Policy issues

Addiction: the policy frameworkemily Finch

AbstractAddiction psychiatry operates within a policy framework. For most of

the 20th century, the ‘British system’ of drug treatment operated with

a small number of drug users being treated by doctors. By the 1960s

formal policy set up the first drug treatment services and passed the

1971 Misuse of Drugs Act, which sorted illicit drugs into classes A to c

according to the degree of harm they cause. cannabis was later down-

graded from class B to c despite concerns about its effect on men-

tal health in vulnerable groups. Further legislation in 1985 defined the

classes of person authorized to posses controlled drugs. Alcohol supply

is controlled by licensing laws first introduced in 1916. in 2003 these

laws were revised in an attempt to reduce antisocial behaviour, despite

having the effect of increasing opening hours. in 1995 Tackling Drugs

Together was the first strategic response to drug misuse, published

with cross-party support. in 1998 the drug strategy was published that

clearly defined four strands of work on prevention, reducing supply,

access to treatment and crime reduction. in 2001 the National Treatment

Agency was set up, with the objective of doubling the number of clients

in substance misuse treatment and monitoring that objective in local

areas. The alcohol harm reduction policy published in 2004 focused on

reducing antisocial behaviour, with little discussion of treatment. Policy

is defined by structures including the Advisory council on the Misuse of

Drugs, the Department of Health and the Home office. it is influenced by

public health, criminal justice, the desire to reduce antisocial behaviour

and the research evidence base.

Keywords Advisory council on the Misuse of Drugs; drug strategy;

licensing Act; Misuse of Drugs Act; National Treatment Agency; policy

Addiction psychiatry is unique in having a strong policy framework surrounding its practice. Much of what addiction psychiatrists do is defined by policy; for example, the fact that purchasing heroin is illegal makes a substantial difference to the course of heroin addiction, its complications and the way in which it is treated. Many of the differences between patients

Emily Finch MD MRCPsych is a Consultant Psychiatrist and visiting

Senior Lecturer at the South London and Maudsley NHS Trust and the

Institute of Psychiatry, UK, and has clinical responsibility for the North

Southwark community drug services as the Deputy Clinical Director.

She is the National Treatment Agency Clinical Team Leader. Her

research interests include the outcome of treatment for opiate users,

dual diagnosis, and coercive treatment. She lecturers and tutors on

the MSc in clinical and public health of addiction. Conflicts of interest:

none declared.

PsycHiATRy 6:1 3

addicted to alcohol and those addicted to heroin and cocaine are a consequence of the place of the substances in our society. To treat substance users, some understanding of the policy frame-work is important.

The history of substance use policy

Throughout the first half of the 20th century, British drug policy was characterized by the involvement of the medical profes-sion and by drug users generally being treated rather than being punished.

In 1926 the Rolleston Report laid the framework for the treat-ment of opiate addicts for the next 40 years in Britain. Broadly, the report puts treatment of opiate users into the hands of the medical profession, making it a medical rather than a criminal justice problem, and supports the use of maintenance opiates in some cases of addiction. This resulted in a rather liberal approach to treatment, which became known internationally as ‘the British system’.1

Between the 1920s and 1950s treatment was mostly main-tenance prescribing of injectable opiates to a small number of therapeutic addicts.

By the mid-1960s it was becoming clear that Britain’s treat-ment system was not responding adequately to the rapidly changing and increasing drug problem. Users were also younger and increasingly not therapeutic addicts but were using opiates for pleasure. The second Brain Report, published in 1965, made many recommendations, including the setting up of the first drug dependence units to treat drug users and the forming of the Advisory Council on the Misuse of Drugs (ACMD), with a brief to advise government on drug policy. The Brain Committee Report also influenced the first Misuse of Drugs Act, passed in 1971.

In the 19th century the temperance movement was the beginning of the medical profession’s involvement in attempts to control the public’s use of alcohol. The first formal attempts to control alcohol consumption were brought in 1916, when restrictions were placed on the sale of alcohol – essentially the first licensing laws. Indeed, one of the most famous attempts to control alcohol consumption was prohibition in the USA during much of the 1920s and 1930s. However, it was later repealed as it was perceived to have driven alcohol use underground and so became impossible to implement. Alcohol use in Britain has always remained legal, although there remains substantial inter-est in mechanisms to reduce individual and population alcohol consumption.

The legal framework

Since 1971, the Misuse of Drugs Acts have made many drugs of abuse illegal. This is the main piece of legislation covering drugs and categorizes them as belonging to Class A, B or C (see Table 1).

These drugs are termed ‘controlled substances’, and Class A drugs are those considered to be the most harmful. The list has been revised many times since 1968; in 2004 cannabis was down-graded from a Class B to a Class C substance, effectively reducing the penalties associated with its use. The rationale for this change was that other illicit drugs such as heroin and crack cocaine cause greater harm to individuals and society. The decision remained controversial, however, with increased interest in the association

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Policy issues

The Misuse of Drugs Act

offences under the Act

• unlawful possession of a controlled substance

• Possession of a controlled substance with intent to supply it

• supplying or offering to supply a controlled drug (even where no charge is made for the drug)

• Allowing premises you occupy or manage to be used for the purpose of drug-taking

Drug trafficking (supply) attracts serious punishment, including life imprisonment for class A offences. To enforce this law, the police have

special powers to stop, detain and search people on ‘reasonable suspicion’ that they are in possession of a controlled drug.

classification under the Act

Drugs classified Penalties for possession Penalties for dealing

Class A ecstasy up to 7 years in prison

and/or an unlimited fine

up to life in prison

and/or an unlimited fine

lsD

Heroin

cocaine

crack

Magic mushrooms (if prepared

for use)

Amphetamines (if prepared for

injection)

Class B Amphetamines up to 5 years in prison

and/or an unlimited fine

up to 14 years in prison

and/or an unlimited fine

Methylphenidate (Ritalin)

Pholcodine

Class C cannabis up to 2 years in prison

and/or an unlimited fine

up to 14 years in prison

and/or an unlimited fine

Tranquillizers

certain painkillers

GHB (gamma hydroxybutyrate)

Table 1

of cannabis use and mental illness.2 In 2005 the ACMD reported on the subject in response to the controversy and did not recom-mend reclassification but concluded that the government should seek to reduce the use of cannabis, especially among young people and those at risk of schizophrenia.3

The Misuse of Drugs Regulations (1985) defines the classes of person who are authorized to supply and possess controlled drugs. They divide drugs into five schedules, each specifying the requirements governing activities such as importing, exporting, production, supply, possession and record-keeping. For example, Schedule 1 includes drugs that are not used medicinally, such as cannabis. Schedule 2 involves drugs such as diamorphine and morphine, which are subject to full controlled drug requirements relating to prescription, safe custody and the keeping of registers.

Only medical practitioners who hold a special licence issued by the Home Secretary may prescribe, administer or supply dia-morphine, dipipanone and cocaine for the treatment of drug addiction. Prescriptions ordering controlled drugs are subject to formal prescription requirements and several technical changes have recently been introduced in response to the Shipman Report (e.g. the requirement for private prescribers to prescribe on a standard form using a unique identification number).

PsycHiATRy 6:1 3

The legal framework surrounding the supply of alcohol is mainly the licensing laws, which restrict the sale of alcohol to some premises only, at various times of the day and to a restricted number of hours in the day. They also restrict the sale of alcohol to minors. Most recently the Licensing Act 2003, which came into effect in 2005, has the objective of reducing antisocial behaviour associated with alcohol use by a variety of measures, including: • tougher closure powers for the police to deal with problem

premises • increased penalties for selling alcohol to people under the age

of 18 • ending fixed closing times, thereby eradicating 11pm and 2am

disorder flashpoints.The Act also gives more power to local residents by: • enabling them to ask for a review of an existing licence at any

time • enabling them to challenge any new licence application • enabling them to hold local councillors to account at the ballot

box for licensing decisions. In effect these changes allow many licensed premises to open for longer periods of time and it remains to be seen whether they meet their desired objectives.

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Policy issues

Policy issues

Influences on policyA variety of factors have influenced substance misuse policy. Public health has at times been important in drugs policy, with the best example of this being the HIV epidemic among inject-ing drug users in the mid-1980s, which resulted in huge policy changes and the setting up of needle exchange and other harm reduction interventions to reduce HIV transmission. Public health has probably been less important in alcohol policy, with govern-ment interventions being driven by the desire to reduce public disorder rather then improve health. Arguably, the desire to raise tax revenue by taxing legal drug use has also been important.

In the past 10 years drug policy has increasingly been driven by the desire to reduce the acquisitive crime associated with illicit drug misuse, with the general recognition of the link between Class A drug use and criminality. Doctors and others treating drug misusers have had to accept a role in reducing crime as well as improving health, with programmes such as drug treatment and testing orders (DTTOs).

More recently the recognition that drug and alcohol misuse are both major causes of social problems and a consequence of them has resulted in the treatment of substance users and the control of supply being major factors in urban renewal and regeneration.

The research evidence base can also be used to inform policy. A good example of this is the finding that drug treatment works and can reduce criminality,4 although alcohol policy has rarely been informed by the evidence that reducing availability can reduce consumption and the harm associated with alcohol use.5

Treatment policy over the last 15 yearsTackling Drugs Together, published in May 1995, was the first genuinely strategic response in England to the complexities of the drugs problem. It had cross-party support and was successful in sustaining a coordinated approach to a difficult issue. It remains one of the best and most influential strategies for effective action against drugs, and it set up the drug action team structure. These remain the successful local partnerships responsible for the commissioning of drug treatment services in local areas.

One of the recommendations of Tackling Drugs Together was to commission a taskforce of experts to review treatment for drug misusers. The report was published in 1996 and concluded that treatment worked and that greater provision would bring sub-stantial improvements for the individual and society.

The 1988 Drug Strategy was a cross-government programme of policies and interventions that concentrated on the most dan-gerous drugs, the most damaged communities and problematic drug users. The Strategy comprises four strands of work: • preventing young people from becoming drug misusers • reducing the supply of illegal drugs • increasing the number of individuals accessing effective drug

treatment • reducing drug-related crime. It was revised in 2002, with a review of progress made up to that point and an increase in emphasis on treatment in the crimi-nal justice system. The strategy came with a large increase in funding and targets for local partnerships concerning the num-bers of clients in treatment and local waiting times.

PsycHiATRy 6:1 39

In 2001 the government created the National Treatment Agency (NTA) as a special health authority, with the explicit objective of doubling the number of clients in structured substance misuse treatment. In 2002 the NTA published Models of Care, which set out formally the structure of drug treatment services, with clear guidance to local areas on how it should be provided. The imple-mentation of models of care and the funding which accompanied it has resulted in a substantial increase in the quantity, quality and range of treatment available across England.

Alcohol treatment policy has failed to keep up with drug policy, with successive governments leaving alcohol treatment entirely to local commissioners and service providers. In 2004 the Alcohol Harm Reduction Policy was published by the Cabi-net Office. It focused generally on measures to control antisocial behaviour due to alcohol, with very little discussion of treatment. In 2006 Models of Care for Alcohol set out a framework for the provision of alcohol services but it is not clear whether enough funding has been committed to implement the framework (see Table 2 for a list of policy documents).

Policy structuresACMD has produced influential reports that have had influ-ence on drug policy. The best known of these is AIDS and Drug Misuse, which pushed for major change in response to the HIV epidemic. The members of the ACMD are a group of senior experts who operate independently and whose brief is to advise government. They continue to provide advice on controversial areas of drug policy and make recommendations for change.

Influential policy documents

• Advisory council on the Misuse of Drugs. AiDs and drug

misuse, part 1. london: HMso, 1985.

• HM Government. Tackling drugs together. A strategy for

england 1995–1998. london: HMso, 1995.

• Task Force to Review services for Drug Misusers. Report of

an independent review of drug treatment services in england.

london: Department of Health, 1996.

• united Kingdom Anti-Drugs coordinating unit. Tackling drugs

to build a better Britain: the government’s 10-year strategy

for tackling drug misuse. london: The stationery office, 1998.

• Department of Health. Drug misuse and dependence –

guidelines on clinical management. london: Department of

Health, 1999.

• National Treatment Agency. Models of care for treatment of

adult drug misusers. london: National Treatment Agency,

2002. (Available as Part 1: summary for commissioners and

managers responsible for implementation, and Part 2: Full

reference report.)

• cabinet office. Alcohol harm reduction strategy for england.

2004.

• National Treatment Agency. Models of care for treatment of

adult drug misusers: update. 2006.

• Department of Health. Models of care for alcohol misusers

(MocAM). 2006.

Table 2

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Policy issues

The Department of Health has a key role in drug treatment policy. In 1999 it published the highly influential Drug Misuse and Dependence – Guidelines on Clinical Management, which sets a standard for the medical treatment of drug misusers.

The Home Office is highly influential in drug treatment – more so than in any other area of psychiatry. Since the inception of the cross-government drug strategy in 1998 the Home Office has funded substantial amounts of treatment in the criminal justice system, including drug treatment and testing orders, which, under the 1988 Crime and Disorder Act, enable the courts to coerce drug users into treatment.

The NTA is tasked with implementing the drug strategy. It is responsible both to the Department of Health and the Home Office and has so far enabled many of the drug strategy targets to be met.

Future directions

In 2007 the National Institute for Health and Clinical Excellence (NICE) will report on several areas of drug treatment. This will give further guidance to drug treatment providers and commis-sioners on what treatments are likely to be most successful in reducing illicit drug misuse. At the same time the Department of Health is revising Drug Misuse and Dependence – Guidelines on

PsycHiATRy 6:1 40

Clinical Management, which will update guidance on clinicians’ practice.

Substance misuse treatment will remain subject to policy changes and various factors will influence the changes. Criminal justice policy may or may not remain a major factor in drug treat-ment. There is still little indication that alcohol treatment will gain the attention of policymakers. ◆

ReFeRences

1 strang J, Gossop M, eds. Heroin addiction and drug policy. oxford:

oxford Medical Publications, 1994.

2 strang J, Witton J, Hall W. improving the quality of the cannabis

debate: defining the different domains. Br Med J 2000; 320:

108–10.

3 Advisory council on the Misuse of Drugs. The Advisory council’s

report – further consideration of the classification of cannabis under

the Misuse of Drugs Act 1971, 2005.

4 Gossop M, Marsden J, stewart D, Rolfe A. Reduction in acquisitive

crime and drug use after treatment of addiction problems: one year

follow-up outcomes. Drug Alcohol Depend 2000; 58: 165–72.

5 Babor T. Alcohol: no ordinary commodity. oxford: oxford university

Press, 2003.

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