Bristol in Brief: Drugs in the South West
The illegal drugs market in the UK is estimated to be worth £9.4bn and results in a £20bn cost to society . Drug use in the South West is common among both adults  and young people  and the region has some of the highest rates of all drug use in England and Wales. In line with the rest of the country, cannabis is the most used illicit substance. There are also a substantial number of people who inject drugs (PWID), with related harms to both the individuals and the wider community.
This briefing will look at what types of drugs are being used across the South West, trends among young people and the responses from different agencies. It will conclude with a look at some policy options for the future.
Bristol in Brief 1
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- The South West has the highest levels of drug use in England and Wales. Cannabis is the most used substance in the region.
- Bristol has particularly high levels of injecting drug use and associated harms, including Hepatitis C infection and soft-tissue damage among people who inject drugs.
- Police forces, treatment and other services are working together to mitigate some of the harms caused by drugs. Criminal justice diversion schemes are a good example of effective integrated service provision.
Key issues include the high prevalence of drug use in the South West (particularly injecting drug use), the high purity of drugs on the market (resulting in hospitalisation for some users), increasing synthetic cannabinoid use and the exploitation of vulnerable people in the supply chain through ‘county lines’. Local authorities, police forces and drug treatment agencies provide a range of services to people who use drugs in order to reduce harm.
Figure 1 – Self-reported drug use in the South West (source: UK Home Office drug misuse findings from 2018 to 2019).
Levels of drug use in the South West
Illegal drug use is commonly underreported, but estimated prevalence across the South West is comparatively high. With approximately 11.7% of people in the region having reported using illegal drugs in the last year, the South West has the highest rate of illicit drug use than any other region in England and Wales (average 9.4%) . It also has a higher proportion of MDMA and cannabis users than any other region. Similarly, the proportion of people who use hallucinogens and amphetamines are among the highest in England and Wales. According to recent government statistics, [2, 3] 9.4% of people in the South West claimed to have used cannabis in the past year, making it the most used drug in the region. Although likely underreported, an estimated 3.8% of people in the South West have used powder cocaine in the past year and Public Health England (PHE) estimated that there were 15,397 people using crack cocaine between 2016 and 2017 . Moreover, a recent analysis of wastewater in 70 European cities indicated that Bristol consumes more cocaine per capita than any other city in the sample, with 969.2 mg of benzoylecgonine (an indicator of cocaine) per 1,000 people; over 30 mg more than in the second highest city, Amsterdam .
Synthetic cannabinoids (e.g. Spice) use has become prevalent among homeless communities and in prisons. It is cheap and particularly easy to overdose on. Though the use of synthetic cannabinoids has received much media attention nationally  and locally [7, 8], there is limited data on the use of such substances in the South West specifically. However, the South Western ambulance service reported an increase in ambulance callouts related to Spice use, from 157 in 2017 to 960 in 2018 .
Substance purity and policing priorities
The purity of drugs varies greatly between batches and across time, meaning that users are often unaware how strong the substance is before they take it. This presents a major overdose risk. Table 1 shows submissions made by the Avon & Somerset Constabulary to a forensic laboratory, June – December 2019.
Table 1: submissions made by Avon & Somerset Constabulary to forensic lab (Jun-Dec 2016)
Although this data does not capture trends across the wider South West area, it helps build a picture of drug markets and policing priorities in Avon & Somerset. Of the submitted drugs, the purity of crack cocaine was highest - at approximately 95%. These figures also might suggest that the Avon & Somerset Constabulary enforce the crack cocaine market more vigorously than other drug markets. High purity heroin is usually no more than 60% pure, but in December 2019 two submissions tested at almost 70%. Most cocaine samples submitted were high purity samples (60% – 85% purity), in stark contrast to a decade ago - when cocaine was on average 25% pure. This reflects a wider trend across the UK that has increased the risk of harm to users, and there has been a significant increase in cocaine-related hospital admissions . It is worth noting that this increase includes people who use crack cocaine and covers an aging cohort.
‘County lines’ drug markets
The ’county lines’ model of drug distribution, where people are used by metropolitan organised crime groups to sell crack and heroin in provincial areas, is prevalent across the South West. The phenomenon is more common in towns that are closer to urban hubs, for example Swindon, than more remote towns such as Torquay or Plymouth . This has led to an increase in police-driven responses to safeguarding vulnerable people . The use of young people in ‘county lines’ markets has received most attention in recent years, but the practice of cuckooing - when a drug dealer uses the home of a vulnerable individual as a base to deal drugs – is also a major area of concern. The Children’s Commissioner estimates that at least 46,000 children across England are involved in gang activity . Police forces in the South West are developing an in-depth understanding of these markets but acknowledge that it is sometimes difficult to distinguish between perpetrators and victims  due to the exploitative nature of the relationships .
Injecting Drug Use in the South West
While more people use cannabis and other ‘recreational’ drugs in the South West, injecting drug use causes greater harm, both to the individual users and wider society. Crack cocaine lends itself to frequent injections, and it is common for PWID to be in an agitated state when they do so. The vasoconstrictive effects of crack cocaine can make it harder for users to find a vein and, as a result, crack injecting often carries a greater risk of associated harms - such as soft-tissue damage.
People who inject drugs (PWID) predominantly use heroin, crack cocaine or both. Bristol has a particularly high rate of PWID when compared to the wider South West area and is renowned for being an epicentre of ‘snowballing’ (an injected mixture of crack cocaine and heroin). In 2011, PHE estimated that of the 5,364 people in Bristol using crack or heroin, between 27% and 51% were injecting . This impacts local communities as well as the users themselves. In 2016, 1,100 reports were made to Bristol City Council regarding used needles , but it is widely accepted that this figure represents the tip of the iceberg. In 2017/18, 297 PWIDs visited the Bristol Royal Infirmary (BRI), staying for a combined total of 2,797 days . The full cost of injecting drug use to healthcare services is unknown. In addition to heroin and crack cocaine, there has also been a notable increase in injectable steroid use and treatment agencies are having to adapt their services to respond effectively.
There are a range of existing services that demonstrably improve the health outcomes of PWID, including needle and syringe exchange programmes (NSPs) and opioid substitution treatment (OST, including methadone). NSPs are evidenced to be highly cost effective, reduce risky injecting behaviours, reduce blood-borne virus (BBV) infections, and act as a funnel into treatment . A systematic review found that NSPs in combination with OST are particularly successful . Over one million needles were supplied in 2015/16 in Bristol, with an approximate 50:50 split between pharmacies and dedicated NSPs.Bristol has comparatively good coverage of clean injecting equipment compared with other regions; 66 needles are supplied for every 100 estimated injections . About 50% of PWID in the UK have Hepatitis C, a quarter of whom are unaware of their positive status. Liberal distribution policies at NSPs have been found to reduce BBV infection rates. Low dead space syringes also reduce BBV infection rates among PWIDs who share equipment, because less blood is left in the syringe after use .
Treatment providers in the South West
In addition to psychosocial support treatment agencies offer a variety of medications to maintain service users, as well as help them become abstinent. Diversion of these medications onto the illicit market remains a considerable, unmeasurable issue. However, pharmaceutical companies now offer a range of new formulations of buprenorphine (a heroin substitute), including fast-dissolving sublingual gels and a subcutaneous injection, which would last up to a month. Although these formulations could significantly reduce diversion, they are currently prohibitively expensive for treatment agencies in the South West.
PHE estimate savings of £4 for every £1 spent on drug treatment, with alcohol treatment saving £3 for every £1 spent . In stark contrast to the £20bn annual cost of drug use to society, only £600m is spent on treatment and prevention . Due to changes in local authority funding, treatment agencies across the UK have had to make profound cuts to their services. In the South West for example, some services have had to reduce the number of one-to-one sessions on offer. Bristol Drugs Project (BDP) and Developing Health & Independence have adapted by increasing their peer mentoring and peer support programmes . Budget cuts have also reduced the scope of outreach treatment which has particularly affected BDP’s ability to work with alcohol clients . Dame Carol Black’s government report has recommended large-scale investment into the treatment sector . There is a concern that this money could end up in recovery-focussed residential treatment when community-based interventions can reach many more service users for the same cost .
Numbers in treatment
The National Drug Treatment Monitoring Systemreports that that 279,793 people in England were in contact with a drug treatment service in 2016-17. This figure includes alcohol-related treatment. Addaction, Turning Point, Developing Health and Independence (DHI) and Bristol Drugs Project (BDP) are the key treatment providers in the South West region. In 2016/16, BDP had 2,982 service users - 2,295 of whom were prescribed OST. Addaction has 5,553 service users across the South West - 2,011 of whom are prescribed methadone or buprenorphine.
With an inflexible central government, local authorities have a somewhat limited range of options in relation to drug policy. There are many developments taking place outside the UK - for example in Portugal, the possession of illicit drugs was decriminalised in 2001. The aim was to shift the focus from prohibiting drug use to regarding it as a health issue, helping to funnel users into treatment . This policy prevents unnecessary harm resulting from drug possession convictions. Portugal now ranks one of the lowest for drug-related deaths - 27th among 29 countries monitored by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA); the UK ranks 4th . Portugal also has much lower levels of drug use than the UK, according to the EMCDDA . Although decriminalisation of possession would have to happen at a national level in the UK, taking a person-centred approach to drug use can happen at a local level. Across the UK, and particularly in the South West, there are a range of interventions being carried out that aim to reduce drug-related harms.
Police-led drug policy reform
In the UK, the police have a certain level of discretion in relation to the prosecution of offences related to drug use. It been suggested that much of the drive for police-led reforms has come from austerity, which forced constabularies to innovate . Diversion schemes, for example, are being used to remove offenders from the criminal justice system and are gaining significant traction across the UK and the West Midlands Police and Crime Commissioner has provided recommendations on how they could operate . Some police forces across the South West are adapting their responses to drug markets and drug use in line with emerging evidence, but there is a lack of consistency. Devon and Cornwall have implemented the Pathfinder diversion scheme, and the Avon & Somerset are due to roll out the Drugs Education Programme (DEP) beyond Bristol.However, the Devonshire Police and Crime Commissioner (PCC) has been described as resistant to drug policy reform .
Implementation of DEP across rural areas may be challenging, and other South West constabularies would be well advised to watch this process closely. In Bristol, Golden Key are running ‘Call-In’, a pilot that aims to provide skills to young people - to provide them with tangible alternatives to supplying drugs. Initial feedback from these diversion schemes is very positive, and there is considerable potential to reduce the harms associated with criminal convictions.
Safer injection facilities
Comprehensive systematic reviews have found that Safer Injecting Facilities (SIFs, also known as drug consumption rooms) have the potential to reduce overdose deaths, increase drug treatment uptake and improve access to primary healthcare for PWID . SIFs would be best placed in neighbourhoods with the highest levels of public injecting drug use. For context, a feasibility study estimated that up to 430 individuals inject in public in the Bristol area on a daily basis . It would cost between £800,000 to £1m per annum to implement a standalone facility Bristol . A mobile unit (in a large vehicle) would cost £250,000 - £300,000 per annum to implement  but would likely struggle to meet the demand from service users.
While the UK government’s own Advisory Council on the Misuse of Drugs (ACMD)  and the Scottish government have called for SIFs to be instituted in areas with the highest need , the UK government is resistant . Nevertheless, Glaswegian activist Peter Krykant has pledged to open one , even though it would be technically illegal. It should be noted that the highly successful Canadian SIFs originally started as an unsanctioned ’pop up’ in downtown Vancouver, operating outside of the law . It has been suggested that UK constabularies could write ‘letters of comfort’, agreeing not to arrest anyone who implements such a facility . SIFs have received public support from the deputy mayor of Bristol, Asher Craig .
Multi-agency partnership is essential to providing good quality and effective drug-related services in the South West and has been shown to benefit staff and service users . Agencies can work together to evaluate alternative service provision, such as Heroin Assisted Treatment (HAT) or SIFs. It has also been suggested that co-commissioning is a good solution to a number of issues, splitting the cost between the agencies that stand to benefit . Multi-agency partnerships are also important when it comes to clients with complex-needs, particularly drug users with comorbid mental health issues. A dual diagnosis often presents a paradoxical problem: services cannot help clients with their mental health until they’re drug free, and they can’t be helped with their drug problem because of their mental health issues. A dual diagnosis often presents a paradoxical problem: services cannot help clients with their mental health until they’re drug free, and they can’t be helped with their drug problem because of their mental health issues . A good example of multi-agency partnerships are the local authorities in Manchester, who have combined their public health and mental health commissioning bodies . There is a sense that the local authorities in Bristol are open to new ideas and are willing to do things differently .
Multi-agency partnerships also occur between universities and local organisations; the University of the West of England (UWE) and the University of Bristol (UoB) work collaboratively with BDP, DHI, the police and PHE to tackle student drug use. UWE and UoB are among the first UK universities to introduce a harm reduction drugs policy rather than zero-tolerance. They are also developing plans to educate students pre-induction because ‘welcome week’ has been identified as a critical period for drug experimentation.
The South West has the highest prevalence of illicit drug use in the UK. An aging cohort of heroin and crack users are of particular concern to health and support agencies. Injecting drug use leads to an array of physical health issues, and NSPs in combination with OST is an effective strategy to reduce the related harms and encourage cessation of drug use. Among young people, Cannabis, cocaine, MDMA and ketamine are the most commonly used drugs – with many purchasing their substances on social media. It appears that Year 9 may offer a critical intervention opportunity to improve drugs education and patterns of use among young people. More broadly, funding is desperately needed for treatment agencies and focus needs to be placed upon multi-agency partnership working. The police are in a unique position to help move drug policy reform forward, and could be instrumental in any future Safer Injection Facilities or Heroin-Assisted Treatment programmes. Given how prevalent drug use is across the South West, it is not given anywhere near enough attention or funding by local authorities or educational institutions.
Josh Torrance, Jasmine Khouja, Emily Crick (University of Bristol)