those who want to reduction, pro-hardline approach to drug roundtable sessions, during which preserve zero tolerance style approaches policy, has been forced to take a step countries explained where they were to drug policy, such as Pakistan, Saudi back, it’s position undermined by the in terms of reducing demand, reducing Arabia, Japan, Thailand, Sweden, China democratic decisions of its own citizens. supply and tackling money laundering. and Singapore. Russia, with one of its most senior Although there were interesting Unsurprisingly, these pow-wows diplomats at the helm of the UNODC, nuggets of information that came from came to nothing. The key battlegrounds may have become the new global all this – the importance of alternative – the use of the death penalty for policeman in the war on drugs. One development in drug producing zones, drug offences, the inclusion of the Russian speaker slated the efforts of Uruguay explaining that it owed it expression ‘harm reduction’ and the the US and the UK in tackling to its citizens to legalise the use and acknowledgment that some jurisdictions production in Afghanistan as a “fiasco”. production of cannabis and Sweden were experimenting with new drug Even so, far from being a joint cementing its reputation as the hardline policies – remained entirely unresolved enterprise, and severely hampered by drug warrior of Europe – the two day and therefore were cleansed from the the arrival and spread of NPS and online meeting was largely an exercise in final statement. In the end, all the UN drug buying, any notion of a unified window dressing. member states could do was to sign a global effort to tackle the drug problem Most of the real discussion had piece of paper saying they would agree is under increasing strain and calls into already taken place. For several months, to disagree. The consensus ended up a question the validity of the UN drug in a complex game of brinkmanship, virtual clone of the agreement made in treaties themselves. representatives from countries had, in 2009. n Max Daly is author of Narcomania: the run up to Vienna, been banging their At a press conference to mark the How Britain Got Hooked on Drugs heads together in order to agree on a end of the meeting, UNODC executive statement. director Yuri Fedotov somewhat

March/April 2014 Druglink | 5 NEWS Focus The emerald experiment W ikip e dia

Bold new laws introduced in Ireland to tackle legal highs and NPS dramatically cut the number of head shops. But the country’s drug users merely switched substances or modes of supply. Tim Bingham reports.

Internationally, there has been a lot of In 2006, 1- (BZP) to ban BZP, which by this time had interest in relation to Ireland’s Novel tablets emerged onto the market and started to dominate the traditional Psychoactive Substance Act 2010 and were being sold in these shops as herbal ecstasy market. Most of these tablets the impact this has had on the country’s ecstasy. Around this time, head shops were being sold as ecstasy. Garda official head shop trade. But to start off, a quick expanded and young people who were seizure figures at the time confirm this: bit of context. not using drugs were being introduced to less than 19,000 ecstasy tablets were The first head shop opened in Ireland these substances as ‘legal highs’. Tablets seized in 2009, compared with 119,000 in 2000, although it sold only drug sold for around €5 and the average pill in 2008 and 285,000 in 2007. BZP was paraphernalia. By 2005, there were six contained 540mg of BZP. banned in March 2009. head shops in Dublin city centre selling In 2007, white powder products Meanwhile, in late 2008, cacti that contained . These started to emerge in the head shops. The phenylmethylethylketone, the ecstasy were being sold for between €30 to €400. majority of these were -based precursor, became unavailable in Europe. During this time magic mushrooms products such as mephedrone and were This had a significant effect on the were starting to be sold in a few of these selling for €25 per half gram. quality and quantity of ecstasy tablets shops. At around this time there were calls available in Ireland.

6 | Druglink March/April 2014 NEWS Focus

So with the double whammy of a underground, back onto banned annual report reveals almost €71m paucity of ecstasy and a ban on its substances. In one instance we seized worth of cannabis was seized, compared inferior imitator BZP, white powder 500,000 BZP tablets. The person who was to €42m in 2011. Although the police substances filled the void and grew holding onto them was of the firm belief have heightened the value of cannabis in popularity. However, services were they were ecstasy tablets.” plants, artificially increasing the value reporting that the most common of these The new law has been effective in of plants seized, twice as many plants powders, mephedrone, was causing terms of young people accessing these were seized and tested by the Forensic significant problems, specifically at the substances through retail outlets. Science Laboratory in 2012 compared to time among the homeless population. However, services are reporting that they the previous year. Van Hout & Bingham (2011) are seeing an increase in young people The report showed some 5.6kg of undertook a study among clients that accessing services with mental health MDMA powder was seized in 2012, were injecting mephedrone called A issues related to synthetic cannabis compared to just under 1kg in 2011. costly turn on: Patterns of use and perceived products. Overall, 165,000 tablets were seized in consequences of mephedrone based head 2012 compared to 101,000 in 2011. shop products amongst Irish injectors. However, despite the law change, the Speaking to colleagues in other European as many people seizures of MDMA paled in comparison countries, no one else was reporting that to the seizures of NPS. There continues mephedrone was being injected. working in the field to be a significant market in banned During the next few years head shops had predicted, after head shop drugs, with similar quantities were opening in virtually every town of new synthetic (46kg) and in Ireland. Some began offering home the head shops closed synthetic cannabis mixtures (32kg) being delivery services and were open 24 hours down, the substances intercepted in 2012 compared to the year a day. The Gardi said that mephedrone before, of synthetic cannabis were seized was directly linked to a spike in crime, still found their way in 2012. particularly theft and mugging, among onto the streets of It’s now easy to access these young people who had not been in substances via the internet and through contact with Gardi before. Ireland the postal system. Customs figures show “The whole head shop thing was a that, post 2011, there have 808 seizures massive deal for us,” one Garda officer of NPS at the border. Intriguingly, the told me. “The drugs they sold broke Research carried out by Denis Murray vast majority of these seizures, 614, were down barriers and taboos. People who of Ireland’s Health Services Executive of NPS imported from Hungary. had never ever come to the attention of published last year showed a rise in This country’s new Psychoactive the Gardaí, who came from good homes drug debts related to the buying of NPS. Substances Act has been effective in and had a good education, were all of a The study, Professionals’ Understanding of closing down head shops and it appears sudden robbing people in the street and Risk Factors for Substance Misuse by Young that the result of this has been to dent beating them. Their motive for doing People and Approaches to Intervention, the ‘legal high’ status of NPS – as most it was to get more money to buy this published by the National University are now bought on the illicit market. stuff. Our robberies were going through of Galway, highlighted young people But there have been unintended the roof because people were becoming with poor school attendance and consequences of the Act, whereby some addicted.” indebtedness, resulting in families being young people are moving over to using On the 23rd August 2010, the intimidated by drug dealers and an other, more risky, substances from street Psychoactive Substances Act became law. increase in the number of young people dealers. The ultimate aim of this legislation was absconding from home due to spiralling Certainly, banned NPS are still to shut down the head shop industry. drug debts. available and being sold under a different Overnight four tonnes of psychoactive Indebtedness relates primarily to name. We know that mephedrone is substances were handed to the police synthetic cannabinoids and to amounts now a frequent cutting agent in cocaine as shops closed their shutters. But as of between €50 and €3600. The research and even ecstasy pills. Some former NPS many people working in the field had found that young people are obtaining buyers have merely shifted their drug predicted, after the head shops closed synthetic cannabinoids from the internet of choice and there is growing evidnce down, the substances still found their and the street. Some are being sold they are using anti-anxiety medications, way onto the streets of Ireland. synthetic cannabis as real cannabis. while ketamine is on the increase among In addition Zopiclone and Xanax, So where is Ireland at in terms Irish clubbers. smuggled into Ireland from Pakistan, of drug use trends? The most recent In conclusion, the Act hasn’t made India and China and sold on the illicit statistics, which cover 2010, published drug use any safer, as drug workers and market from legal prescriptions, began to last year by the National Drug Treatment drug users have even less idea as to what grow in popularity among users Reporting System show that for under- the contents of the pills and powders because of the heroin drought. 18s, cannabis – whether synthetic or really are now. Indeed, the Act generated a not – accounted for almost 50 per cent of resurgence of BZP tablets. One Garda treatment presentations. n Tim Bingham is an independent source said: “With the closure of the Evidence from law enforcement trainer and researcher on drug trends head shops a lot of drug use went reflects this trend.T he Garda’s 2012 and harm reduction in Ireland

March/April 2014 Druglink | 7 Communities Stress release

The rise of problematic stimulant use within the gay drug scene is stretching already limited services for LGBT users. Rebecca Lees investigates what is driving this scene and what is being done to help those who needed help.

For the lesbian, gay, bisexual and helping gay men experiencing drugs The results are increased needle sharing transgender community, drug and sexual and safe sex issues in the capital. and risky sex in organised chem-sex health issues are, as one drugs worker Charities report that, whereas the parties. puts it, two sides of the same coin. Yet drugs of choice used to be ecstasy, “Gay men and drugs have always support from mainstream services isn’t cocaine and ketamine, there has been gone hand in hand but it used to be that always joined up and there remains a marked swing towards crystal meth, they might go to a club, pull and end a great sense of stigma, isolation and mephedrone and G (GHB or GBL), and up in bed at the end of the night,” says shame reported by LGBT people seeking this shift has coincided with a rise not Moncrieff. “The pattern has changed and support. just in HIV cases but also in hepatitis C now it’s deliberate. Smart phone apps The landscape has changed and other STIs. such as Grindr facilitate very easy access dramatically in a short space of time, Monty Moncrieff, chief executive of to meeting other men and co-ordinating with the use of club drugs – and chem London Friend, the UK’s oldest LGBT sex, including bareback sex (without sex – exploding. A few years ago, there health and wellbeing charity, says that condoms). It’s bringing a huge challenge were fears the UK was on the brink of a drug use by gay and bi men has changed into drugs work.” crystal meth crisis following an epidemic dramatically in the past five years. “In London Friend’s services include in America. The predicted explosion 2005, nobody was using crystal meth at counselling, coming out support, social didn’t happen; Home Office figures show all and nobody was using mephedrone,” groups, HIV prevention and sexual that 17,000 people in England and Wales he says. “A very small amount were using health awareness. Since 2011 it has took crystal in 2012. Yet of this relatively G alongside other drugs, but now, about also been the home of drug and alcohol small number, a disproportionate two thirds of the people we see are using support service Antidote, which was amount was from the gay community – these drugs.” Originally a legal high, initially managed by Turning Point. and the consequences are alarming. mephedrone was easily available and is, Operating on the same principles as Department of Health figures released as Moncrieff puts it, “just so more-ish”. mainstream support but applying them last year show a 21% increase in new And it’s not just the drugs themselves in an LGBT-competent way, the project’s HIV infections between 2011 and 2012 that have changed. The way users are specialist nature is critical to clients, amongst gay and bisexual men in taking drugs has shifted, with more and many of whom have experienced a lack London, leading the Terrence Higgins more injecting mephedrone and crystal of understanding, isolation and shame at Trust to call for a ‘greater focus’ on rather than swallowing or snorting them. mainstream clinics.

8 | Druglink March/April 2014 Moncrieff believes that this sense of survey asking clients if they feel it’s research is underway. Substance misuse shame and anxiety is at the root of the important to access an LGBT service and organisation New Link Wales, which drug use and sexual behaviour of about the response is clear, with just 12% of promotes engagement with diverse 90% of Antidote’s clients, even though users considering accessing mainstream communities, has already conducted a different triggers bring them through services. “They feel safe in this scoping study and is now working with the door in the first place. A“ ll your life environment and that they don’t have Cardiff University and Cardiff Mardi Gras you’ve been told that your relationship to explain themselves,” says Moncrieff. to get a fuller picture of the issues. is second class,” he says. “People have “There’s a commonality that makes it “Within the LGBT community grown up with that and it’s led them to easier.” in Wales there is a deep level of think their sex life is dirty or shameful. dependency,” says chief executive Men are constantly reconciling their gay shame and anxiety Lindsay Bruce. “There are a lot of identity with the rest of their identity theories about why but we don’t know and a lot of their drug use is connected is at the root of the which apply to Wales yet. One of with that. We hear people saying that drug use and sexual the issues we’re looking at is gender their drug use facilitates this amazing atypicality. People with a ‘fem’ identity sex that they have never felt entitled to. behaviour of about spend a lot of time pretending to be When you strip it down, the correlation 90% of our clients straight and take longer to come out, between drug use and identity is stark.” so there is more closet stress. With the One drugs worker in the north west, butch community, they are visibly gay who asked not to be named, agrees LGBT drug users also tend to inhabit and wear it; for example, matching that LGBT users face a lot of prejudice a slightly different demographic to the blokes drinking pint for pint, so they from mainstream service providers. mainstream. A mainstream service are more vulnerable to hate crime and In Manchester, Liverpool and the might be set up to work with opiate and discrimination. surrounding areas, crystal meth hasn’t crack users, which doesn’t necessarily “Some turn to drink and drugs to taken hold as it has in London, but GBL is correlate with gay drug use. Mainstream relieve this stress but other people prevalent and the use of ketamine is, she users are more likely to have a chaotic use drugs differently. I’d be interested says, ‘huge’. Cocaine is also popular with lifestyle, whereas gay men are more in looking at sexual rituals. There is gay men. Drugs are being taken in places likely to be working, in a relationship an excess, as in ‘let’s try everything like saunas, with users becoming so high and own a home or be a reliable tenant. once’. The excess becomes the point of they don’t know what they are doing or, “Our clients come from absolutely all pleasure and it’s not about climaxing but later, what kind of sex they have had, walks of life, including high-powered about how long you can go for, so they increasing their risk of HIV and other professional jobs,” says Moncrieff. use stimulants and Viagra to overcome infections. “They are more likely to have a recovery biology.” “There is a need to promote safer sex capacity because, often, their lives are Cocaine, amphetamine and crystal and provide condoms,” she says. more stable. The problems are with meth use is prevalent in Wales, whilst “I don’t think (mainstream) drug keeping their job or relationship when another problem is the use of hormones services have quite grasped that sexual the drug use is creeping up and starting by transgender people. There’s a feeling health and drugs are two sides of the to have an impact, and this is a change within the community that buying same coin. They don’t fully understand for services to understand and to provide illicit hormones isn’t misuse, yet unless the nature of LGBT drug use, for a for.” properly prescribed, there are dangers couple of reasons. Firstly, there’s the As the prevalence of HIV and such as overdosing. Another issue is the stigmatisation of what it is to be gay hepatitis C rises and more clients seek use of unprescribed painkillers following in the media. Secondly, there’s the post-exposure treatment, one of the gender surgery, and these complex vulnerability. Young people are still challenges for services is to educate matters are not on the radar of some being thrown out of home for coming about dangers users might be unaware mainstream services. out. Homophobia is alive and well and of. Many clients don’t initially realise, New Link Wales acts as a bridge gays are the last bastion to pick on. And, for example, that G is addictive. As a between communities, volunteers, of course, the type of sex they have result, after partying relatively safely agencies and training providers to disinhibits them and takes away that for a long time in a controlled way with make sure minorities such as the LGBT stigma and shame for the moment.” drugs such as ecstasy, they suddenly find group can get appropriate and effective Hence the need for specialist LGBT themselves needing strong stimulants support. London Friend also provides drug services. Working with the gay every couple of hours, every day. As a training to other services to help them community can be a highly specialised consequence they can be awake for two, understand the issues their LGBT clients role, not just in terms of understanding three or even four days at a time, which may be experiencing. and being comfortable talking about has a significant impact on their health. “The question for us is: how are we gay and lesbian sex but also for medical It seems that there’s a long way to going to improve the health of LGBT reasons, such as knowing the reactions go before the LGBT community receives people?” says Moncrieff. “How do you of recreational drugs with prescription the attention other drug using groups make it easier for people to be who they drugs. For example, HIV is measured in get. As the worker in the north west are? It’s about drugs but it’s also about a ‘viral load’ – the amount of HIV in the points out: “When six kids collapsed wellbeing and happiness. A lot of people bloodstream – and cocaine and crystal after taking GBL in Liverpool it was are feeling low-level pressure internally meth can increase the viral load of a in the news, but it’s been happening on a daily basis, and it’s a big public HIV positive person and cause them to in the gay community for years. The health challenge.” become ill quite quickly. LGBT group is constantly ignored and London Friend carries out an annual it needs looking into more.” In Wales, n Rebecca Lees is a freelance journalist

March/April 2014 Druglink | 9 Communities Cultural shifts Stereotypes of Asian substance use probably assume heroin to be the main problem drug. But is this an outdated view? Max Daly speaks to those on the frontline.

Britain’s Asian population has always among non-whites, the proportion of last and university taking legal highs and had a reputation as the least likely year drug users during the same four- cannabis,” says Ashfaq. ethnic group to take drugs. In the mid- year period had increased, from 5.1 per So what does Ashfaq think is behind 1980s, when deprived urban areas in the cent to 5.7 per cent. these changes? “Cocaine is seen as more UK were witnessing escalating heroin This was not driven by a rise in drug socially acceptable than heroin. They use addiction, it appeared from those coming use in the Black community, which had drugs because of peer pressure. It is seen into services that Asian people, many also seen a fall, from 7.6 per cent to 6.2 by some people as being cool, a sign of also living in poverty in these cities, had per cent, but instead by Asian drug users, being upwardly mobile. They start using remained unaffected by the epidemic. up almost 50 per cent in four years from it as a party drug, but some get addicted. According to a 1986 report by Lord 2.6 per cent to 3.8 per cent. “The interesting thing for me is that Kamlesh Patel (who at the time worked The rise is largely the result, the the culture of Bollywood promotes with Asian drug users in Bradford), Asian statistics show, of an increase in the cocaine use, as a confidence booster drug users certainly existed – and some use of cannabis and stimulants such and dietary aid. It’s not said directly, it’s were dependent heroin users. It was just as cocaine by Asian people – despite a subtle.” that they seemed to be ‘missing’ from downturn in the use of these drugs by Whether any Bollywood films do the treatment system. One contributory white and Black people. cast cocaine in a positive light remains factor was the heightened stigma It’s a trend that has also been spotted open for debate, but certainly in recent attached to intoxication and addiction by those working on the frontline. years there have been a rising number within the Asian community and the “We have seen a big rise in of instances where stars have either reluctance of some Asian problem drug recreational cocaine use among young ended up in rehab with a drug problem users to seek help in white-dominated men, particularly at weddings and or have been rumoured by newspapers drug services. parties,” says Sohan Sahota, founder and Bollywood bloggers to be involved in This is also reflected in terms of of Nottingham-based drug treatment drug taking and selling. recreational drug use, according to charity Bac-In. Sahota, who set up the Despite the changing nature of drug official drug use statistics from the project in 2003 to help dependent drug use within the Asian community, and government’s annual British Crime users from BME backgrounds, says services battling for survival under Survey (now called the Crime Survey he thinks the rise in cocaine use has swingeing cuts to provision, there are for England and Wales). Since the accompanied a similar rise in alcohol signs that drug treatment for Asian government began collecting statistics use among young Asian people in people is moving with the times. on the ethnicity of Britain’s drug users the UK. KIKIT is setting up the UK’s first in the late 2000s, white and Black people Sohota says that as a result of this Islamic 12 Step programme which will have consistently been far more likely trend, drug treatment services like his start operating from a mosque-run to have taken drugs in the last year than are seeing an upturn in the number of community centre in Sparkhill in April. Asian people. Asians coming forward for help with Clients of the new service will all sign However these bald statistics hide problematic use of cannabis, alcohol and up to a code based on one created by a changing dynamic in the ethnicity of cocaine. Millati Islami, a US Muslim project based drug use and addiction in Britain, and Mohammed Ashfaq, managing in Baltimore, USA. Millati Islami, which it is a development that has become director of KIKIT Pathways to Recovery, now covers several US states, has been apparent, at first hand, to drug services a drug project based in Sparkhill in running Islamic 12 Step sessions since specialising in helping Asian clients. To Birmingham with a large Pakistani 1989. put it simply, the perceived gap in drug population, has also seen a change in the Ashfaq drew up the UK version, which use habits between Asian people and the profile ofA sian drug users. He is seeing he aims to roll out acros Birmingham by wider population is rapidly narrowing. fewer people with heroin problems and the end of the year, with the help of the In 2008-9, 10.8 per cent of the white more who have issues with other drugs. Imam at Birmingham Central Mosque population aged 16-59 said they had “Cocaine use is shooting up among to ensure it catered for all branches of used drugs in the last year. By 2012-13, middle and upper class Asians. There are Islam. this had fallen to 8.6 per cent. However, more young men and women in colleges Clients starting the programme

10 | Druglink March/April 2014 have problems with a variety of drugs We have seen a big rise in recreational including heroin, crack, cocaine and cannabis. Despite the huge levels of cocaine use among young men, stigma attached to it, alcohol misuse particularly at weddings and parties is also being tackled within the programme. “Nowadays,” says Ashfaq, “heroin is seen as a far dirtier drug than alcohol among young Muslims. Heroin is for ‘scag heads’, while alcohol, although totally against our religion, is more acceptable.” t The other element that stereotypically characterises Asian drug use is the link between trafficking of heroin from Pakistan to the UK. It is true that some British Pakistanis have become embroiled in the drug trade at all levels including drug dealing, laundering and smuggling. Lord Patel says that the rise of young Asian heroin sellers since the 1980s resulted in some of g s p o l i sl a m ic mosques. b lo o rica them becoming addicted to the drug hi s t themselves. However, as Ashfaq points out, the Policy Commission, reflected Sahota’s distribution of heroin has become a truly description. It said that drug problems ISLAMIC 12 STEPS multi-cultural affair and Muslims are within Asian communities were almost unfairly accused of creating addiction certainly underestimated because high 1. We admitted that we were neglectful in white communities. “Although people levels of stigma attached to drug use of our higher selves and that our selling heroin are from all over the and directed at users and their families lives had become unmanageable. community, a lot of people associate meant that the problem often remained 2. We came to believe that Allah could heroin with us,” says Ashfaq. “Some a hidden one. and would restore us to sanity. people in Birmingham associate heroin Lord Patel says one consequence 3. We made a decision to submit our as a problem brought to British society of this is for families to package their will to the will of Allah. by the Asian community. The far right children off to live with relatives in 4. We made a searching and fearless exploits and exaggerates this for their Pakistan or India to get treated. However, moral inventory of ourselves. own ends by saying: ‘you lot bring it over, he says that the treatment regimes, 5. We admitted to Allah and to you got our kids on it’.” particularly in Pakistan, are harsh. In ourselves the exact nature of our So what makes culturally specific addition, heroin users familiar with wrongs. BME drug treatment services different paying £100 a gram for heroin end up in 6. Asking Allah for right guidance, from a regular service? According to a place where it costs 50p a gram. we become willing and open for Sahota, they need to be able to “deal with He is concerned that gains made change, ready to have Allah remove complex problems and issues of stigma”. in improving drug treatment for our defects of character. His says that BME angled services are BME service users since the Labour 7. We humbly ask Allah to remove our vital because mainstream services are government set up the ring-fenced shortcomings. still unwelcoming places for BME drug Pooled Treatment Budget could now 8. We made a list of persons we have users. be lost, as a result of cost cutting and harmed and became willing to make “I’ve been working in drug services disinvestment. Experts agree that it amends to them all. for 18 years and mainstream services are is outlying services, such as those for 9. We made direct amends to such still failing to accommodate BME drug BME users, which are most likely to get people wherever possible, except users. “They need to deal with a variety the chop. Indeed Bac-In, for example, when to do so would injure them or of complex problems on top of the usual has had to deal with near-crippling others. issues around addiction, such as self- reductions in funding in recent years, 10. We continued to take personal image, status, caste, passive rebellion, while KIKIT is also struggling to keep inventory and when we were wrong, cultural and religious disobedience and afloat. promptly admitted it. cultural polarisation.” “Taboo and stigma are still there, 11. We sought through Salaat and Iqra “With Asians in particular,” Sahota but only a little bit more than the wider to improve our understanding of says, “there seems to be a stronger denial population, and this is now not the Taqwa and Ihsan. about problems related to drug abuse, main problem facing Asian drug users. 12. Having increased our level of Iman due to a deep sense of pride, social All the good work on drug treatment (faith) and Taqwa as a result of stigma and cultural shame leading the under Labour is in danger of being applying these steps, we carried this users into isolation and community reversed, and the services that suffer are message to humanity and began ostracism, making it difficult for them to peripheral services like BME services,” practising these principles in all our seek help.” says Lord Patel. affairs. Drugs and Diversity: Ethnic Minority Groups, a report in 2010 by the UK Drug n Max Daly is co-author of Narcomania: How Britain Got Hooked on Drugs

March/April 2014 Druglink | 11 Commissioning

At your service?

There are few subjects more fraught in our sector right now than the issue of how drug and alcohol services are commissioned. In the first of a two part article on commissioning in England, Sara McGrail reveals how smaller agencies are being forced out of the market.

manages and provides services across the whole of the care pathway in one area. It’s attractive for commissioners as it takes all that pesky coordination out of their day job. However it also often rules out smaller organisations from bidding – as they may lack experience of delivering all of the services across It was the Monday before Christmas that the pathways. From a performance the head of a small treatment service management perspective, bundling in the south-east heard that her agency may look attractive. After all you only had not got through the first stage of have one organisation to take care of the tender. It wasn’t really a surprise. – but in reality, bundling narrows the Although the agency had been providing market, restricts choice and gives large local services for over thirty years, providers significant advantages over commissioners had made it close to commissioners. That’s why it causes impossible for the charity to compete for Monitor such concerns. its own services. As a result of the bundling, the The commissioners had decided to commissioners in this case set a “bundle” all 4 of the existing contracts turnover threshold (the level of existing into one mega-contract. This is an funding those bidding must already increasingly popular approach. Bundling have) of £20 million. This was later – used primarily as a cost cutting reduced to £12 million after a challenge. mechanism by commissioners – is an However for the charity – as for many approach that the healthcare regulator charities dedicated to working in one Monitor has concerns about. A case of area – their turnover was never even putting “all your eggs in one basket”, going to reach half of that specified. bundling means that just one provider

12 | Druglink March/April 2014 Once again, they – and organisations like only excepted from the PPCC regulations, considered an NHS service, the rights them – were excluded. they are also not commissioned under of people who use drug and alcohol In research commissioned by Action the NHS constitution. What’s more, treatment services to exercise choice on Addiction in 2012, The Size and Scope while nationally we are going through an and make decisions about their own of the Voluntary Addiction Sector in England exercise to establish a National Service healthcare are not protected. and Wales, the NCVO found that within Framework for Sexual Health Services For the charity, this meant the only the substance misuse field only 8 – to set some ground rules down about legal recourse open to them would be to charities have a turnover in excess of £10 what can and should be commissioned – go to judicial review. However the costs million. The commissioners’ requirement no such exercise is taking place for drug of this (the process would have started at that all bidders had a turnover of £20 and alcohol services. about £45k) are prohibitive – impossible million meant that less than 2.2% of non and possibly unethical – for a small statutory providers nationally would charity to fund. The only option was to be able to bid. So much for opening Continuing to spend bid within a subcontractual arrangement provision up to the non-statutory sector the amounts we are – and for the charity to acknowledge that and Small to Medium Enterprises. its days of independence were probably For a small local charity with a on procurement gone. proud history of delivering high quality processes that Across the country this situation services, the cards were on the table. is being played out over and over. Their only possible way of defending the don’t naturally Small local charities are finding it hard services they had provided – successfully yield better returns to compete with the large national – for over 30 years was to enter into a companies and relatively affluent consortium arrangement with a larger for communities Foundation Trusts. It seems that these provider. is wasteful in the are the organisations who will come to When we talk about consortia in dominate the drug and alcohol service this context we need to be careful. extreme sector in England. These apparently Commissioners generally require one straightforward commissioning responsible agency to hold the contract decisions are bringing about a quiet yet to guarantee accountability. More The charity contacted PHE, the irreversible revolution within the drug often than not, when people refer to Department of Health, the Parliamentary and alcohol sector. a consortium they actually mean a and Health Service Ombudsman, Local Since January 2011 the majority of subcontracting relationship. In the long Government Ombudsman and Monitor drug and alcohol service commissioners term this also crushes competition. It to ask who was responsible for oversight in England have commenced restricts the local and national market of commissioning of these services procurement processes for their drug for services – driving smaller local given their exclusion from the PPCC and alcohol treatment services – charities and social enterprises out of regulations. No one could answer the though this information is not collated business if unsuccessful, or effectively question. In the end they – like many anywhere. Even with a conservative forcing merger if they are successful. other small charities – made the decision estimate of the costs of this you can This in turn reduces innovation, to seek legal advice. approximate a total spend on each increases costs and limits choice for According to the charity’s lawyers, one of around £120k (both bidder and commissioners and service users. commissioning of drug treatment commissioner costs). This suggests that Within the Procurement, services is effectively unregulated. It over the past three years we have spent Patient Choice and Competition is clearly set outside the framework of – in England alone – somewhere in the (PPCC) regulations there is a clear the PPCC regulations. As it is defined region of £17 million pounds just on the understanding that this is problematic. as a “Part B” contract under European administrative processes that underpin Health regulator Monitor, whose role legislation there is no requirement for procurement. If you add into that the it is to police the PPCC regulations, the local authority to do much more costs of implementation of any new advises that bundling should only be than attend to some minor regulations or recommissioned service – including used where there is a demonstrable with regard to advertising and notices. TUPE – you are looking at costs averaging advantage to people using services that The Social Value Act which is meant around £350,000 per area. This would can only be achieved in this way. Using to make local authorities consider the give us a nationwide spend over the last the regulations as its guide, Monitor social and economic impact of their 24 months of around £50 million. should have been able to intervene commissioning decisions – though likely To put this in context, according in this commissioning – and press in future to be augmented by additional to DTORS treatment cost calculations commissioners to alter their approach. European regulations – currently only from 2009, £50 million is enough money However they couldn’t. The reason for requires authorities to consider the to provide an additional 8245 people this is that drug and alcohol treatment impact of procurement decisions rather with effective drug treatment from (and sexual health services) are the than mandating this approach. There entry to successful completion, provide responsibility of Public Health England is no clinical oversight, and unlike an additional 1500 staff within drug and these two areas of healthcare are not other health services, as it is no longer treatment services or to inflation proof

March/April 2014 Druglink | 13 the current allocations for drug and medication and no rationing of services When the charity head talks about alcohol treatment spending until 2019. (Medications in Recovery, July 2012); on the the tender now, she is philosophical. Public procurement is bound – at other they are dictating to the field that Looking back over the last few years, she least in theory – by European and UK recovery must mean abstinence (Putting commented that the last time services legislation. This legislation – aimed at Full Recovery First, March 2012). were re-tendered, the service users guaranteeing fairness, transparency and With conflicting central guidance, really suffered as the treatment map equity in the spending of public money – no national service framework, no became confusing and risky. As a result, in reality does little for health and social regulation and no clinical oversight one commissioner left abruptly, and care services except to create work for of commissioning, a provider sector the new provider prematurely ended an lawyers, managers and consultants – dominated by multimillion pound unworkable contract. Her charity and and headaches for commissioners and businesses and an expectation that another were asked to pick up the key providers. Very few people understand services will be provided progressively working functions and provide some it fully. The language is arcane and more cheaply through systems of PBR continuity and safety for the clients. legalistic, the processes are complex. which have already been demonstrated They did so. She wondered what might An average set of tender documents to be hugely flawed – is it any wonder happen in the future if there is no will contain as a rule around 10000 that commissioners are happier to alternative provider to help out. words. The responses required from re-procure than to make their current And the future for the charity? “We providers will usually lie somewhere systems work? To compound the started with nothing but a passion to between 18000 and 30000 words. So as problem in many areas it is no longer provide good services for people in our well as being expensive, tenders are specialist drug commissioners who are area” she says, “One way or another time consuming – with commissioners managing the process – but general we’ll carry on doing just that”. But with required to evaluate maybe up to 10 bids local authority commissioners shifted no local contract any more, the charity at a time. into the new public health departments. could struggle. “Our aim is to work with For a small organisation, responding Effective local partnerships – our old a small local team – paid for through to a tender effectively overwhelms DATs and DAARTS – who may have charitable donations and grants – to the whole management team. Larger moderated some of this nonsense – continue to provide some of our basic organisations have the resources to have all but disappeared after years of services. We’re looking at continuing employ full time bid writers – whose job neglect and some would argue deliberate our work with communities who find it is solely to sell the company’s products undermining by central government. hard to reach services. That’s something at the highest price they can to whoever While no one wishes to see a return we’ve always delivered and funded will buy them. Maybe this is why one to the dogmatic style of the National ourselves because the communities tell of our largest providers advertises its Treatment Agency – whose reduction us they need it. There’s other services management jobs saying “You don’t of local partnerships to mere contract too that the local authority don’t fund, need to know about substance use, you managers on behalf of the Home Office but that we provide. And we want to use just need a good track record in sales”. has played a part in giving us the system our experience to build new services The question you have to ask is whether we have today – it is clear that we cannot for people in need. One council may not all of this serves any purpose at all? exempt the commissioning of drug and want us, but others do and we have a Where services consistently alcohol treatment from all regulations number of innovative projects to build on underperform, where interventions applying to other forms of healthcare. and years of experience and reputation don’t meet basic quality standards, Continuing to spend the amounts behind us. We do see a positive future for commissioners have to – maybe as a last we are on procurement processes that us as a charity.” resort – be able to withdraw investment don’t naturally yield better returns and commission a different provider. for communities is wasteful in the In the next article, the author will be However, a good commissioner working extreme. Small innovative charities looking at the impact of commissioning to a good specification should be able and SMEs have been for a long time the decisions on treatment services – and to drive improvement through effective basis of many effective local treatment how changes in commissioning have contract management. When a contract systems. To simply leave them by the impacted on service users in England. reaches its natural end – and many can wayside and hand services over to She will also be looking at what be extended to 5 years – commissioners the big nationals is something we will alternative approaches could be used to have to go through a tender process. come to regret – not least because it ensure we use public money effectively When the central direction of travel stifles cooperation and collaboration. to get the services we need to the shifts, commissioners may also choose Charities and trusts become rivals, not communities who need them. to re-procure the services they buy. organisations united in the common But even for a casual observer it interests of their service users. The is clear that there is currently much collaborative approaches that defined n Sara McGrail has worked as a confusion in the central direction for the English substance use field have commissioner, service director and local commissioning in drugs and all but disappeared and even in those was the chief adviser to the National alcohol. While the Government on areas where there is no procurement Audit Office on the evaluation of the one hand are publishing guidance on process on the horizon, competition is Value for Money of the previous drug recovery services that categorically state the watchword and cooperation outside strategy. Latterly she has developed that there should be no time limit for the direct requirements of the contract is proposals and specifications on behalf of treatment, no arbitrary reductions of increasingly rare. organisations across the UK.

14 | Druglink March/April 2014 ALCOHOL... MEDICINES Are we competent?

The 3rd Annual Substance Misuse Skills Consortium Conference

June 25 2014

Resource for London, 356 Holloway Rd, London N7 6PA

- http://www.skillsconsortium.org.uk/SaveDate2014.aspx - [email protected] for information / to book

March/April 2014 Druglink | 15 Druglink interview

Tim Sampey

Earlier this year, Build on Belief held a well-attended launch event at the House of Lords. Co-founder member and Chief Operating OfficerT im Sampey, recalls that it all started as a racket – badminton that is. Interview by Harry Shapiro

Around late 2004, Terry Swinton and badminton for free and getting people on us a sense of empowerment, of owning I went to a service user meeting at the courts. We did this for about three or it and we had some confidence because Blenheim/CDP where I was a client. four months and then Terry said, ‘there’s of running the badminton club. For the We were bullied into it really by the something really interesting happening first year, out of our service user budget, manager. We went along because we here. People are coming along, they are we paid to have a member of staff on were bored. It was full of people plotting enjoying themselves and a sense of the premises but they weren’t allowed to how to overthrow the commissioner and camaraderie is building up’. come downstairs from the office without how to get their hands on the money. I’d been getting close to finishing with our permission. Terry had this wonderful Terrible. We weren’t interested in the treatment; I was getting tired of key expression, ‘It’s easy. It’s like running a classic service user stuff; sitting in DAT working and groups, but didn’t really pub without the alcohol. You’ve just got meetings and treatment and care groups, know what to do next. I hadn’t worked to break up the fights. No problem’. talking to the NTA. for 15 years and had a criminal record. Back then, we had no idea of conflict But I was very interested in playing Terry said, ‘why don’t we set up a social resolution other than, ‘do you want to badminton. I got into this while I was club on a Saturday?’ I had the same step outside and repeat that?’ None of in rehab. I had always been a severe problem as a lot of people; back then my that stuff. It was very chaotic. But we asthmatic, so this was the first real parents weren’t talking to me, my wife wanted to own it ourselves. sport I had ever done in my life and I had just left and all my friends were still loved it. So it was suggested that we on drugs. Weekends were terrible. go to the commissioner and ask for So we went back to Gaynor and told So what went on at the club? £200 to buy some rackets and other her what we wanted to do. She said, When we started, we just did equipment. We set up a little badminton ‘write a business plan’. She has always sandwiches, tea and coffee and showed club at Blenheim/CDP on a Wednesday been phenomenal like that – she came a film.T hat was it. We had to build up a afternoon. We’d go down there and see to service user meetings and I could volunteer team and back then Terry and if anybody wanted to play. But it wasn’t always ring her up and ask to come over I would ambush anybody. We’d go into free, it cost a quid and people were for a coffee and a chat. So we drew up a drop in centre and say, ‘what are you saying they couldn’t afford it. So we a little business plan and went back to doing at the weekend?’ My girlfriend and went back to the commissioner and said, Blenheim/CDP and said, ‘Can we use the her daughter volunteered, so did Terry’s ‘we want £20 a week on top to pay for building on a Saturday?’ It’s important to girlfriend. My only line of conversation courts and buy coffee afterwards’. The emphasise how revolutionary that was at parties was, ‘what do you do at the commissioner was (and still is) Gaynor in 2005. We were both still clients – Terry weekend?’ Driscoll and she said yes. Blenheim/ was still scripted – and we wanted to set We built up to about 75-80% of the CDP acted as the banker, we’d go down up a little weekend service that wasn’t volunteers in recovery and developing there, get the money and come back abstinence-based. It also had to be fully the club became a very organic process. with the receipts. It was a way of playing independent of Blenheim/CDP to give It had been going for about six months

16 | Druglink March/April 2014 before we said – ‘why don’t we do ‘check you had to break confidentiality – where Chelsea, Hammersmith and Ealing. Yet in’ and ‘check out’ like they do in the somebody was a risk to themselves we were still on the Blenheim payroll rehabs?’ Everybody sits down at the start or others – and where children were and they were sorting out tax and of the day to say how they feel right now; concerned of course. If the person is in national insurance. But it was getting this is what my week’s been like and so treatment, I will ask if I can talk to their a little difficult with their accountants, on. Then when we finish, we clear up key worker and usually they are fine so everything had to be formalised. We and sit down and talk about what we did with that. Only on two occasions have I looked at becoming a social enterprise, today, what made us feel good, whether had to call social services directly. which didn’t really work for us, so the we could have done something better. After about two years, we went to only logical step was to become a charity. Saturday and Sunday. Then we started I asked everybody at our meetings to add in other things based on the skills what we should call ourselves and What was the ethos of the service? of the volunteers; so we started an art nobody could come up with anything. workshop, photography, music and I So I just came up with the name Bob, it It has always been a non-abstinence found a shiatsu massage therapist. It sounded nice and friendly and informal based service which means that anybody was very quiet up to then – we were (a bit like the government drug website can come in, so long as you can control lucky to see get ten people in. We Frank). Then I was having dinner one your behaviour – so nobody so drunk relentlessly went round libraries, police night and it came to me what the letters they can’t stand, or so stoned they stations, treatment services, putting up could stand for; Build on Belief. And that just gouch out, or so wired on crack posters. Then around 2007, it began to was that. that they’re not in control. We don’t click; ‘one day I was on my home to see differentiate between drugs or alcohol my mother, and Terry phoned to say we and have never followed any particular had 14 people in and it was a chaotic. It seems that BoB is as much an model of recovery. Four years later, we had 50 people in and organisation for the volunteers as then we found out what chaotic really it is for those who those in off the Didn’t this create tensions between meant. streets? volunteers who were in recovery We started writing our own training for volunteers; drug and alcohol Yes. It is a form of interactive aftercare. from different perspectives? awareness, harm reduction, needle People volunteer, they get training and exchange, communication skills. We start building their self-esteem and Oddly, no. There were arguments over began to ask ourselves the question; ‘we belief in re-integration. And so it works ‘what is recovery?’ and because I drink are giving these people £6 for travel and on two levels. It provides a weekend alcohol socially, some people said, ‘oh, sandwich. What do they want?’ Well, a service in K&C (meaning K&C had a you’re not in recovery’. But we were lot of them want to work in the field, so seven day a week service); we can refer building something that was really that’s why we started the training and people to treatment having done an working, so we never got into that whole social events and the award ceremony initial assessment. And we have people debate and by bringing in all these where we book the town hall and invite that cross over; at the House of Lords different points of view, it meant that the commissioner, local politicians and launch, we presented awards to two guys whoever came through the door, they service providers. So we created this who had been coming in off their heads had somebody they could talk to. support network for the volunteers for some time until one day they said, which became quite important – and we ‘How can we become you?’ We said, ‘sort So what happened beyond tea and started getting calls from people from all that out and you’re in’. sandwiches? over London who wanted to volunteer; we had one woman who would drive up from Maidstone. We built up to a team of So where is BoB at now? We did struggle for a few years; it was 50-60 volunteers with anywhere up to 50 hard to get volunteers (we couldn’t We are commissioned by K&C to provide people coming in. operate with less than four). Some a weekend service here and in the people thought what we were doing north of the borough and a recovery was brilliant, others thought it was So where does BoB come into it? café here during the day – and we are outrageous. Nothing serious happened subcontracted to provide similar services at the club, some arguments, the police Up to then, we had been the Kensington for CRI and Central and North West were called a few times, so there was a and Chelsea Drug Service User Reference London NHS Trust, a mentoring service risk element to it, but we were very lucky Group (DSURG) which I always thought in Kingston and another service in that we had Gaynor and Jean Daintith was a commissioner joke because it’s Hammersmith. (head of adult social care service for an anagram of DRUGS. And through all We’re a London-based service and we Kensington & Chelsea and the DAT chair) that time, Blenheim/CDP has been our are not preparing to step outside London. firmly behind us.T hey both had pretty banker. But the sums of money from If you want to provide a weekend service, fearsome reputations, so those people the commissioner were growing – up we are the only people to go to and we who were against us, didn’t want to get to around £100,000 – largely now to pay are often included in the tenders of the into it for fear of upsetting them! proper wages for me and Terry because large service providers. What we want to Blenheim/CDP were very good. We it had a become a full-time job plus we do is to roll out the model across London. hassled them for volunteer training; had manager here in the head office in conflict resolution and confidentiality – Earl’s Court and in other services that For more information, go to we realised that there were times when we were now running in Kensington & www.buildonbelief.org.uk.

March/April 2014 Druglink | 17 HARM REDUCTION The X factor ©I nd e p nt

A controversial service in Wales that analyses people’s drugs has been dismissed by some as a naive mistake. But Mike Powers argues that it could be a vital new weapon in harm reduction’s arsenal.

‘Calling all coke dealers: Welsh youth clubs, bars, local authorities, the Andrew Westwell, who analyses the government will test your Class A drugs ambulance service and the police are few samples that can’t be identified, for FREE!’ also authorised to send in samples. The says. “There’s an awful lot of stuff people So frothed the Daily Express Wedinos site’s harm reduction section are taking and they don’t know what it in February, in a mainly fact-free counsels users to dose low, not to redose, is. There’s no data. We have a rigorous, news story that tried to present the and to follow standard safe practice scientific and analytical approach Welsh-government funded Wedinos around drug use. to identify what substances people programme, one of the UK’s most The qualitative, not quantitative test are using. We are providing quality innovative harm reduction schemes, as a results are then posted online, identified information that is not currently there.” free drug-testing service for drug dealers. only by a reference number. Over “This is simply pragmatic harm It’s true that Wedinos (Welsh 395 samples have been analysed and reduction information,” agrees project Emerging Drugs and Identification of published. Over 100 different compounds lead Josie Smith. “It’s no good academics Novel Substances) will test any drug have been identified and there are knowing what’s going on. Users need to for anyone, and then post the results currently only three unidentified items know, too.” online – as the Express’s lawyers will have outstanding, says Alun Hutchings, ‘Blodwyn’ is the online handle for a checked before publishing. But the truth of Cardiff Toxicology Laboratories at man who runs a web forum dedicated about what Wedinos does, why it does University Hospital Llandough. to the discussion of novel psychoactive it and what impacts it will have on drug Dozens of different drug categories substances (NPS). His site has 3,500 use in the UK are a world away from the have been submitted, from banned registered users and around 300 active tabloid’s distortions. and other stimulants and daily posters. There are around 1,000 Users can send samples by post synthetic cannabinoids, to steroids used daily ‘lurkers’ who visit to read content to the Wedinos laboratory in Cardiff, by bodybuilders, cocaine and heroin. but do not participate in the debate. where they undergo tests including gas The project’s aim is to give information He says that Wedinos is “a huge move chromatography-mass spectrometry to users who would otherwise be forward for people” and that it makes the (GCMS), and nuclear magnetic resonance consuming drugs without any idea of use of NPS “much safer”. spectroscopy (NMR). Substance misuse their contents, and to help them avoid “Wedinos has been incredibly services, nightclubs, pharmacists, harm. favourably received as it offers so much

18 | Druglink March/April 2014 transparency for people using NPS,” he emergency consultant at Calvary move that Caldicott says has laid the says. “It’s also going to mean that people Hospital, Canberra. He says he was project open to attack by conservative will be able to challenge unregulated concerned at the increase in emergency thinkers. vendors’ claims regarding chemicals. It’s presentations of drug users who had Shadow Welsh health minister, also a great service if someone suffers a experienced harm after consuming NPS. Tory Darren Miller, told journalists in bad reaction – they can get the substance With no way of analysing the drugs February: “This free service is not just tested and find out exactly what it is.” on-site, he sought the expert help of testing recreational highs, but illegal Last month, the forum sent some Hutchings and Westwell. and dangerous drugs including heroin, pills one of its members had bought “In 2009, I moved back to the UK, to cocaine and crack, and gives advice on online which claimed to contain Abergavenny. It’s not the drugs capital snorting and injecting substances. only legal compounds. Wedinos of the UK, but we were seeing some very “While the service may have been found the pills contained 5-MEO- weird things coming through, and I was set up with the best of intentions, it is DALT, a hallucinogenic tryptamine, pretty stunned,” he says. So stunned, obviously open to abuse by dangerous along with methiopropamine – a he revived his Australian drug analysis criminals peddling harmful substances analogue – and project and looked for funding and in order to fund other crime. It even alpha-PBP, a class B, banned cathinone backers. includes advice on how to snort, inject stimulant. and smoke those substances. I think “Educating people not to accept these We cannot be it’s quite clear that the Welsh Labour ‘branded’ pills and powders is a key government have given up the fight message that we want to send out to as responsible for against drugs.” many people as possible,” says Blodwyn. every person who “We don’t provide purity information,” The Wedinos system (the name is says Westwell, neutering in just five also a portmanteau of the Welsh words decides to use words Miller’s claim that the data is of wedi and nos, meaning ‘after dark’) has drugs. People any use to dealers. “It is ridiculous to roots that go back to the emergence say it’s for drug dealers to identify the of (an MDMA analogue) in will take drugs quality of the drugs they are dealing as 2005 and mephedrone (a substituted regardless of the we give no information on purity. We ) in 2007 in Australia. simply tell you what is in that sample. Neither drug had ever been seen on the law. What this does It’s about allowing users to make international recreational drug markets, is tell you what the informed choices. but they were identified by a group of Caldicott rejects Miller’s right to even medics and harm reduction practitioners hell you are taking join the debate, much less influence that included Dr David Caldicott. Their policy. “Why does anyone ever listen arrival heralded the international arrival Today, the group is funded by the to what politicians have to say about of NPS, aka ‘legal highs’. Public Health Wales at a cost of around drugs policy?” he says. “They are either Wedinos was named, conceived and £100,000 a year, with initial setup costs uninformed or out of touch with the established in late 2010 by Caldicott, who in 2011 of £300,000, which was required culture, or the toxicology, or the socio- at the time was working at Nevill Hall to buy machinery. criminal aspects, or they are informed, Emergency Department in Abergavenny, The service has faced ethical, legal and allow their political prejudices to South Wales. He collaborated with and practical challenges. Police advice determine their public utterances. Alun Hutchings of Cardiff Toxicology was instrumental, says Smith, in So how will the project measure Laboratories at University Hospital arranging ways to transport possibly its success? Smith says she wants to Llandough, and Andrew Westwell of the illegal drugs from one place to another. see a reduction in visits to A&E, along School of Pharmacy and Pharmaceutical “We had to prove there was a rigorous with reductions in arrests and fewer Sciences at Cardiff University to create a chain of custody. Any system we set up mental health problems. A user feedback pioneering service that would allow drug had to contain a mechanism whereby component is also underway, with users, for the first time ever, to know there was proof of transport from A to B changes in users’ behaviour documented exactly what their drugs contained. to C, with C being the lab and then to a and analysed. Westwell and Hutchings Caldicott had worked in Australia, safe and secure place for destruction.” say the volume of materials tested and was part of a team that first The ethical dimension of supplying and results published will be trends identified mephedrone in 2007. “We individuals with information regarding to monitor, while users are already demonstrated proof-of-concept when their drugs’ authenticity was obviously delighted with the service. we described mephedrone. We showed a concern, says Smith but she points “Before Wedinos, the only information that a hospital setting could be used out the limits and boundaries the site offered was by dealers – and that is to identify illegal drugs. The system operates within: “As has always been often no information at all,” says Smith. and mechanism was designed at that the case, each individual is ultimately “We have put control and information time, “but the government at the time responsible for their own safety. We into the hands of those people who had this right-wing approach, one of cannot be responsible for every person are already determined to use or are complete intolerance. We had the system who decides to use drugs. People will considering using drugs.” set up and ready to go. We just needed take drugs regardless of the law. What somewhere to locate it,” he tells me. this does is tell you what the hell you are n Mike Power is a freelance journalist Caldicott is still a Wedinos board taking.” and author of Drugs 2.0: The web member, though he has now returned Now, anyone can send in any drug revolution that’s changing how the world to Australia, where he works as an whatsoever and find out what it is – a gets high.

March/April 2014 Druglink | 19 international Chinese take away

A massive police raid on a meth-making village in China exposed the links between the country’s vast chemical industry and Mexican drug gangs. Peter Shadbolt investigates. ©Reu t e r s

Boshe village in China’s Guangdong Police said the village – predictably district, a centre for paper and printing province (population 14,000) had many dubbed China’s version of Breaking Bad – plants, had become the banknote of the elements necessary to be China’s was supplying a third of China’s market counterfeiting capital of the world. largest methamphetamine factory. in crystal meth; now the second most With all the elements necessary Corrupt local officials, an used drug in China after heroin. for the establishment of a successful impenetrable Chaozhou local dialect, a In a town where almost all the large-scale drugs operation – weapons village clan system so tight that families surnames are Cai, keeping the and access to fast and often counterfeit not connected with the drug syndicates neighbourhood secret hermetically money to purchase precursor chemicals, were left to guess why a town where a sealed from outsiders and the authorities pay bribes and purchase other hardware farmer can earn just 700 yuan (£70) a had allowed it to operate as a massive – Boshe village seemed to be simply month was filling up with luxury cars. meth lab for years. diversifying the industrial base of a Even so, there could be little doubt “Basically this is a family clan region well known for poverty and crime. what was going on behind the crudely business, otherwise the meth industry Professor Karen Laidler, an analyst welded grille doors of scores of hamlets would not have been able to grow so in illegal drug trends at the University in the narrow streets of the scrappy quickly in the past few years,” the dean of Hong Kong, said the ‘Breaking Bad’ provincial town. of the Faculty of Law at Chongqing label, with its image of small-scale cellar The operation, according to police University, Professor Chen Zhonglin, operations, understates the reality of estimates, involved a fifth of the said. “The tight family connections made China’s increasingly internationalized population, produced so much in the anti-drug operations harder.” illegal drugs operations. the way of noxious waste that it had According to one local, who said "China has been understood by the poisoned the local fields and pulled so police estimates of the extent of UN and many other organisations as a much electricity off the grid that many the network were exaggerated, the country where the precursor chemical of the meth factories had their own syndicates were even closed to those was quite prevalent and was generators. within the village. being exported to other countries for the When 3000 police successfully raided "Only those family members or manufacturing of various amphetamine the town in late December (earlier relatives of the ringleaders have the type drugs,” Laidler said. attempts had been met with resident chance to join them,” he said. “China did respond to those concerns roadblocks, homemade weapons and The coastal area between Hong Kong and implemented a number of laws in the acid used in production of the drugs and Guangdong’s Shantou has been relation to the control and regulation of hurled from the rooftops) they uncovered associated with drug smuggling since ephedrine. However, it’s difficult to say a prodigious operation. the Opium Wars of the mid-19th century, how much is going and how much is Three tons of methamphetamine its sheltered bays and islands giving it coming in terms of precursor chemicals. worth an estimated £142 million were perfect access to the South China Sea. “The manufacturing in Guangdong? seized from 77 clandestine meth In the early 1980s, the area was awash I suspect that much of that was for laboratories, 182 arrests were made with surplus weapons from the Sino- export.” including the town’s Communist Party Vietnamese war that made their way Hong Kong, she said, on a U.S. boss Cai Dongjia and 13 other party from Guangxi to eastern Guangdong. By blacklist for the transit of heroin officials. the late 1990s the province’s Chaonan throughout the 1970s and 1980s until

20 | Druglink March/April 2014 it was lifted in the 1990s, was no potassium permanganate and closely with the Chinese to produce longer necessarily a gateway for drugs piperonylmethylketone (PMK). It is crystal meth. manufactured in China. the fifth largest exporter of ephedrine For those working in the “The transit routes are not forced to and the third largest exporter of pharmaceutical industry in Asia, the go through Hong Kong any longer – there . blurred line between illicit drugs and the are many large ports in China where The sheer scale of China’s chemical pharmaceutical industry remains a point drugs can be imported and exported industry, with an estimated 80,000 of contention. Developers are continually quite easily.” individual chemical companies in 2009, searching for alternatives to easily Since 2012, China’s Food and Drug presents widespread opportunities extracted precursor chemicals found in Administration (CFDA) has restricted the for chemical diversion. With many of many common products. retail sale of ephedrine-containing over- these companies located in Guangdong One Asia regional pharmaceutical the-counter drugs, prohibiting online province – and close to some of China’s executive who spoke to Druglink said the sales and requiring retail pharmacies to busiest ports – the location of illicit illegal drugs industry in South East Asia check and record the ID of consumers of methamphetamine factories in the was now so big that it had the capacity drugs containing ephedrine. region makes sense. to skew the marketing spreadsheets Nevertheless, state media alleged that Most precursor chemicals seized in of some of the region’s largest some of the precursor chemicals found Mexico and Central America destined for pharmaceutical companies. in the Boshe raid had been extracted illegal production of methamphetamine, As recently as six years ago, he from Contac, a popular cold medicine according to the U.S. State Department, said, retail sales of certain products produced by the beleaguered British drug were legally exported from China and containing ephedrine, pseudoephedrine maker GlaxoSmithKline (GSK) already diverted en route. and would show massive under scrutiny in China – where four of In a further evidence of the increasing unexplained spikes in their sales. its executives are being detained – over transnational nature of Guangdong “Of course, the immediate reaction of bribery charges. province’s “Breaking Bad” factories, pharma marketers was that they wanted Analysts, however, doubt that the just a week after the Boshe raid, a slice of the action,” he joked. “But since teams of students allegedly employed Philippine anti-drug agents acting on then, the FDA has cracked down on it by the syndicates to extract the U.S. intelligence smashed a meth lab and by issuing quotas. There is, of course, a pseudoephedrine from capsules could seized 84 kilos of methamphetamine in medical need for these products so they have produced enough of the chemical a raid on a cock-fighting farm south of monitored the sales, especially out of to account for the 23 tonnes of raw Manila. hospitals, of these products. materials seized in the raid. Arrested in the raid were three known “When they could see a big volume According to the United Nations affiliates of Mexico’s Sinaloa drug cartel, it rang alarm bells. I think it’s true to Office on Drugs and Crime (UNODC), one of the most powerful and notorious say that whenever a product sells a precursor chemical seizures increased drug syndicates in the world. Named lot other people in the industry are substantially in 2012. after the state on Mexico’s Pacific Coast always looking at it and wondering why, The number of substances diverted where it was formed in 1989, the cartel’s particularly when there are strong sales for illicit drug manufacture increased heartland extends from Sinaloa, to for something curious like Contac. from 20 controlled substances in 2011 Mexico’s Durango and Chihuahua states, “When one product is growing at (primarily ephedrine and hydroxylamine but it is known to operate in locations twice or three times the rate of other hydrochloride) to 40 uncontrolled as diverse as Russia, Australia and Sierra similar products then that’s a red flag. substances in 2012, including Leone. For instance there was a product in pharmaceutical preparations such as “The Mexicans are already here,” Thailand that was being used in the ethyl phenylacetate Philippines drug task force chief manufacture of ‘yaba’ – it was getting In 2012, 1,128 criminal cases were Bartolome Tobias said, adding that they strong sales without any marketing at all reported in China that involved the were getting help from “Chinese drug and the authorities cracked down on it.” diversion of precursor chemicals and syndicates”. “It might make it attractive to police seized a total of 5,824 metric The Mexican attorney general’s marketers at first blush, but you don’t tons of various substances used in the office last year released a report that have to be too bright to work out what’s manufacture of illicit drugs. named Hong Kong triad groups 14K happening.” While the numbers represent a and Sun Yee On as the main suspects He said that recent regulations significant increase on the 1,834 metric in the supply of ephedrine and ethyl applied in Thailand meant that the line tons of precursor chemicals seized in phenylacetate to Mexican cartels feeding between big pharma and illegal drug 2011, the US State Department says low- into the lucrative American market for manufacturers was becoming more level corruption and bureaucracy remain methamphetamine. distinct. a problem in China. Prior to 2012, Chinese police mostly “We occupy different worlds. These “China’s collaborative law dismantled small-scale operators, but in operators in China – if they’re not able to enforcement efforts are hindered by September 2012, police raided their first get these products off the shelf, extract cumbersome internal approval processes industrial-scale facility in Hunan, seizing the active ingredients they need and that often limit direct access by U.S. 660kg of crystal meth and 19.8 metric convert it into methamphetamine – law enforcement officials to local tons of unidentified materials used in they must be making the raw materials counterparts at provincial Public Security the manufacture of the drug. themselves and I guess that means a Bureaus,” the US State Department said. Among the 14 people arrested in much more vertically integrated model China has one of the world’s the raid, one was a Mexican national, of criminality.” largest chemical industries, producing a development which analysts say large quantities of precursor was the first indication that Mexican n Peter Shadbolt is a freelance chemicals, such as acetic anhydride, transnational syndicates were working jourmalist

March/April 2014 Druglink | 21 Research

Should dependent drinkers always try for abstinence? Mike Ashton of Drug and Alcohol Findings on the milestones in the bitterest controversies ever seen in addiction treatment research.

The issue of whether dependent drinkers should always to professional circles, but the following decade, bitter be advised to try for abstinence has been central to disputes originating within US research hit the headlines, alcohol dependence and its treatment for decades. Far in one case spawning legal proceedings. One major spat from receding in to a box marked ‘pointless debates’, centred on a 1976 report from the Rand Corporation on abstinence as a treatment objective has recently returned new government alcoholism treatment centres. It found to prominence as an essential component of influential that fairly complete remission was the norm, that most visions of ‘recovery’. patients achieved this without altogether stopping drinking, Not so long ago the issue in Britain and elsewhere and that as many resumed normal drinking as sustained was not just about advice, but whether alcoholics should abstinence. actually be denied treatment until deterioration forced Aware of the storm their findings might provoke, the them to accept the need to stop drinking altogether and authors disavowed any intention to recommend alcoholics forever. Here we look at the milestones in this debate, resume drinking. Nevertheless the storm broke, as subject of the bitterest controversies ever seen in addiction suggesting the prospect of controlled drinking was likened treatment, drawing on work done for the Alcohol Treatment to “playing Russian roulette with the lives of human Matrix. beings”. With striking prescience, the authors themselves Why such heat over a seemingly innocuous decision felt the most important implication of their findings was between patient and clinician on which form of reduced that “the key ingredient in remission may be a client’s drinking to go for? In part it was generated by concerns on decision to seek and remain in treatment rather than the the one hand that allowing controlled drinking would let specific nature of the treatment received” – an insight alcoholics (assumed to be unable to stop once they start) off revisited decades later after another major US study – the the necessary hook of non-drinking and set them up to fail, Project MATCH trial, highlighted in cell A2 of the Alcohol and on the other that insisting on abstinence did nothing to Treatment Matrix. improve outcomes, but did limit treatment to the minority One reason the Rand authors knew their findings might of problem drinkers prepared to countenance a life without be controversial was the reaction three years before to an drink. audacious and for the time methodologically advanced Behind this were alternative visions of dependence as a experiment conducted by husband and wife team Mark and distinct category characterised by inevitable loss of control, Linda Sobell. or one end of a continuum of learnt behaviour, which even They had allocated hospitalised physically dependent at its most extreme, can be replaced by learning to drink in alcoholics with what generally seemed a poor prognosis: moderation. either try for abstinence or for controlled drinking. The The controversy dates back at least to a 1962 report, latter chosen principally on the basis that patients had Normal drinking in recovered alcohol addicts, by British asked for this, shown in the past they could manage psychiatrist D. L. Davies on seven ‘alcoholic’ patients from it, and had a supportive environment to return to on south London’s Maudsley Hospital said to have sustained discharge. Within each group, half were allocated to controlled drinking. In 1994 they were judged to have normal abstinence-oriented treatment and half to a radical deceived a research-naive clinician. The basis for this procedure geared either to the abstinence or controlled- reassessment was a 1985 paper documenting interviews drinking goal to which the patient had been assigned. with the patients and others and a (re)examination of It entailed allowing patients to drink, showing them via records, to which the original author (he had died three videos how they looked when drunk, and training them years before) was unable to respond. The allegations came how to manage or avoid what for them were situations from the prestigious figure of Griffith Edwards, who later conducive to drinking or over-consumption. embraced normal drinking as a goal for many patients. Over the last half of the follow-up year patients assigned But he maintained that (emphasis added) “abstinence is to try for controlled drinking, and who had been trained the only feasible objective” for those with a fully developed how to manage this, spent nearly three quarters of the time history of dependence. Among his criteria for identifying out of hospital and prison and not drinking heavily, though who should attempt which were those (see below) trialled all but four of the 40 continued to drink, the best results by the Sobells in the USA. of all the patients. Those given the same treatment but That episode was relatively gentlemanly and limited selected for abstinence did almost as well, but many more

22 | Druglink March/April 2014 did so by not drinking at all. The review seems to advocate shared decision-making It seemed a clear vindication of an intervention based when selecting a treatment goal, with moderation as well on seeing addiction as learnt behaviour and of the judicious as abstinence on the table, so the patient makes a positive allocation of even physically dependent patients to try to choice rather than being ‘told’ what to do. Incidentally, learn moderation. Controlled-drinking patients had been a Dutch study showed that shared decision-making can selected partly because of their “sincere dissatisfaction be systematised, and that as a result, in relation to life with [Alcoholics Anonymous] and with traditional in general, patients feel more able to make their own treatment modalities”; the study showed this rejection of decisions. They are more in control and less submissive US orthodoxy need not condemn them to the progressive – possibly portending a more stable shift away from a deterioration predicted for untreated alcoholics. dependent mind-set than could be achieved by less explicit Just as with Davies’ research at the Maudsley, a later shared decision-making. follow-up of the same patients cast doubt on the validity of What seems mainstream contemporary opinion was the findings, and led one of the authors to publicly (in the enshrined in alcohol treatment guidance published in New York Times) allege scientific fraud.T he Sobells were 2006 by the Department of Health and National Treatment cleared by an investigation set up by their employers and Agency for Substance Misuse. It stressed that goal choice by one commissioned by a committee of the US Congress, should not exclude drinkers from support or treatment, and their research (though sharing some of the flaws but did see abstinence as “the preferred goal for many characteristic of the time) was judged fairly presented. problem drinkers with moderate to severe levels of alcohol In 1995 (and again in 2011) the Sobells revisited dependence, particularly…whose organs have already controlled drinking as a treatment objective in an been severely damaged through alcohol use, and perhaps editorial for the Addiction journal, which attracted for those who have previously attempted to moderate… eight commentaries. It accepted that “Recoveries of without success”. individuals who have been severely dependent on alcohol Even for these drinkers, if abstinence is not acceptable, predominantly involve abstinence”, possibly because moderation is better than nothing, and may lead to poor social support and lack of a stake in society in the abstinence. We know from research that no matter how form of a career and a job tend to go along with severity physically dependent, moderation is feasible for some, of dependence. Beyond this minority, they argued that especially when there are sufficient supports in the reducing alcohol-related harm across the population patient’s life. demanded acceptance of the moderation goal, because But the more severe the dependence, the more likely many (especially less or non-dependent) drinkers simply abstinence is to be the suitable strategy. On how the will not accept interventions which presuppose abstinence. decision should be made, in relation to care planning in Their argument had been demonstrated by a Canadian general, the guidance sees patient choice as not just an trial which tried to randomly allocate drinkers (most of entitlement, but a strategy which improves the chances whom seemed to be drinking heavily enough to meet that the treatment approach will succeed because “it has criteria for dependence but had yet to be severely affected been selected and committed to by the individual”. by their drinking) to treatment aiming for abstinence or This is how Drug and Alcohol Findings summed up moderation. Of the 35 allocated to abstinence, 23 either the evidence: “Treatment programmes for dependent rejected it or expressed reservations, but just five of the drinkers should not be predicated on either abstinence 35 allocated to controlled drinking. That was at the start of or controlled drinking goals but offer both. Nor does the treatment. After it had ended the picture was the same; literature offer much support for requiring or imposing whatever goal had been impressed on them by their goals in the face of the patient’s wishes. In general it seems clinicians, most in the end chose to drink moderately. that (perhaps especially after a little time in treatment) Skipping other important studies in Britain and patients themselves gravitate towards what for them are elsewhere (for which see these Findings notes) we come feasible and suitable goals, without services having to risk up to date with Britain’s largest alcohol treatment trial, alienating them by insisting on a currently unfavoured the UKATT study of psychosocial therapy for 742 patients goal”. seeking treatment for alcohol problems at specialist treatment services in England and Wales. I’m not looking at Click here for an extended web version of this article. For the main findings, but a secondary analysis of how patients fuller accounts see this US analysis and if you can this British fared depending on whether they had opted for abstinence perspective (turn to chapter four of the book). See also this as an initial treatment goal. Findings analysis of a recent UK study (the background notes are From our analysis you will see that regardless of their particularly informative) and this recent review. initial choice, patients did about equally well, and that This article is based on cell C4, one of 25 cells in the Alcohol even among those who at first wanted to stop drinking Treatment Matrix constructed by Drug and Alcohol Findings altogether, more later substantially reduced their drink- for the Substance Misuse Skills Consortium. This and the related problems while continuing to drink, than did so by corresponding Drug Treatment Matrix map treatment sectors and abstaining. influences which might affect impact, and for each sub-territory UKATT was among the studies assessed in a recent (a cell) list the most important UK-relevant research, reviews and European review whose conclusions were largely in line guidance. with others from North America. Though they were perhaps more enthusiastic about embracing moderation as a treatment goal, in order to make treatment attractive to the 20 to 80 per cent of dependent drinkers who preferred this goal.

March/April 2014 Druglink | 23 Missing links

New to the field in 1992, a major lesson for me clear or firm conclusions – is likely to leave many was discovering the absence of drug and alcohol readers trying to work out what the implications services for under-18s. Agencies recognised this age are for their discipline and practice. In addition, the group’s existence and needs, but felt constrained book lacks an index – a major failing in a volume by legalities in treating them. They were also aware with so much valuable content. that introducing young people into adult services There is also a sense that events may well have Reviews was in no way appropriate to their needs and overtaken some of the well-identified groups of situations. practitioners. One such is ‘substance misuse youth YOUTHoRIA: The 1996 publication of The substance of young workers,’ a job description which raises hopes ADOLESCENT needs by the NHS Health Advisory Service was a that such staff have been trained and are in post, SUBSTANCE welcome acknowledgement of the gap in services but who are likely to have been re-assigned or MISUSE – and played an important role in identifying needs dismissed in the wake of public sector spending PROBLEMS, and populations previously invisible to, or over- cuts in the past four years. The ACMD, amongst PREVENTION AND looked by decision makers, if not service providers. others, has pointed to the recent dis-investment TREATMENT Along with the ACMD’s 2003 Hidden harm, this in drug and alcohol services, an area where young report was instrumental in shaping and informing people’s services have always been seen as a bit Phil Harris policy and provision for young people affected by of a luxury. The current political focus on new Russell House Publishing substance misuse. psychoactive substances and legal highs is not yet ISBN 978-1-905541-82-9 Yet neither report figures in Youthoria’s 35 pages translating into specialist provision for this new(ish) 2013 of references. This ambitious and information- phenomenon and demography. Paperback packed volume aims to ‘identify differences In a different context, Harris points out that: ‘...all 280 pages between young people’s and adults’ substance too often, treatment systems are developed that are £ 27.95 use’ and, therefore, relevant responses and service based on political agendas rather than the clinical provision. The book attempts ‘to integrate these needs of those they try to help.’ He consistently Buy now disciplines [prevalence patterns, adolescent emphasises the importance of needs-responsive development, substance misuse problems, services for young people, and an understanding prevention and treatment] into a cohesive vision of those needs and the ways in which they might of young people’s substance misuse.’ This suggests be best responded to so that when political and that although much has been clarified about budgetary climates are favourable, evidence and young people’s substance use and needs since the knowledge is readily available to commissioners publication of the 1996 HAS report, practice and and practitioners. There is a welcome reminder of service provision still fall short of need. the centrality of alcohol to young people’s needs. Youthoria’s introduction indicates its intended Reviewers habitually look at books’ references to or potential audience, from youth workers through see what is, and isn’t, there. Given the emphasis on families to commissioners and academics. The the significance of peer cultures for young people’s variety of this audience is behaviours, I noted the omission of Dick Hebidge’s certainly catered for by the Sub-culture: the meaning of style. extensive and comprehensive Harris emphasises the need to consider all content of the book. But the factors that can influence substance-using this coverage might also behaviour in young people’s lives. Willy de Haes’ act as a deterrent to some work supports this analysis, pointing to young of its anticipated audience. people’s wider social and emotional needs. De There is so much content Haes says that whether or not they are met heavily and discussion it can influences what we now call the ‘protective factors’ become overwhelming. And which are liable to reduce young people’s propensity the treatment of much of to experience problematic substance use. He, too, is the content – a thorough absent from the references. exposition of theory, evidence n Blaine Stothard is a prevention specialist and and research studies without Druglink’s book reviews editor

There is so much content and discussion it can become overwhelming

24 | Druglink March/April 2014 Volume of substance

This book covers a number of important topics been associated with 12-step programmes, and within the field of substance misuse. Opinion the chapter describes residential rehabilitation, is forthcoming and evidence-based, and the including evidence for its effectiveness as well chapters provide worthwhile reading to anyone as the problems with this approach, including working in the field, including those in clinical comments by service-users. Mutual help and practice, drug service workers, nurses, policy- the idea of recovery communities improving makers, and students and teachers on addiction Reviews opportunities for people within their communities courses. Helpfully, the book contains enough are also discussed. background information on the history of drug laws, EMERGING Recovery in the UK context is also explored, maintenance prescribing, treatment and recovery, PERSPECTIVES and the Payment by Results system explained. for the interested lay-person. ON SUBSTANCE The authors remind us that recovery is neither a The title addresses theoretical, practice and MISUSE. simple nor straightforward process, and outline the policy issues about problematic use of drugs problems with criminalisation and the benefits of Willm Mistral (Editor) and alcohol, and presents a range of emerging, treatment services. The authors make a justified Wiley-Blackwell, 2013 evidence-based perspectives. It covers aspects of call for more state-funded support for services to ISBN 978-1-118-30212-5 international and UK drugs and alcohol policy: support clients in recovery, as well as calling for a Paperback for example there is an outline by Richard more holistic recovery agenda, through investment August 2013 Velleman, of the controversial yet effective in housing, educational opportunities and recovery- 230 pages Heroin Assisted Treatment (HAT). Involving as conducive workplaces. The authors point out the £ 70.00 it does the substitution of illicit heroin with a wider benefits this has for society.T he history of supervised, controlled dose of medicinal heroin treatment and prescribing is discussed in detail in clinical settings, HAT has been shown to be Buy now throughout. an effective second line treatment for those for David Nutt’s concluding chapter ends with whom fails. There is a small but highly comment on how drugs laws have inhibited significant number of trials across Europe and research advances and neglected clinical the US that demonstrate the effectiveness of this opportunities. Professor Nutt makes suggestions on treatment for a small, so-called ‘untreatable’ sample how to move research forward through sensible and of patients. facilitative drug laws. Another focus is on drinking, with an intriguing The book skilfully and succinctly summarises spotlight on women and the implication of drinking current knowledge about substance misuse, along behaviours in the context of social media. As well with thought-provoking perspectives on the wider as Rebecca Brown’s focus on women and social issues related to an individual’s use and the impact media, Karenza Moore and Fiona Measham focus on it has on themselves and society. In doing so, it gender and drug misuse, with a review of feminists’ provides a valuable snapshot view of topics, which pioneering work from the 1980s, alongside more students and professionals might further explore. recent calls to revise our understanding of female n Victoria Brooks MSc is Doctoral Researcher, drug misuse, and newer critiques of post-feminism. National Addiction Centre, King’s College London Substance misuse in the context of children and the family is outlined by Lorna Templeton, in a chapter describing the costs and burdens faced by so many families (and wider society) when a The book skilfully family member misuses drugs or alcohol. This is and succinctly preceded by a critical exploration by Louise Hill of the development of services for children and young summarises people affected by parental substance misuse. current Psychotherapeutic approaches to tackling addiction are summarised, with particular focus knowledge on the Self Help Addiction Recovery Programme about substance (SHARP), a day treatment programme founded on the premise that recovery is much more likely to misuse, along be durable and rewarding if clients are supported with thought- through mutual aid groups such as Alcoholics Anonymous and Narcotics Anonymous. This provoking complements the analysis of the various forms of perspectives on pharmacological treatments in an earlier chapter. Indeed, the concept of recovery, while being the wider issues mindful of the importance of substitute prescribing, is given its own chapter. Here, Willm Mistral and Stephen Wilkinson outline the extent of the substance misuse problem, with treatment figures from the US and Europe. Recovery has traditionally

March/April 2014 Druglink | 25 48 factsheet GBL

Produced in association with UK Background: Appearance and taste: DrugWatch. UK DrugWatch is an informal online professional information network established by a GBL (gamma-butyrolactone) is a At room temperature GBL is a colourless, group of professionals working in the ‘pro-drug’ of GHB, which means that slightly oily liquid that is clear to semi- UK drugs sector. The aim of the group it converts to GHB within the body. opaque. It has a distinctive taste that is to raise/establish standards for drug GBL occurs naturally in certain food some users have described as being information, alerts and warnings. It products, is found in small quantities distinctly chemical, like a solvent, nail is currently an unfunded, bottom-up in the human body and is available varnish or paint stripper. initiative that works in the spirit of commercially as an industrial solvent mutual co-operation. Details of current and as an ingredient in cleaners, paint members can be found here. removers and engine degreasers. GHB Route of administration: is a drug which is available as (or under the brand name GBL is mainly taken orally. Due both to Xyrem) as a treatment for narcolepsy its unpleasant taste and to it being a skin in adult patients and has been used irritant, most users dilute it with juice or therapeutically in the treatment of other liquid. IV use is strongly advised alcohol and opiate dependency. GHB was against; one user reported that this lead developed in the early 60s as a human to “the most horrific pain you can think anaesthetic, but was discontinued of…the tiny amount of GBL that was on due to unwanted side effects. It was the outside of the needle was enough to used as a sleep aid and body building make me cry”. supplement in the 80s and later as a Dependence and withdrawal: recreational psychoactive. GHB and GBL Regular use of GBL builds tolerance, are sometimes referred to as G, Liquid meaning users need to take more to Ecstasy, Liquid X, Juice or Geebs. feel the same effects. GBL is physically addictive and stopping it without medical supervision can be fatal; sudden Drug class: withdrawal poses dangerous health risks and can require an in-patient detox. GBL is not active in its own right; its Clinical presentation of withdrawal may mechanism of action stems from include anxiety, confusion, agitation, its identity as a pro-drug of GHB. tremor, cramps, insomnia, aggression, GHB is a central nervous system delirium, delusions, paranoia with (CNS) depressant, with sedative and hallucinations, tachycardia (racing heart), anaesthetic qualities. low blood pressure and occasionally a schizophrenic-like state.

Legal status: Typical effects and side effects: GHB was brought under the Misuse of Drugs Act as a Class C drug in 2003. As These are some of the typical effects and some users then switched to GBL and side effects experienced by people who 1,4-BD as legal alternatives to GHB, these use GBL; not everyone will experience were also brought under the control of all effects listed and many can be dose the Misuse of Drugs Act as Class C drugs dependent. in 2009. There are some exceptions to GBL’s legal status that cover its legitimate (i.e. non-recreational) use.

26 | Druglink March/April 2014 Physical Mental

Physical relaxation Heightened sex drive Euphoria Loss of inhibitions

Can enhance effects of Increased erections Increases dopamine levels Can ease stimulant stimulant drugs comedowns Unconsciousness Increased orgasms Enhanced sociability Sleep aid

Nausea and vomiting Hypothermia Anxiety Aggression

Physical addiction Severe respiratory depression Paranoia Confusion

Collapse Death Psychological addiction Coma

Onset and duration of effects: been found to reduce the efficiency of some HIV medication and have also been implicated in sexual assaults or ‘date Onset varies between individuals and rapes’. can depend on a number of factors (including when the user last ate), but effects can be felt approximately 10-30 minutes after ingestion. 45 minutes to Dosage information: 1½ hours later the effects begin to level off and decrease, depending on tolerance GBL has a very steep dose-response to the drug its effects can be felt for 2-4 curve, meaning that it can only take hours. After-effects like grogginess and a tiny amount to push the user from sleepiness can be felt for as little as two having a good time to experiencing hours or as long as twelve hours after accidental overdose, unconsciousness, use, although some users find a sense of coma or even death. Some rough increased well-being the following day. guidelines follow, please note that these will not apply to everyone who takes the drug: Overdose: Low Dose Medium Dose Heavy Dose/ GBL can be fatal. It is very easy to Overdose overdose on it, both because the strength can vary from bottle to bottle and 0.3-0.6mls 0.6-1.25mls 1.25-2mls+ because the doses involved are measured in such small quantities. These risks are greatly increased by mixing GBL with alcohol or other sedative, depressant drugs or drugs such as ketamine. Mixing with alcohol is particularly dangerous as this can trigger instant collapse or an overdose reaction. GHB and GBL have

March/April 2014 Druglink | 27 Headspace ...drugs from the left field

A hidden threat

Much of the media hype around the rise in Yet every major media outlet went with the legal highs story. That’s not to legal high deaths mask trends that are far more deny that legal highs remain popular, or that often their use can carry severe newsworthy and alarming, says Mike Power. health risks. It’s also true that from a journalist’s perspective, legal highs are a great story – I have written extensively News reports on the latest drug death tripled in just a year – from 7 in 2011 to on the subject myself (including in figures (2011-2012) from the National 20 in 2012. this month’s edition of Druglink on the Programme on Substance Abuse Deaths Using the npSAD’s own 2009 figure as Wedinos project) and will continue to do (np-SAD) managed to simultaneously a year zero, there has been a combined so: they offer a fascinating data point to miss the point, and miss a few great 22-fold increase in deaths from these anyone interested in the multi-stranded stories. specific substances in four years; there debate around drug use and law. Legal highs, the press release said, were none just four years ago. Where But the real killers remain heroin are the top priority in drugs policy today. was that story? and (36.4 per cent of 2012 “The prevalence of these drugs in the deaths); and hypnotics/sedatives such as post-mortem toxicology tests submitted diazepam (30.3 per cent). to the report has increased 800 per cent The harm reduction Might it not be useful to present this in three years, from 12 in 2009 to 97 in messages around safer information a little differently each year? 2012.” A single paper for each drug category Shocking stuff. But disregarding the ecstasy use that were so would allow journalists to quickly poor maths (12 to 97 is a 700 per cent prevalent 20 years ago are compare figures across the years.A increase) there’s also poor logic and reclassification of PMA into a separate poor science at work here, and evidence being lost in this moral category would allow better monitoring of a determination to maintain the panic about legal highs of the prevalence of these pills and their flourishing moral panic surrounding health effects. legal highs or Novel Psychoactive There were two other angles reporters Substances (NPS) that was sown by the Users of these fake ecstasy pills are did not spot. I didn’t see any stories at Labour government in 2010, and tended unwitting, they are young, and they all on the drug problem within what carefully ever since. do not have long-term drug addictions people rarely refer to as “the white The figure of 97 NPS deaths was or indulge in risky behaviours such as community”. No panicked editorials, no quoted far and wide – but closer reading injection, or even polydrug use. Their representatives of the white community showed that only 68 deaths were found deaths are shocking and unexpected. were summoned to explain or justify by npSAD to have been specifically The harm reduction messages the fact that 97.3% of the 1,613 deaths caused by the use of these drugs. around safer ecstasy use that were so recorded by npSAD were of white people. Now look more closely: of those 68 prevalent 20 years ago – with users Is this not statistically interesting? deaths, 20 were actually caused by PMA advised to dose cautiously with new and Nor did I see an anguished and PMMA, substituted . untrusted batches, to avoid other drugs commentariat pontificating over the fact Neither drug can be said to be novel, and alcohol, and to remain moderately that those whose drug use killed them since they have existed for decades – hydrated and cool, are being lost in this were overwhelmingly male, with men they were first synthesised in 1967 by moral panic about legal highs. Apply making up 72.2% of all fatalities. psychedelic chemist, Alexander Shulgin. them with renewed vigour to PMA and But when it comes to drugs, statistics, Both are Class A drugs, not ‘legal highs’. PMMA, and lives would be saved. policy and journalism, there’s an awful A further two deaths were attributed to Moreover, as a proportion of the 1,613 lot that just doesn’t add up. 4-MA – which is just another name for deaths, NPS as defined by this study PMA. So, 22 of the 68 legal highs deaths accounted for just 4.2 per cent of all were from PMA or PMMA. That leaves us drug-related deaths in the UK. Take out n Mike Power is a freelance journalist with 44 NPS deaths. the 22 PMA/PMMA deaths and you have and author of Drugs 2.0: The web PMA and PMMA, sold under false 44 fatalities, or less than three per cent revolution that’s changing how the world pretences as ecstasy tablets, almost of all drug deaths in the UK. gets high

28 | Druglink March/April 2014 Your professional insurance can help raise funds for DrugScope.

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