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Guerrilla public health

21 November 2017
 Black and white illustration of one hand giving a syringe to another hand, with the words 'deadly exchange' above in bold and capital letters.

Image of Harry Shapiro
Harry Shapiro

Saying no doesn't always work, and many people who use illegal drugs just want non-judgemental help and advice. From safe-use graphic guides, to safe places to exchange needles, this is a potted (and sometimes controversial) history of drug harm reduction in the UK from the 1980s on.

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Drug harm reduction focuses on safe drug use, rather than stopping drug use. Publications, events and support centres offer people evidence-based information and advice.

If you ask a child what they want to be when they grow up, they’re unlikely to say, “I’d like to become addicted to heroin”. Yet significant numbers of people, politicians and media outlets believe heroin addiction is simply a lifestyle choice. The truth is that it’s often a response to childhood trauma, including sexual, mental or physical abuse. It can happen in any strata of society, but it’s more likely when compounded by poverty and deprivation.

Many people who use drugs want evidence-based, non-judgemental help and advice that will reduce the risk of them harming themselves or others. ‘Harm reduction’ sits at the intersection between public health on the one hand, and human rights and civil liberties on the other. Harm Reduction International defines it as, “specific policies, programmes and practices that aim to reduce the harms associated with the use of controlled/illegal drugs in people unable or unwilling to stop”. The focus is on preventing harm, rather than stopping drug use itself, and a central feature of the history of harm reduction is that of marginalised communities helping themselves. And what started out as disparate activities by small groups in different countries, has grown to become a global movement.

The early 1980s

The decade began with an outbreak of solvent misuse, or glue sniffing. Several young people died, mainly suffocating after pouring solvent into large plastic bags to inhale the fumes. Back then, I was an information officer for the Institute for the Study of Drug Dependence. We published a leaflet called ‘Teaching About a Volatile Situation’, which was aimed at education and health professionals. It suggested, among other things, that if young people were going to sniff glue, then it would be better if they used small crisp packets than that they suffocate and die. We didn’t call it harm reduction, but it was both an inspiration for future interventions, and a harbinger of controversies to come. The media dubbed the leaflet “A Glue Sniffers’ Charter”, and for a while our government funding was threatened.

But the real impetus for harm reduction in the 1980s was the HIV/AIDS epidemic. Once they knew the virus was spread by bodily fluids, the gay community began promoting safe sex and encouraging people to use condoms. It quickly became apparent, too, that drug users who shared needles and syringes were also at serious risk.

An epidemic unfolds

In the UK, the turn of the decade saw heroin use undergo a radical change. Until the late 1970s, the heroin scene had largely been confined to London and the surrounding areas. Users were injecting white pharmaceutical heroin legally prescribed by doctors (until a law change in 1968), and then illicit supplies from East Asia. In 1979, the Shah of Iran was overthrown by Ayatollah Khomeini, prompting wealthy people to flee, some of whom converted their wealth to easily smuggled heroin for sale abroad. The big difference with Iranian brown heroin was that you could smoke it. This meant you could use it without sticking a needle in your arm, making it attractive to young people. When brown heroin reached the UK it caused mayhem.

The UK of the 1980s was experiencing large-scale unemployment, poverty and deprivation. Heroin filled the economic and psychological vacuum, providing young people with both job opportunities and an escape from the realities of a life without hope. And, because the worst of the social and economic problems were outside of London, the focus of the heroin scene switched to cities like Manchester and Liverpool, and further north to Glasgow and Edinburgh, where whole industries had been either wiped out or dramatically scaled back.

Health professionals now faced a triple whammy: mass youth unemployment driving a market in heroin and then, as heroin smokers realised what little money they had was literally going up in smoke, a switch to injecting with the risk of contracting HIV.

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The Merseyside Drug Training and Information Centre was set up in the 1980s to offer informal, user-friendly, non-threatening help and advice.

Heroin, HIV and harm reduction

In September 1985, Professor John Ashton and Howard Seymour from the Merseyside Regional Health Authority attended a World Health Organization health education conference in Dublin. Also in the Mersey delegation was Allan Parry, an ex-street drug user and community activist in Liverpool.

While in Dublin, the Mersey team met with Glen Margo, Director of Health Promotion for San Francisco. Glen was a key figure fostering AIDS awareness among the gay community, who himself would eventually die of AIDS. Professor Ashton recalls, “We asked him what he would have done back in 1980 that didn’t happen. The answer was needle exchange”. They invited Glen to come to Liverpool for a week of intensive lectures to educate health professionals on the risk of injecting drug users contracting HIV.

As heroin use among young people in Liverpool gathered pace, there was little help and information available other than for those getting treatment, which many didn’t want to do from a general fear and mistrust of authority. With the help of John Ashton and Howard Seymour, Allan Parry set up an informal drug information centre, the Merseyside Drug Training and Information Centre. It provided a user-friendly and non-threatening environment for drug users to get help and advice.

The need for needle exchange

In 1986, the Scottish Committee on HIV and Injecting Drug Misuse published a report, known as the McLelland Report, which stated that the Lothian police’s policy of confiscating needles and syringes from users was encouraging sharing and helping to spread HIV. Furthermore, they controversially recommended establishing needle exchange schemes.

Back in Liverpool, drug workers and public health professionals realised that they needed to get ahead of the virus before it took hold among the city’s drug injectors. Using the toilet conveniently located next to the drug treatment service (in case a nurse was needed), Liverpool saw the launch of one of the first needle exchange schemes in the UK.

On paper, providing injecting equipment to drug users was illegal under the 1971 Misuse of Drugs Act. But Alan Matthews, an ex-youth worker turned drugs worker explains:

“We had a very forward-thinking head of the drugs squad, Peter Deary, who said they wouldn’t arrest people carrying works [needles], and we also got the support of the Liverpool Echo. We asked them not to run ‘needles for junkies’ stories, but to give us six weeks to see what happens and then we would give them the story as an exclusive.

“It was all word of mouth, no advertising, and we saw about 300 people in those first few weeks who had never been near a drug service. We had a guy come down from Glasgow, another from Manchester, and one day this steroid user turned up. We were operating out of this little toilet, so you didn’t even have to go into the information centre. Suddenly everything went dark and there is this big beefy guy filling the doorframe. We never asked questions of anybody: they could give a false name, and we also logged postcode and gender just to collect some basic statistics. But I said to this guy, who looked nothing like a heroin user, “Do you mind me asking what you’re injecting?”. “Steroids” he said. “Oh, does that happen a lot then?”. He said all the guys down the gym were injecting and they all shared. “Have you heard about AIDS?”. “Yes,” he said, “but you only get that from using heroin not steroids”. So I told him about AIDS and injecting, and he became an outreach worker at the gym.

“Another guy ran a shooting gallery [where people would come to inject] and one day he came with a few syringes to exchange. We asked him if he had anymore. “Oh, yes loads”. “’Well, bring ‘em in”. “Oh, I thought it was just for personal use”. Next day he turns up with three bin bags full of works, needles sticking out and everything. We gave him sharps boxes and everything, and he became an unofficial outreach worker too.”

The political response

While all this was going on at street level, John Ashton was looking for political cover from the top.  He had a good relationship with Sir Donald Wilson, Chair of the Merseyside Regional Health Authority, who John describes as “an unusual, eccentric character, an old-fashioned paternalistic Tory who was on first name terms with Margaret Thatcher”.

John also knew Sir Donald Acheson, the Chief Medical Officer who had been trying to explain sexual activity between men to ministers to get an AIDS campaign off the ground. “As they were mostly ex-public school, you would have thought they’d have known,” says John. He says it was Acheson who sold the idea of needle exchange to the health minister Norman Fowler, who then won over enough Cabinet colleagues, although the Prime Minister was having nothing to do with it.

So, on 18 December 1986, Norman Fowler announced in Parliament that there would be extra cash for drug treatment to encourage users to come into services. Two surveys, one conducted in London and the other in Newcastle, both concluded that for every heroin user in treatment, five were not. Fowler also announced the establishment of a needle exchange pilot scheme that would be formally evaluated. By then there were unofficial schemes already running in Liverpool, south London, Peterborough, Cambridge and Swindon.

 Front cover of the Misuse of Drugs Act 1971
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There are three main statutes regulating the availability of drugs in the UK, the Medicines Act (1968), the Misuse of Drugs Act (1971), and the Psychoactive Substances Act (2016). You can find out more about UK drug laws on the Drugwise website.

‘The British System’

HIV-related harm reduction wasn’t just about needle exchange; it also signalled a sea change in UK drug treatment practice, or rather a reversal.

Way back in 1926, a health ministry committee had decided that, as a treatment of last resort, it was legitimate medical practice for a doctor to prescribe drugs such as morphine, heroin and cocaine to somebody addicted to those drugs in support of their addiction. Unique in global addiction treatment, this became known as ‘The British System’.

In those days, drug addiction in the UK was largely confined to a very small group of middle-class, middle-aged patients whose addiction developed after being prescribed drugs for a medical condition. By the late 1960s, the user population had expanded and evolved into those using drugs recreationally. These users were obtaining large amounts of heroin and cocaine from a handful of London-based private doctors. The law changed in 1968: prescribing was now mainly restricted to newly established specialist drug clinics run by consultant psychiatrists.

Very early on, these psychiatrists maintained the British System, trying to head off the development of a market in illegal imports. But, within a few years, the clinics moved towards prescribing only oral doses of the heroin substitute methadone, with the express aim of getting people off drugs altogether. The result was users voting with their feet.

A treatment u-turn

In the 1980s, in a landscape of rampant heroin use and a killer virus, there was pressure on specialist drug clinics to be more “flexible”, as one senior Department of Health official put it. This was underscored in 1988, when the government’s drug advisors published their landmark 'AIDS and Drug Misuse' report, which declared unequivocally that stopping the spread of the virus was more important than getting people off drugs.

This began a chain of events where clinic prescribing policies began to change, and there was a wholesale review of the treatment system to enable it to cope with the dramatic rise in the number of heroin users. The net result of needle exchange, and a more flexible approach to the long-term prescribing of methadone, was that the UK had the lowest rates of HIV among drug injectors in Europe.

From there the perceived benefits of harm reduction began to be applied to other areas of the drug scene. There had been previous references to harm reduction in the Institute for the Study of Drug Dependence’s magazine Druglink, but the most notable article on the subject first appeared in the January 1987 issue. It was written by Dr Russell Newcombe, a drugs researcher based in Liverpool. In ‘High Time for Harm Reduction’, he broadened the concept beyond injecting heroin users to include all illicit drug use, on the basis that ‘Just Say No’ campaigns had clearly failed with those who had already chosen to use drugs. Those people should have access to information to mitigate the risks.

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The ‘Just Say No’ campaign originated in the USA in the 1980s. The slogan was used by the then First Lady Nancy Reagan, as part of the country's 'war on drugs'.

Raves and risk

The late 1980s saw the rapid growth of what became known as rave culture – an all-night dancing phenomenon driven by MDMA, or ecstasy. The links between stimulant drugs and all-night dancing had a long history: the 1920s cocaine warehouse parties in Soho, Mods on ‘purple heart’ amphetamine pills in the 1960s, and Northern Soul and punk dancers of the 1970s on amphetamine powder. Ecstasy became known as ‘the hug drug’ because of its unique property of inducing empathy between users.

But there was also a dark side. In 1989, teenager Claire Leighton became the first documented ecstasy fatality after collapsing at The Hacienda in Manchester. At the time, packed-out raves were happening in extremely hot venues with no proper air conditioning, and with the cold water turned off so people were forced to buy bottled water. Nobody could establish why some users had such an extreme reaction to ecstasy (and the mystery remains), but it led Alan Matthews to begin researching what seemed to be the toxic combination of heat and stimulants. He discovered that similar incidents had taken place with elite cyclists using amphetamine, most notably the British cyclist Tommy Simpson who died during the 1967 Tour de France.

The message was clear: to reduce the risk of dying from MDMA, users needed to do everything they could to keep cool and hydrated. The information went into a leaflet called ‘Chill Out’, published by the Merseyside Drug Training Unit in 1992. It was one thing to supply needles and syringes to heroin users right out on the margins of society where few cared, quite another to be telling ‘normal’ teenagers how to use E more safely. The media went into outrage overdrive, with The Daily Star urging parents to throw unit director Pat O’Hare in the River Mersey. But it wasn’t that long before similar harm reduction advice was appearing in both mainstream medical literature and government campaign material.

Interventions expand

Harm reduction interventions in the UK have expanded since the 1980s. The Misuse of Drugs Act has been amended to allow drug treatment services to provide injecting paraphernalia to keep HIV rates down, and also to tackle Hepatitis C, which is far more prevalent today. There is a drug called naloxone that blocks the effects of heroin, and is being used successfully to reverse heroin overdoses and save lives.

On the wider drug scene, a charity called The Loop has been allowed to operate at festivals and other venues. They provide an on-site drug testing service, alongside campaigns advising users to try bits of tablets or dabs of powder rather than whole doses, as the strength of some ecstasy is at an unprecedented level.

It isn’t all good news

Despite evidence from around the world, and proposals for Ireland and Scotland, there is no move in England to pilot drug consumption rooms. These are facilities where injecting drug users can come off the streets to use drugs under medical supervision. It offers drugs workers the chance to engage with those who might not already be using their services, and it’s a way to reduce drug litter on the streets. Meanwhile, needle exchange services are now largely run from pharmacies, rather than specialist drug services, with little or no opportunity for engagement. Drug overdose deaths have been rising, and a significant percentage are among those who have never been in treatment.

Despite the clear public health benefits, the idea of harm reduction remains controversial. Governments and anti-drug groups around the world claim it simply encourages and endorses drug use, for which there is no evidence, and that harm reduction is just a stalking horse for drug legalisation. It is true that many activists do support law reform: in their view many of the harms to drug users are caused by the laws themselves.

But there is a deeper level of animosity at play here. I recall attending a so-called civil society meeting in Vienna where user-activists wanted to include references to harm reduction in the meeting outcome document. This was met with astonishment by the American delegates, who argued that drug users had forfeited their human rights and civil liberties by using illegal drugs. The sub-text of that exchange was, “How can a sub-human be entitled to human rights?”.

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The newspaper headlines featured on the front cover of this information booklet show just how controversial drug harm reduction could be.

The next chapter

Even so, harm reduction both as an intervention and a symbol will not be denied.  It began as pockets of community-driven health interventions where activists collaborated successfully with sympathetic health officials to help protect the lives of drug users. From there it has grown into a global movement, with national and international organisations, academic, policy and practice conferences and academic peer-reviewed journals. And it doesn’t stop there.

There are the beginnings of a tobacco harm reduction movement whose aim is to reduce the damage caused by smoking by encouraging smokers who want the effects of relatively benign nicotine, but not the life-threatening tar, to switch to other options such as e-cigarettes. The battle lines between advocates and opponents are already drawn. A new chapter begins.

All of the printed materials and ephemera featured in this article can be found in the DrugScope archive. Recently acquired by Wellcome, it began as the library of the Institute for the Study of Drug Dependence in 1968. It's a multi-disciplinary collection containing material mainly from the UK and USA, including pamphlets, official government publications, original research papers, conference papers and proceedings, ephemera, counter-cultural publications, and a large collection of reprints from a wide range of academic journals, newspapers and magazines.

Image of Harry Shapiro
Harry Shapiro
Harry Shapiro is director of DrugWise, the UK independent drug information service, and the author of several books, including 'Waiting for the Man: the story of drugs and music', 'Shooting stars; drugs Hollywood and the movies', and several music biographies including of Jimi Hendrix and Eric Clapton. Harry is currently working on a history of the UK drug scene over the past 100 years.