BIRMINGHAM HYPODERMIC

Drug traffickers operate in almost every country in the world but there are some particularly well worn routes from areas which produce drugs to markets where demand is high.

This map aims to show the main routes to the UK, rather than all the world’s routes.

Click on the drug names to see the routes, then click on individual countries to find out more about drug production or trafficking there.

UK Harm Reduction Alliance
statement on
the meaning of ‘harm reduction’

Introduction
Many responses to drug use have been defined at some time as ‘harm reduction’, and this has led to much some confusion as to what harm reduction actually is.

In order to clarify the situation, UKHRA – the UK’s leading organisation campaigning for a rational, harm reduction oriented response to drug use – has prepared a definition of harm reduction, and identified the core principles of harm reduction.

Definition of harm reduction
Harm reduction is a term that defines policies, programmes, services and actions that work to reduce the:
• health;
• social; and
• economic

harms to:
• individuals;
• communities; and
• society

that are associated with the use of drugs (Newcombe 1992) .

The principles of harm reduction:
The following principles of harm reduction are adapted from those set out by The Canadian Centre on Substance Abuse (CCSA 1996) , and Lenton and Single 1998 :

Harm reduction:

• Is pragmatic: and accepts that the use of drugs is a common and enduring feature of human experience. It acknowledges that, while carrying risks, drug use provides the user with benefits that must be taken into account if responses to drug use are to be effective. Harm reduction recognises that containment and reduction of drug-related harms is a more feasible option than efforts to eliminate drug use entirely.


• Prioritises goals: harm reduction responses to drug use incorporate the notion of a hierarchy of goals, with the immediate focus on proactively engaging individuals, targetting groups, and communities to address their most compelling needs through the provision of accessible and user friendly services. Achieving the most immediate realistic goals is viewed as an essential first step toward risk-free use, or, if appropriate, abstinence.

• Has humanist values: the drug user's decision to use drugs is accepted as fact. No moral judgment is made either to condemn or to support use of drugs. The dignity and rights of the drug user are respected, and services endeavor to be ‘user friendly’ in the way they operate. Harm reduction approaches also recognise that, for many, dependent drug use is a long term feature of their lives and that responses to drug use have to accept this.


• Focuses on risks and harms: on the basis that by providing responses that reduce risk, harms can be reduced or avoided. The focus of risk reduction interventions are usually the drug taking behaviour of the drug user. However, harm reduction recognises that people’s ability to change behaviours is also influenced by the norms held in common by drug users, the attitudes and views of the wider community Harm reduction interventions may therefore target individuals, communities and the wider society.


• Does not focus on abstinence: although harm reduction supports those who seek to moderate or reduce their drug use, it neither excludes nor presumes a treatment goal of abstinence. Harm reduction approaches recognise that short-term abstinence oriented treatments have low success rates, and, for opiate users, high post-treatment overdose rates.


• Seeks to maximise the range of intervention options that are available, and engages in a process of identifying, measuring, and assessing the relative importance of drug-related harms and balancing costs and benefits in trying to reduce them.

Drugs prohibition is “unworkable and immoral” says Chief Constable

The Chief Constable of North Wales Police Richard Brunstorm, recommends in a report published today, that his Police Authority officially support his call for the legalisation and regulation of drugs, as part of their submission to the drug strategy consultation being conducted by the Government. He also recommends that they affiliate to Transform Drug Policy Foundation. The Authority meets on Monday 15 October to discuss the recommendations.

Danny Kushlick, Transform Director said:



"We are absolutely delighted at Mr Brunstrom’s paper. The Chief Constable has displayed great leadership and imagination in very publicly calling for a drug policy that replaces the evident failings of prohibition with a legal system of regulation and control for potentially dangerous drugs”.


“Mr Brunstrom’s call is less surprising when you consider that prohibition, and the illegal markets it creates, is the single largest cause of crime in the UK, generating £100 billion in crime costs alone over the last ten years. As a senior policeman he has witnessed first hand the counter productive effects of abdicating responsibility for this dangerous trade to unregulated and often violent criminals. His call for drug markets to be brought back within the sphere of Government control stands in enlightened contrast to the populist law and order posturing of our Prime Minister, who recently announced that ‘drugs are never going to be decriminalised’.”


“The current Government consultation on the drug strategy has inexplicably ruled out any discussion of alternatives to prohibition, despite the policy’s systematic failure over a number of decades. Mr Brunstrom’s paper puts these pragmatic alternatives firmly back on the table, where they should be, if a meaningful debate about ‘what works’ is to be entertained. It is to be hoped that the Police Authority support the Chief Constable’s recommendations and that other Police Authorities seriously examine the impact of enforcing prohibition. It signals the start of a renewed critique of prohibition, which Mr Brunstrom’s paper describes as ‘both unworkable and immoral’ and should force the Home Office and indeed Government to take the issue far more seriously than it has until now. An enormous amount of respect is due to the Chief Constable for supporting a ‘pragmatic and ethical’ policy, despite its taboo nature in front line party politics. Those that denounce him should be wary of relying on what Mr Brunstrom calls ‘moralistic dogma’.”

NTA Announcement:

User Satisfaction Survey - 2007
The National Treatment Agency's Third Annual User Satisfaction Survey is one of the best opportunities for service users to give feedback on what's good and bad about the drug treatment they are receiving. Survey responses are then used in the process of improving treatment services to meet users' needs.

We know that treatment isn't always perfect, that's why the NTA is urging service users to voice their opinions and have their say on drug treatment services in England by filling in the 2007 User Satisfaction Survey. In the past two years, when we asked service users for their opinion on drug treatment, they replied in droves – making this the biggest annual survey of service user opinion in England so far.

The survey enables service users to:

• tell the NTA in confidence how they really feel about their drug treatment

• suggest ways in which treatment could be improved

It also allows service providers to:

• better understand what service users need

• shape treatment services so that needs can be met

The findings help improve the quality of drug services, because the results are used in the official review of services. This important information can then be fed back to the treatment agencies to enable them to improve the quality and effectiveness of the programmes they offer.

Make sure your voice is heard!

Throughout England this September, the NTA's User Satisfaction questionnaires will be available from the majority of adult drug treatment services. If you are in treatment, please take this valuable opportunity to let us know what is working and what needs to be improved. And, if you know people who are in treatment – please encourage them to take part.

P.S …

All information provided within the questionnaires is solely for research purposes and is completely confidential and anonymous. You do not have to give your name and have the right to not to answer any questions if you do not wish to. Each questionnaire comes with a pre paid envelope to post your answers back to the NTA. You do not have to hand them into your treatment service.

For further information about the survey, including a summary of what England's service users thought about their treatment in the last two years, please follow the link here or contact the NTA research team on

Tel: 020 7261 8959.

Remember - This is about finding out what you think about your drug treatment, which will help us at the NTA make the right improvements.

DEFINING THE DRUG USER by RAFFI BALIAN & CHERYL WHITE
Who are drug user unions for? What role should non-drug users play in Users' Unions? Answering these questions will help to eliminate confusion, in-fighting and conflicts of interest among drug users and non-drug users, and confirm a place for non-drug users who have unconditionally invested invaluable energy helping drug users for many decades. At the same time, defining the "drug user" will weed out those who wish to join Users' Unions to exploit the meagre resources and "privileges" afforded to drug users during the recent past.
Until recently, there seemed to be little confusion concerning the identity of drug users. At harm reduction and HIV-related conferences, illicit drug users congregated, often in hotel lobbies or in a user's room, and vented about the conference organizers' failure to ensure drug user representation and the location and exorbitant costs of conferences which often discouraged drug users' attendance. Drug users also resented the fact that they were only offered speaking opportunities in small workshops in contrast to the plenary sessions. These "key note speaker" positions were (and continue to be) offered to three-piece suited academics, non-users or, on rare occasions, ex-users. These kinds of insensitivities were doubly offensive considering the fact that knowledge around illicit drugs and drug using behaviour were relayed to these scholars by underpaid and overworked front-line workers and users. When the venting session was over, users traded vein creams, different kinds of needles, crack pipes, and all kinds of harm reduction materials and information which were then duly passed on to their clients and fellow users. The only debate during this period was whether "chippers", weekend heroin or cocaine users, fitted within the definition of drug users--a question that was never resolved to our knowledge.
Nowadays, the number of participants in this debate seems to have dramatically increased. As we see it--and this division is for the purpose of this debate alone--on one side are the chaotic , illicit drug users (those for whom consumption is not a choice and whose lives are circumscribed by their drug use - "chaotic" is not a judgment of the user but an acknowledgement of the environmental and psycho-physiological context of their use); and the other side appears to be composed of licit and illicit recreational drug users, "born again" ex-users as well as AIDS professionals, drug and treatment agency personnel, and other activists who have joined the movement(s) for various reasons.
This polemic is not academic. At long last, user-driven programs are being recognized as more effective than most traditional approaches. Governments, agencies serving drug users, and even many AIDS Service Organizations (ASOs), are no longer shying away from the possibility of hiring users or encouraging user-driven agendas. The privileging of certain kinds of knowledge over others is also not the driving issue at this time: there is a realization that academic (in other words, privileged) knowledge is incomplete without first hand experience. The disagreement has moved to a more insidious level, which is sometimes difficult to identify clearly. What currently fuels the debate regarding who is a user within harm reduction movements is the attempt by some to want to make the claim to being a user (with all of its limited "privileges") without actually having to suffer any of the actual oppression that goes along with it.
Theory
Based on our past anti-racist and feminist organizing experiences, it is important to develop a clear definition of "drug users" because, if we are true to the directives of harm reduction organizing, these folks are going to be designing the programs specific to their own needs and setting the goals and agenda of the larger movement(s). Uma Narayan, in an article entitled "The Privileged of the Oppressed," claims that oppression has its privileges. First and foremost is the privilege of "exclusive inside knowledge." For example, no matter how much a person abhors racism, unless that person experiences racism's complex nuances, she or he will never be aware of the entire range of racial discrimination.
A similar pattern exists for the drug user. The "exclusive inside knowledge" of the user, developed through lived experiences, and often at huge emotional, personal, familial, and financial cost, is of paramount importance. Many people often forget or deliberately neglect the exorbitant price users have paid to attain Narayan's "inside knowledge" and exploit users' fragile "privilege", for example by soliciting users for their inputs but not crediting or paying (or underpaying) them for their services. At best, users have been the recipients of insignificant fees for responding to marginally relevant questionnaires; at worst, they have been unwitting subjects of unsolicited observations with the results of such studies being used against them. Why are these exploitations not exposed, one asks? Like all oppressed groups, users have to pick their fights sparingly; they are too vulnerable and too busy surviving to challenge such issues as plagiarism and failure to receive credit or recognition for their contributions.
So, who is a drug user?
In the political context of this discussion, a drug user is someone whose life is circumscribed by her/his drug use. This means that their every decision must factor in the variable of drug use and how everything will impact upon it. Drug users do not necessarily have the luxury of stopping at will. Although some users can sometimes stop using for a particular occasion or period, this should not be confused with any liberal notion of "choice" in the conventional sense, due to the current criminalized and anti-drug user environment in which all illicit drug users live out their daily lives. Their drug use or non-use is contingent on a myriad of social, emotional, psychological, financial, medical, physical, and legal conditions. A drug user is someone whose drug use is like the skin of a person of Colour - they wear it and cannot closet it wherever it is convenient to do so (of course we recognize that, unlike people of Colour, drug users may eventually stop using, whereas one cannot stop being Black, for example). Due to the illegal status of drugs and stigmatization, drug users find it very difficult and sometimes impossible to negotiate between safe and unsafe drug use, and as such, their lives become chaotic. "Choice" is thus an oxymoron for drug users (contrary to the claims of Imani Woods--although we are not proponents of the "Disease Model" either).
Drug users face discrimination in every facet of their lives. Many are constantly harassed by family and acquaintances, accused of being selfish and weak-willed individuals. At work, if they manage to get work, (even at organizations that consider themselves to be "user friendly", or who claim to be in the avant-garde of harm reduction), they are vulnerable to some of the worst kinds of work-related oppression. For example, their drug use is held against them as a trump card for dismissal; others are refused group insurance for admitting drug use or simply for being on methadone; many face the extra burden of having to educate everyone and their dog about drug use and the related issues, in essence, paving the road for future users who come onto the scene, be it in a workplace, among friends, in an organization or wherever (many people of Colour who read this will identify with this last point). And, for those users who are political and able to voice the key issues, they become a lot of people's token "druggie"--the one user invited to committee meetings, asked to review pamphlets, give evidence/make presentations, etc. This is neither fair nor will it provide any kind of holistic account of illicit drug use because experiences among illicit drug users are as diverse as the people who make up the group. And that is why it is NOT okay to have one or two users present amidst a sea of non-users and to then claim that the initiative is "user-driven." There must be representation of diverse users to ensure that diverse issues are being addressed. To have a few privileged users present again and again does little to create a holistic movement of users that can seriously challenge the status quo.
Should We Differentiate Between Licit and Illicit Drug Use?
Certainly. It is a rare person indeed who doesn't drink alcohol, smoke cigarettes, drink coffee, or, at the very least, partake of that most decadent drug of all, chocolate. While ours is a drug using culture (a pill for every ill, so to speak), those who do not differentiate between licit and illicit drugs must accept that a Drug Users' Union is therefore not needed, as there is no need to differentiate between drug types and different experiences of, and relationships with, drugs.
But the experiences of licit drug users, whether they use them recreationally or not, are completely different from those of illicit drug users. To be sure, some of the services offered to alcohol users can also be shared by heroin injectors; however, the services and supports needed by illicit narcotic users go far beyond the needs of alcohol consumers, prescription drug users and cigarette smokers. Otherwise, decriminalization (as a precursor to legalization), would not be the most pressing prerequisite of harm reduction strategies. Moreover, due to the illegal nature of some drugs, the consumers of those drugs face many additional barriers, including barriers to health (especially related to lack of drug purity, accessibility and the hazards of procurement), the justice system, and travel restrictions, to name only the first few that pop into our minds. Finally, in a culture where certain types of drugs are illegal, every illicit drug user is, by default, a criminal, and thus, they are condemned to the probability of communicable and fatal diseases if and when they eventually end up in jail. In prison, they are refused new needles or clean crack paraphernalia, do not have access to methadone, and are continually monitored by invasive methods that violate their human rights, including random urine analysis. In Canada, when drugs are found in drug using prisoners' urine, they are denied conjugal visits, certain privileged job opportunities, visits, day passes, and parole, to name only a few of the deprivations faced by incarcerated users. We have only scratched the surface of the issues pertaining to the consumption of illicit drugs and the repercussions for those users. However, even this minor presentation of some of the key issues, we believe, renders it abundantly clear that there is a DRAMATIC difference between consumption of licit and illicit drugs and that the lives of those persons who are consuming drugs from the latter group need special consideration and protection in a way that clearly renders them distinct from consumers of the former group, whether they be habitual or recreational users.
Role of Non-Users and Recreational Drug Users In Drug Users' Unions
Recreational, illicit drug users are also at risk of oppression by virtue of being criminalized for their drug use. It is for this reason that we believe that these people must be part of a broader harm reduction movement(s) which seeks as its prioritization the legalization/ decriminalization of all drugs. But they also have the privilege of choosing when to identify their drug use. And, if they had to stop using, their lives wouldn't become completely chaotic.
There is a clear role of support and solidarity that recreational users can play. They just can't say that they know based on lived experience. And, they can't steal the experiences of users and pass them off as their own. Nor can they partake in any initiative that excludes users, makes a living off of their suffering or which claims to speak for them without adequate representation of them. If they engage in these tactics, they are no friend of users and must be 'outed' as such.
Non-users and recreational users who have demonstrated a commitment to the issues of User Unions and who are truly dedicated to bettering the world for users of all kinds, but particularly for those who are most marginalized, should be honorary members, welcome to participate in meetings, happily greeted and walked with at rallies, but not given voting privileges and not given opportunities that need and must go to users (e.g. invitations to present at conferences on using and harm reduction; job openings which clearly call for someone with first hand knowledge of, among other things, using illicit drugs, etc.). If this is insufficient and unsatisfactory, we are open to discuss other mechanisms for such exceptions, provided that these mechanisms are designed and accepted by users. But even if users refused to have non-users' in their Unions (as honorary members or otherwise), any agent for change or any political activist with an ounce of dignity would understand that users need their own space and that Users' Unions are for users just as the American Indian Movement is for First Nations People, and the Black Panthers is for African Americans and the National Action Committee on the Status of Women is for women. As committed anti-racist and feminist activists, we would neither be offended, nor would our commitment to these organizations /issues be lessened should they not invite us to be members of their respective organizations (honorary or otherwise); on the contrary, we would never place them in situations where they'd have to make such awkward decisions. If, for any reason, these organizations ever surmised that our membership would be a good thing, we are sure that they would approach and invite us to join.
Role of Ex-Users in Drug Users' Unions
Ex-users pose one of the more complex problems in terms of their inclusion in any group that is about active drug use and which includes active drug users. There are at least three important issues:
1. Ex-drug users possess similar "inside knowledge" around many key issues as active users do, and as such, the contribution that they can make to the movement(s) is important;
2. Due to the agenda and outright brainwashing of traditional "Addiction and Treatment" programs, many ex-drug users become "born again" abstentionists and have the potential to sabotage any "safer using" strategies; and
3. Having said that, there are also many ex-addicts who believe in harm reduction, but the presence of users will often trigger insurmountable cravings for drugs and may compromise their ability to abstain. Therefore, the onus is on the ex-user to decide whether:
a. s/he is strong enough to be around active users;
b. s/he is willing to cope with the reality of relapse; and
c. s/he firmly believes in harm reduction, user-centred philosophies.
There should be no pressure on users to be "sensitive" around ex-users because this movement(s) is about users, and is supposed to be about dealing with the harms associated with drug use. No drug use = no issue!
Empowering Ourselves
It is true that in this climate of the war on drug users, there are real barriers to effective organization and work. However, we have to decide whether these barriers paralyze us. We believe that empowered people will invest the time and the energy necessary to deal with the problems that afflict them--but only when they get to set the agenda, determine the location and time and are provided with assistance (and these are the kinds of things that non-using supporters can help us with) in the form of child care, transportation and a safe place to fix so they're not 'jonesing' throughout the meeting, etc., etc.
We are about to establish a Drug Users' Union in Toronto which will be for, and driven by, drug users. Certainly, we shall negotiate the term "user" when we start this Union as well as the role of non-users with other users who want to co-conspire in the struggle. Both of us are steadfast, however, that we will never be part of any Drug Users' Union where the roles of non-users are not decided by users. To all our co-conspirators in the struggle(s), we would greatly appreciate any feedback on our opinions and ideas. Please feel free to E-mail us at: raffib@lefca.com
Solidarity,
Raffi Balian, Cheryl White
Cheryl White works as the coordinator of an HIV/AIDS and Harm Reduction Project located in downtown Toronto, Ontario, Canada and is a political singer/songwriter, currently gearing up for her first CD. Raffi Balian has worked as a harm reduction consultant and is the father of two wonderful men, a writer of fiction and non-fiction, and a political activist. Both Raffi and Cheryl have been denied entry into the United States because of their status as methadone patients/drug users (and, in Raffi's case, because of his criminal record.)

Drug 'rewards' given to addicts
By Mark Easton
Home editor, BBC News



Rewards include methadone and cash vouchers, a survey found
Heroin and cocaine addicts on the government's treatment programme are being given drugs as a reward for clean urine samples, the BBC has learned.
The National Treatment Agency (NTA), which runs the £500m a year scheme, admits the practice is "unethical".

Its own survey of almost 200 clinics in England found users were being offered extra heroin-substitute methadone or anti-depressants for good behaviour.

The NTA said it wanted to see certain practices "squeezed out of the system".

'Best principles'

A third of clinics in the survey said users who produced a drug-free urine sample may be offered increased doses of heroin substitute as a reward - known as "contingency management".

A quarter admit that clients can choose the type of substitute drugs they want.

The dose people get ought to be determined by the individual's needs not by whether or not they're co-operating with the regime

Paul Hayes
National Treatment Agency

The survey also found clinicians offering anti-depressants, cash vouchers or access to detox as a reward.

The NTA said offering drugs for anything other than clinical need was wrong.

The agency's chief executive Paul Hayes told the BBC: "It isn't a practice we would advocate.

"One of the things that's important before we start rewarding people through things like contingency management is to make sure that we're doing it according to the best principles for drug treatment.

"There are a range of practices associated with drug misuse in this country that are not what we would want them to be.

"One of the reasons the NTA was set up wasn't only to expand the provision of drug treatment but was also to improve its quality."

'Very different'

He added: "It is entirely appropriate to prescribe other drugs alongside prescription drugs that are to deal with withdrawal. Not as a reward, which is why we wouldn't advocate it.

"What we would say is the dose people get ought to be determined by the individual's needs not by whether or not they're co-operating with the regime.

"That's why the contingency management programme that we're thinking of introducing based on American research is going to be very different to the ad hoc rewards that operate in not very well managed services in this country at the moment."

Matthew Taylor, of the Royal Society of Arts, a think tank looking at how best to get addicts off drugs, said an overhaul of current policies was needed.

The idea of bribing the patient to achieve a result which wasn't actually something they felt important is quite abhorrent

Dr Michael Ross
Former drug service clinical director in Bradford

"I think the reality is that our drug strategy just isn't working," he told the BBC's Breakfast programme.

"Only a very small proportion of those people who are put through drug detoxification successfully complete the programme, and even when people do successfully complete the programme they revert to drug use very quickly.

"So we need a different approach, and the fact that some people feel that they need to incentivise drug users with other drugs in order to keep them off illegal drugs is, I think, part of that general problem."

Dr Michael Ross, former clinical director of Bradford's drug dependency service, said drug addicts needed to be self-motivated to achieve results.

"The idea of bribing the patient to achieve a result which wasn't actually something they felt important is quite abhorrent," he said.

The drugs treatment project is the centrepiece of government strategy.

Only about 6% of users on the programme leave free of drugs each year.

However, there is evidence that giving addicts access to services can reduce crime and improve health even if they continue to take drugs.

Helping you understand new
clinical guidance for drug misuse
Regional events on NICE guidance and
the updated Orange Book
The National Treatment Agency for Substance Misuse (NTA) and The National Institute for Health and Clinical
Excellence (NICE) are holding a series of events to inform providers, commissioners, service users and carers
around the country about important new clinical guidance.
A suite of new clinical guidance documents will have major implications for the drug misuse treatment field: NICE clinical guidelines on psychosocial interventions and opioid detoxification (published in July 2007) The updated Drug Misuse and Dependence – Guidelines on Clinical Management (Orange Book) to be
published in September 2007) NICE technology appraisals on naltrexone, and methadone and buprenorphine (published in January 2007).
Members of the expert panels involved in the development of this guidance, together with NTA and NICE staff,
will be on hand to lead discussions and explain the evidence base that informed their processes. The dates for
the events are:
North West Monday 26 November
North East Thursday 29 November
Yorkshire and Humber Friday 30 November
East of England Monday 3 December
London Tuesday 4 December
East Midlands Wednesday 5 December
South East Tuesday 11 December
South West Thursday 13 December
West Midlands Wednesday 23 January
The events will begin in the morning and will include lunch. The agenda will vary from region to region
depending upon regional priorities and the availability of speakers, but will contain the following key
presentations: What needs to be implemented and what support will be needed An explanation of the nature and extent of the NICE clinical guidelines, technology appraisals, and the
clinical guidelines (Orange Book) Workshops to discuss local and regional issues relating to the implementation of the guidelines.
For further details and to book a place, contact your regional NTA team – details on the NTA website at
www.nta.nhs.uk/areas/regions. Please note that places are limited and may have to be prioritised by regional
teams.
Copies of the NICE documents are available from www.nice.org.uk.
Details of the Orange Book update (and the current draft) are at
www.nta.nhs.uk/areas/clinical_guidance/clinical_guidelines/cgl_update0607.

USERS LOSE OUT IN LABOUR’S
AUTHORITARIAN STATE
Drug users are more vulnerable
after ten years of Labour as the state has
become more authoritarian. Liberal
Democrat MP and former barrister
Simon Hughes told Release’s 40th
anniversary conference that antisocial
behaviour orders, the extension of stop
and search, the introduction of a DNA
database and the massive increase in the
prison population
have made it much
more likely that drug
users will get caught
up in the criminal
justice system. At the
same time access to
to legal aid has not
kept pace with the
changes making it
more difficult for
users to get help once
they do, he said.
Release, which itself
provides advice and
information to drug
users, has recently had
its Government
funding cut.