Street Drugs in the Northern Powerhouse: Perspective and Policy

Launch of The BAP President’s Symposium

Jo Neill, BAP President and Professor of Psychopharmacology at UoM, April 2018

Photos by Russell Bloor and Keith Nuttall

On 28th March on an “almost sunny” day in Manchester, world experts in the field of substance misuse gathered for a ground breaking and unique event, a one day public symposium where we considered the argument for reforming UK Drugs policy from a wide range of perspectives.

Driving home from work one Friday evening in October 2016, I heard Eddie Mair interview former undercover drugs police officer Neil Woods. I was mesmerised. Neil talks about his experience over 14 years gathering evidence to prosecute Organised Crime Groups (OCGs), the dangers he faced and the guilt (and post-traumatic stress disorder-PTSD) he suffers from ‘betraying’ drug users he had befriended over these years, people often highly  marginalised by society. These vulnerable people also received custodial sentences because of our current drugs policy in the UK. He mentioned the book he had written about his experiences: Good Cop Bad War and the worldwide organisation he is now Chair of in the UK, LEAP (Law Enforcement Against Prohibition). His work is now aimed at raising awareness and campaigning for total reform of the current drugs policy. Once home, I emailed our very own BAP (British Association for Psychopharmacology) expert in this area (and 2016 lifetime achievement award winner) David Nutt asking if he knew Neil. David’s typically concise and pertinent reply was “he’s a great guy”. I have now found this out for myself! So, an idea started to germinate, why not bring these 2 experts together with others for an event to raise public awareness of the issues surrounding prohibition of street drugs and their potential therapeutic potential for psychiatric and other disorders. At the same time, this could provide the perfect topic for a new initiative for BAP, the President’s symposium, where the President organises a one day event on a topic of their choice during their 2 years in office, hosting it at their institution or within their Trust, so forming a Regional/BAP partnership. So I began to put my plan into action. I discussed the issue with my new boss, Jayne Lawrence, head of the Division of Pharmacy & Optometry (DPO) at the University of Manchester (UoM), who was very supportive. Indeed, she has worked with the Royal Pharmaceutical Society (RPS) on issues surrounding illicit drugs. Then I formed a steering committee with our experts at UoM: 2017 BAP lifetime achievement award winner, Bill Deakin, cognitive neuroscientist, Rebecca Elliott and Reader in Substance Abuse, Tim Millar. Rebecca then recommended a very bright and capable 2nd year medical student to help with social media and communications for the event, Alice Capper, who, with her friend Becky Bola joined the team. Michelle Riddehough provided administrative support and the campaign began! One side-effect of this was me finally being pushed to enter the world of twitter. So, to help publicise the event I dived into twitter, with a great deal of help from Alice & Becky, #mcrstreetdrugs2018. With Kory Stout, Digital Marketing Coordinator at UoM, they organised a twitter wall for questions and comments during the day which proved to be very illuminating.

The audience of over 200 people consisted of a wide variety of people ranging from the general public, clinicians, pharmacists, academics and students. Also in attendance were representatives from charities Shelter, ReThink, and Change Grow Live; Also in the audience, representatives from UKLEAP, from the Loop who provide free harm reduction advice and information, welfare support, drug safety testing and training; police officers from Cheshire, Wales and Derbyshire. We even had a TV star in the form of Danni Brooke (from Hunter), also a former undercover police officer and speaker for LEAP UK. As you can imagine, this led to a great deal of lively discussion and debate and a very real shift in perspective for many members of the audience.

We started the day with an (uncharacteristically) short welcome address from me, of course highlighting the work of BAP.

I then introduced the audience to Professor Dame Nancy Rothwell, the President of UoM and world leading neuroscientist who highlighted the work conducted at UoM into substance abuse.

First up in the morning session, Fiona Measham (The Loop), chaired by Bill Deakin.

Fiona is Professor of Criminology at the University of Durham. She discussed her work on drug testing through the charity she founded, The Loop. The Loop organise drug safety testing (Multi Agency Safety Testing – MAST) at various UK festivals including Secret Garden Party, Boomtown and Park Life. Other European countries, including the Netherlands, Portugal, Spain, Austria, and Belgium have drug safety testing services. The Loop are now working towards extending these services into city centres. The process involves people handing over a sample of the drugs they have purchased, without fear of arrest, to analyse what it contains and any potential contaminants. Fiona explained the many ways in which drug safety testing can reduce harm including enabling health care professionals to deliver health and safety advice to otherwise hard to reach populations.  Indeed she showed that many of these people had never spoken to an expert about drug use before. In addition, drug safety testing identifies and removes high risk substances from circulation and can provide early warnings to the community; provide intelligence to emergency services and to monitor drug trends. Importantly a connection can be made between what individuals think they are taking and what is actually obtained. She told us about the increase in strength of ecstasy (MDMA, 3,4-Methylenedioxymethamphetamine) from an average of 50 mg per pill in 2000 to 165 mg in 2016, with these drugs now being much cheaper, at approx. £10 for 3 pills and £40 for a gram of cocaine. She explained how the Loop’s free testing service has led to a significant reduction in hospitalization, from 19 down to only 1 person at Secret Garden Party and a reduction in medical incidents of 25% at Boomtown where it is estimated that 8/10 festival goers are using illicit drugs.

Then Neil Woods told us his story. He explained how he infiltrated the world of organised crime by posing as a street drug user and shoplifter, he told us how much fun shop lifting is if you know you can’t be prosecuted! He explained how he narrowly avoided being seriously assaulted by drug dealers, how he befriended some of the most vulnerable members of society to gather evidence, primarily to prosecute drug dealers higher up the chain. Over time, he realised that his work was doing more harm than good, interrupting the drug supply for no more than 2 hours for his largest OCG arrest and he explained why he now works for LEAP working towards replacement of prohibition with regulation of street drugs. Neil has a very engaging style and a way of narrating his experiences in a truly moving and humorous way, with a range of stories about his experiences. Some very interesting facts emerge from his work e.g. the annual market value of the illicit drugs trade is £10.7 billion in the UK, much of this money going to OCGs. He describes how policing drug use has created a “Darwinian soup” where the OCGs with the most violent tactics rise to the top. The audience were totally transfixed listening to him and this was followed by a very lively Q&A with him and Fiona.

To hear more about his amazing experiences and to understand why he is now advocating an end to prohibition and for regulation of all illicit drugs, listen to his interview with Eddie Mair, read his story in brief on the UoM website and read his book!

Before lunch, we heard from Ashok Soni, OBE and President of the Royal Pharmaceutical Society (RPS). With 30 years’ experience as a pharmacist, including owning and operating several pharmacies, and working for Lambeth, Southwark and Lewisham LPC (Local Pharmaceutical Committee), he is very well placed to give us the pharmacist’s perspective. He explained how he is not in favour of regulation of illicit drugs, however he does not support the current criminalisation model. He supports a harm reduction approach and reflected on how this has evolved over his 30 years in practice. Pharmacies now offer needle exchange, methadone and buprenorphine substitution therapy for opiate dependence. He also discussed the unintended consequences of this scheme including patients selling methadone on the streets, to purchase others drugs. During the discussion that ensued, one attendee suggested that giving heroin in a controlled environment would negate such negative consequences and so reduce harm. Most likely Pharmacies will be involved in a new world where illicit drugs are available on prescription for those who need them. As Neil Woods explains, regulation needs to be very carefully considered, with each drug having its own regulatory framework and guidelines, something that the BAP could lead on. There was a lively discussion regarding who would supply the drugs if they were to be regulated, probably the pharmaceutical Industry, and how the pricing structure would work (e.g. would OCGs evolve their business to undercut NHS prices?)

Then we had a break for lunch and from the conversations I heard, a great deal of dialogue about the issue of prohibition and regulation, with people arguing and debating. Exactly our intention!

First up in the afternoon session, Chaired by Rebecca Elliott, was BAP’s Val Curran, Director of the Clinical Psychopharmacology Unit at UCL and Research Lead at Campden & Islington Drug Services.

Val presented a talk titled “Cannabis and cannabinoids: benefits and risks”. She started out by taking us on a historical tour of cannabis use for recreation, spiritual and medical uses, as for other psychoactive substances. Cannabis has been used for thousands of years for these purposes and by many cultures, it is certainly not a new phenomenon. She explained how the components of street cannabis have changed over the past 30 years and showed a clear correlation between addiction rates and an increase in strength. The main components are cannabidiol (CBD) and delta-9-tetrahydrocannabinol (THC), the ‘good’ and the ‘bad’, the beneficial and the harmful. She explained  how high potency cannabis, classed as skunk or herbal type, with very high levels of THC and hardly any CBD is now the most widely available form of cannabis on the streets. When Val’s team conducted an analysis of the ratio of CBD to THC in users’ samples, they found less than 1 part CBD to 9 parts THC, ie a ratio of less than 0.1 (Freeman et al. 2014, doi:10.1111/add.12634). Of course,as she described, there is the link between cannabis use in adolescence and psychosis, and the endocannabinoid system plays an important role in brain development at that age. Val’s research team have identified a polymorphism in the AKT1 gene that predicts dependence to cannabis and acute psychotic response. Identifying people with this susceptibility gene could provide much information about prevention and mechanisms of, cannabis-induced psychosis, and for treatment. There are several promising medicinal uses of CBD including muscle spasm associated with multiple sclerosis, for epilepsy, to reduce nausea for example in  chemotherapy, to increase appetite in HIV/AIDS, to reduce tics in Tourette’s syndrome, for migraine, arthritis, anorexia and psychosis. Of course it is hard to research cannabinoids for medical benefits due to the UK’s current drugs policy and a change to current drug laws would enable much needed research in this area. This is an important issue also discussed later by David Nutt in this presentation. Several pharmaceutical companies are developing cannabinoids as medicines. Indeed, work we are doing with CBD showing restoration of cognitive and social behaviour deficits in our animal model of cognitive impairment in schizophrenia was presented at the BAP summer meeting in Brighton in 2016, on-going work in my lab. My own experience is that, even conducting this research in animals is very difficult, we had to wait for one year for Home Office approval and it was not cheap!

Then, serving Greater Manchester police (GMP) officer, Andy Costello, who, at well over 6 feet tall, told me that he could never work undercover(!) gave us a very sobering account of the impact of Spice on the homeless population in Manchester in his presentation:  “Spice-A Policing Journey” Spice is a Synthetic Cannabinoid Receptor Agonist (SCRA) with pharmacological properties like THC, originally available in Head Shops as it was initially considered to be a herbal product, and therefore not covered by the 1971 Misuse of Drugs Act. Spice is much harder to detect in biological samples than cannabis and is easily smuggled into prisons on letters.  Andy told us that when SCRAs were available in Head Shops, it attracted many “Spice Tourists” to Manchester and caused antisocial behaviour in a restricted area around the Head Shops. When the Psychoactive Substances Bill was passed on 26th May 2016, Head Shops closed down over-night, driving SCRAs onto the streets. The Spice tourists disappeared and the problem of SCRAs moved into the homeless, young offenders and prison population, indeed it is estimated that 90% of the male prison population use SCRAs. The police were told to solve the problem and in December 2017 seized millions of pounds worth of SCRAs and put many drug dealers behind bars, unlikely of course to solve the problem as we heard from Neil Woods. A more holistic approach has also been championed by GMP. In collaboration with Manchester Metropolitan University (MMU) the MANDRAKE (MANchester Drug Analysis & Knowledge Exchange) project has been established to provide intelligence-sharing, chemical analysis and harm reduction combining the work of GMP, public health and homeless charities across the GM region. In 2017 pills sold as ecstasy (MDMA) led to 10 hospitalisations in the North West, A&E staff struggled to identify the cause and the usual treatment for MDMA overdose did not work, but within 2 hours MANDRAKE identified the substance as Crystalline Spice and were able to provide information to the relevant services and this most likely saved many lives. GMP have also produced information leaflets for the public on how to deal with SCRA overdose and have several other on-going initiatives to reduce harm; including a sensible response to drug possession, knowledge exchange with partners, a Manchester Drug Early Warning System and a large commitment to improving public health. Andy finished by explaining that this is a Manchester-led response for what is not just a Manchester problem.

Andy Costello’s talk was followed by Tim Millar, Reader in Substance Abuse & Addictions at UoM, presenting a talk titled: “Drugs & death: premature, preventable mortality amongst illicit opiate users”. Tim explained how prohibition can increase harm irrespective of the number of drug users, i.e. even if it did result in a smaller number of users (which it doesn’t, see below), if the harm per user is greater under prohibition, then overall harm is increased. Indeed in a UK Government Report published in 2014 (based on an in-depth study of drug laws in 11 countries ranging from those with most prohibition, e.g. Japan, to those with least, Uruguay) it was stated that: “we did not in our fact-finding observe any obvious relationship between the toughness of a country’s enforcement against drug possession, and levels of drug use in that country”. Tim showed that over half of all deaths related to drug poisoning in the UK involve an opiate. He then presented a large dataset on all causes of death among a known group of treated and untreated opiate users. Several shocking and thought provoking facts emerged from this large study. Opiate users were found to be almost 6 times more likely to die prematurely compared with the normal population. The causes of death were, in the following order: cancer, circulatory system failure, digestive system failure, respiratory system failure, liver disease, and most common of all, infectious disease. Opiate users are also more likely to be murdered than the general population and these risks all increase with age in this population. The risk of fatal overdose increases with age and, although this is less common in women at an early age, this gender gap closes with advancing age. Opiate Substitution Treatment (OST) that, as Ash Soni explained in his earlier presentation, can be provided by Pharmacies, significantly reduces the risk of fatal overdose while patients are in treatment, but there is a very large increase in the risk of fatal overdose in the first 28 days after discharge. In summary, opiate users are highly stigmatised, marginalised and excluded by society, they are more likely to be homeless and have a much greater risk of premature death from many causes. OST halves fatal overdose risk but too few of the at risk population access treatment.

Finally (and of course by no means least), David Nutt, former chair of the Advisory Council on the Misuse of Drugs  (ACMD) in the UK and founder and chair of DrugScience gave his presentation “Time to put science not politics at the heart of UK drugs policy”. David started by summarising the main points and findings from all the other speakers for the audience. Then he continued by taking us on his journey from Chair of the ACMD, to forming DrugScience. He posed 3 key questions about our drug laws: i) Are they proportionate to the relative harms? ii) Do the benefits of the laws (i.e. reduction in use) outweigh the downsides? The downsides include organised crime, impedance of medical research, marginalising vulnerable people and reducing their access to treatment and the most important question iii) Do they reduce harm and drug use? David then went to highlight at least 6 major flaws with current UK drugs policy. In particular, current drug laws are in his view ‘dishonest’ and not based on any scientific evidence. David then explored the cause of this dishonesty including the power of the alcohol industry, the media greatly over-stating the harms of illicit drugs and ignoring those caused by alcohol. Re-classification of cannabis from Class C to Class B as an election approached in 2009, against the advice of the ACMD (the experts in the field) led to 1 million people having unnecessary criminal convictions for cannabis possession, which, as we heard from Andy Costello, many police forces do not want to prosecute, preferring to put resource into harm reduction instead. Our drug laws are not applied fairly with 3-4 times the number of black and minority ethnic (BME) males arrested than Caucasians despite having the same levels of cannabis use. One particularly damaging effect of prohibition covered by several of our speakers is the increase in harm it causes, because when a supply route for one drug gets cut off (by law enforcement seizing or destroying large quantities of the raw material for example) a more dangerous substitute often  floods the market. The rise of SCRAs such as Spice is a good example of this and David gave another example in the case of ecstasy. Since 2005 there has been a steady rise in the number of deaths due to a drug with a similar chemical structure to ecstasy, PMA (para-Methoxyamphetamine). Why did this new drug appear? When law enforcement activity led to the seizure of large quantities of safrole (from sassafras oil) the starting ingredient of MDMA, underground chemists simply used anethole instead (from the ubiquitous aniseed oil). This has had dreadful consequences for ecstasy users. PMA is a far more toxic substance, it has a slower onset of action, leading users to take more, it is a monoamine oxidase-MAO inhibitor inducing serotonin syndrome and so leads to hyperthermia, brain damage and death. It is sold as ecstasy so A&E departments and police treat for ecstasy, not PMA poisoning. PMAs and SCRAs are perfect examples of how prohibition causes more harm than good, and why drug safety testing and holistic policing is essential.

Many illegal drugs have potential medical benefits. However, we cannot research them because so many are Schedule 1 substances (ironically classed as having no medicinal benefit) including cannabis which of course, as we heard from Val Curran, has multiple medicinal uses. David provides some simple solutions for us to consider:

i) Review our drug laws, re-write these, based on evidence rather than politics.

ii) Re-schedule prior medicines to enable research.

iii) De-criminalise personal possession.

iv) Liberate and fund drug testing services like that provided by the Loop.

v) Legalise cannabis as suggested by the Liberal Democrats.

David’s talk was followed by another Q&A session with many searching questions for David and all the speakers. Finally we gave our thanks to all those who worked so hard to make this unique event happen. What a fantastic day!

Whatever your personal opinion on this topic, there are several key facts that cannot be ignored: people have always used drugs recreationally and will continue to do so; prohibition does not work to reduce this and causes more harm than good; interrupting the production and supply of illegal drugs leads to more harmful substances being produced; a large proportion of the police do not support criminalisation of individual drug use; drug safety testing reduces harm; there are several medicinal uses of street drugs and research is impeded by our drugs policy. The current UK drugs policy is outdated, not based on scientific evidence and does not keep people safe from harm. Other countries are way ahead of the UK in leading the way on drug policy reform. Of course, if regulation is to be introduced, there are many practicalities to be sorted out. The discussions that evolved throughout the day showed that people are taking this issue seriously and are keen to work together to come up with a solution.

Following the success of our Manchester event, I would like to take this symposium to other venues in the UK, so please do contact me if you are interested in hosting it. In the meantime, I strongly advise you to visit the websites of: The Loop; LEAP; Drug Science and follow them on twitter, to find out more about work going on in the UK on drug safety testing, harm reduction, education, providing information and reformulating current UK drugs policy.

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