In their report on HIV published last week, the Health Protection Agency (HPA) said that the prevalence of HIV infection among injecting drug users in treatment who had injected in the previous 4 weeks was 1.3% in 2006 compared with 0.7% just 6 years before.

According to the latest prevalence data, infection with hepatitis C among injecting drug users in contact with services has also risen since the beginning of the decade - from 33% in 2000, to 42% in 2006. You'd be forgiven for wondering how these increases were possible - given the increased investment for drug services we have seen over the periods covered by this research. Maybe the fact that levels of reported needle and syringe sharing increased in the late 1990s and have remained elevated since has something to do with it - in 2006, almost a quarter (23%) of current injectors reported sharing injecting equipment with other injectors in the previous month.

Its just over a year now since I sat in a meeting with a number of specialists from the field and a young man from the treasury - a lead on a key area of development of what has become our new drug strategy- who found it impossible to believe that harms other than crime were of any importance. "I have been working in drugs for over 18 months now," he said outraged, "and I have never heard anyone challenge the fact that crime is the only significant harm related to drug use. You must all be wrong".

Its hard to believe during the 18 months tenure of this young man in the drugs field that no one in the Cabinet Office or Home Office or NTA mentioned health at all, given the furor throughout 2006/7 about what were perceived as troubling reports of the levels of drug related death - particularly in some key areas like Glasgow, Liverpool and Brighton.

To reduce drug related deaths by 20% was the modest but realistic target of the 1998 drug strategy. This would mean that from a baseline of 1,480 drug-related deaths the target would be to reduce mortality to 1,184 by 2004. We failed to meet this target and by 2006 despite showing a small decrease, it was still pretty close to the 1998 baseline. Throughout 2005 - when there were 1,506 drug related deaths - and 2006 concerns grew. Despite having excised this particular target from the 2002 refresh of the drug strategy, in terms of the original 10 year plan it looked like failure. In September 2006 at the behest of the DoH, the NTA called a special meeting to discuss this and at their board meeting in December of that year they reported:

"The levels of blood borne viruses amongst drug misusers and particularly injecting drug users have recently increased together with the rates and levels of sharing of injecting equipment...Worryingly, BBV incidence has also increased amongst new (predominantly younger) injectors...Drug related overdoses have fallen but remain high at 1382 in 2005 (np-SAD 2006). The national target to reduce overdose deaths by 20% by March 2004 was not achieved. Drug related overdose deaths are the second most common cause of ‘years lives lost’ in young men. Recent Home Office work on drug related mortality amongst newly released male offenders shows that they are 29 times more likely to die compared to peers in the community, during the first week of release from prison."

The response? An action plan for reducing drug related harm. In May last year Caroline Flint, then Minister for Public Health announced the plan plus additional funding of £1.9 million. At little over 1000 words, widely spaced over 4 and a half A5 pages the strategy was a disappointment, delivering not much action and not much plan. The £1.9million that seemed so paltry became even less significant when it became clear that much of it was already committed to existing contracts. In a public posting on the SMMGP message board the NTA lead for this area of work said: "I think it is best to view the current strategy as a set of broad objectives, with more detailed actions and milestones to come at a later date... The budget for this year is actually nearer 1.2 million, given that the healthcare commission and St. Georges work is already allocated..."
(see all of the post here)

A more detailed plan never did appear (though it is rumoured that a much more detailed and ambitious plan was in existence but was pulled late in the day), however some of the activities made it through to the NTA 2007/8 business plan . This has given us some milestones to look at - against which we are able to make some judgments about progress. Maybe in May we will get a formal report from NTA and the DoH about progress but in the meantime you might want to check it out yourselves.

• The key areas against which there has been achievement have been the Healthcare Commission Inspection of Harm Reduction Services , the placing of a greater emphasis on improvement in harm reduction services and the NICE reviews including the one of Needle and Syringe Schemes that is ongoing. This - while obviously not being the same thing - may lead to the minimum standards for needle exchange and harm reduction for inclusion in contracts promised for December last year.
• In terms of the publication of new guidance for local enquiries into drug related death (due March 2008) I can find hide nor hair of it anywhere. At the moment all that's out there is the 2003 guidance from DH .
• The inclusion in TOPs and NDTMS of data regarding injecting behaviour should improve our understanding of risk activities among the in treatment population and is welcome. However the questions remain around public health surveillance of the not-in-treatment population.
• I can't find out how much progress has been made towards the improvement of prison harm reduction and healthcare - this is a key focus of IDTS. Someone told me that Hep B immunisation in prisons is moving along at the moment, however official information on the current state of play is thin on the ground. No news is .... well, no news.
• I can't find much at all that indicates the competency based training has been taking place but the module may be developed by now (it was due January) even if its not yet published.
• Unless I am mistaken there was no campaign to reduce BBVs and DRDs among at risk groups - though as I am not a member of an at risk group, this may have been so well targeted that I missed it. Similarly I'm not aware of any ongoing centrally co-ordinated or funded peer education pilots.
• We don't have figures yet for Hep b immunisation - lets hope it has met the target. Oh hang on, there wasn't one.

There was nothing in the Action Plan that was objectionable or wrong - and nothing very ambitious either. It was just a pretty inadequate exposition of activity in a pretty important area of strategy - and to be honest the implementation is looking a bit piecemeal. However £1.9million is actually not very much money when you consider the £149 million that goes into DIP programmes and so we can't expect that much to be achieved.

What's probably most disappointing when you review this area of work is that nowhere in any of the top level documentation of substance use does there seem to be any acceptance that Harm Reduction is in any way a priority. A search through the new strategy reveals just this one bullet point:

continuing to promote harm minimisation measures including needle exchange and drug-assisted treatments that encourage drug users to enter treatment, in order to reduce the risk of overdose for drug users and the risk of infection for the wider community;

In terms of the three year action plan all we see is mention again of a national campaign to reduce blood borne viruses and drug related deaths and ... no, well actually, that's it. There are no targets in either the PSAs or the Local Indicator Set that relate to harm reduction.

It seems we have lost ground. A rough comparison of a 1997 survey of needle exchange and what has been published of the NTA survey of needle exchange from 2006 indicates that while distribution of needles has remained more or less static, the variety of equipment available and the number of additional services available with that equipment has shrunk significantly. Reports from drug users and providers bear this out indicating that while greater availability of pharmacy exchange is welcome, the fact that it seem to have come at the expense of free-standing needle and syringe programmes providing immunisation, social and healthcare interventions, advice and support and pathways into treatment is problematic. A shift in patterns of drug use would seem to indicate that some people will now be injecting with greater frequency - though at a time where obtaining more than a pack of 10 1ml monojects is challenging in many parts of the country.

So whatever did happen to harm reduction?

The 1998 UK Drug Strategy Tackling Drugs to Build a Better Britain was the first to acknowledge its aims as being Harm Reduction - even offering us a definition of the approach -

"Harm reduction is a general term that covers activities and services that acknowledge the continued drug misuse of individuals but seeks to minimise the harm that such behaviour causes."

But by 2002 in the last update to Tackling Drugs to Build a Better Britain , a swing in policy that had been apparent to many for some time was firmly fixed. No longer was the UK strategy going to attempt to equally focus on health and crime harms. It was clear early on that spending would go where the greatest immediate benefits would be felt by the greatest number of people. Research commissioned by the Home Office identified that the greatest economic harms related to drug use were to do with crime. (You can read a fascinating critique of the thinking behind this set of decisions here in Dr Nukes Guide to PSAs.). DIP and the now defunkt Drug Harm Index was born. And harm reduction ceased to be the centrepiece of our approach. The only important target now was crime reduction.

All the new investment, all the management, all the research time and all the political will would fall behind that.

Harm reduction would become a fringe activity, something that, unless directly helpful to a crime reduction target, such as demand reduction through methadone maintenance, would become the poor relation of other interventions. No longer a philosophy that underpinned our national strategy, from 2002 on, harm reduction effectively meant pharmacy needle exchange and precious little else.

Maybe Paul Flynn MP was right when in his Comment is Free piece in the Guardian in February, he described the new drug strategy as:

"... like a duck on the water quacking loudly, "tough, tougher", while beneath the surface there is furious paddling in the direction of harm reduction.... Don't listen to what they say. Watch what they do."

On an individual level Harm Reduction means working with people in a non judgmental way to reduce the harms they experience as a result of drug use. For some people this could mean something as simple as getting them clean needles. For others it may mean helping them get decent housing, access to education and employment or treatment and support for a mental health problem.

So when the new drug strategy goes on about the government commitment to greater individualisation of treatment, more choice and greater flexibility, is it talking about harm reduction? Well maybe. Recognising individual choice and agency is a critical underpinning of effective harm reduction work. What it doesn't give us however is a clear acknowledgement that treatment programmes will be oriented towards reducing harm rather than some other political goal. In fact the strategy clearly states that abstinence is the desired end result of all treatment - however much of the small print in and around the strategy indicates a clear recognition that for some people abstinence may take many years to achieve.

On a strategic level Harm Reduction is about establishing an approach to drug use that prioritises tackling the actual problems related to (either as precursors or as a direct effect of) drug use over the sometimes politically attractive option of taking a purely moral or medical or criminological position.

Does the new strategy do this? I'm not sure to be honest. There are some signals about greater pragmatism for example the shift towards support for a wider range of prescribing options. What is interesting is that despite using the language of prevention for its main public documents, the strategy actually contains as little in terms of actions that explicitly support "anti drugs" approaches as it does for harm reduction. There is certainly less emphasis on criminal justice interventions and more on community and social support. This may be both encouragingly humane and a welcome shift away from the dominance of the medical or criminal approaches - but is it harm reduction?

If Paul Flynn is right then the government are selling a tough on drugs strategy while hiding a real commitment to harm reduction. I do hope that's true. Of course the problem with secret commitments is that no one knows you've made them, and you can't be held accountable for them.

But in many ways this isn't the government's problem anymore. Its the local areas, the DATs the partnerships and the providers who now have the job of implementing strategy. Surely this is great, it means that those areas that are facing real problems around drug related deaths and blood borne viruses - like the metropolitan and the London boroughs, will be able to spend more on it. Well yes .... and no.

As we know by now, the pooled treatment budget is shrinking fast. Not only that but its actually shrinking fastest in some of the areas facing the greatest problems in terms of prevalence of BBVs and overdose. The pooled treatment budget is the only source of funding for harm reduction, but it is now allocated on the basis of numbers in structured treatment in relation to an estimated prevalence figure, not numbers in contact with services. This means that those DATs who have a large population of drug users not in touch with structured treatment - often because they have highly transient populations and lots of people who are of no fixed abode will be receiving less money per head than those areas who have high populations of relatively stable and consequently lower risk drug users. We now have no targets at all anywhere in the performance framework for drug services that relate to blood born viruses or drug related death.

So, reducing money + a funding formula that favours the provision of structured treatment over easy access harm reduction regardless of local need + no meaningful local or national measures or targets relating to either blood borne viruses or drug related deaths... Sounds like a recipe for disinvestment - and disaster.

Earlier this year I did an interview with a journalist sent out by Channel4 news to report on the new drug strategy. As he was leaving he said "Why talk about it at all, I mean Harm Reduction? The only other option for government is 'Harm Maximisation' - and no one's going to admit to that" .

Without a clear indication from government of its support for harm reduction through the CSR and national strategy we are in danger of not just ending up in the same costly pit of horror that is US drug policy but also increasing the exposure of many of the most vulnerable in our community to drug harms that are avoidable. And that surely is Harm Maximisation - whether we admit it, or not.

Tags: Harm Reduction