UK addicts may be given free foil for 'safer' heroin smoking

By Terrapinzflyer · Sep 20, 2009 · ·
  1. Terrapinzflyer
    UK addicts may be given free foil for 'safer' heroin smoking
    UK authorities could give out free foil to protect heroin addicts' health

    Heroin addicts could be given free aluminium foil to encourage them to smoke rather than inject the class A drug under plans being considered by government advisers.

    Drug treatment experts say that inhaling heroin instead of injecting reduces a user's risk of contracting HIV and Hepatitis C. An addict heats a blob of heroin on the foil in a process known as "chasing the dragon".

    The Advisory Council on the Misuse of Drugs (ACMD) is examining whether the law should be changed to allow Britain's 300,000 problem drug users to receive foil as a way of protecting their health. Since last year, the ACMD's 31 members, who advise the Home Office, have been considering whether section 9A of the Misuse of Drugs act, governing "paraphernalia" or equipment used in the consumption of illicit substances, should be amended to allow the UK's network of needle exchanges to supply foil. At present, it prohibits the supply of "articles to be used for the preparation or consumption of illicit drugs".

    Critics say the ban endangers users' health because most drug workers are too afraid of being prosecuted to risk giving out something that many see as a sensible harm-reduction measure. An estimated 100 of England's 1,300 needle exchanges already defy the law by providing foil. Some have even had tacit support in the form of "letters of comfort" from their local police force, such as Avon and Somerset, which emphasises that it does not see the pursuit of section 9A as a priority.

    The ACMD's technical committee has held two private evidence-gathering sessions on the subject with with Jamie Bridge of the International Harm Reduction Association, which backs legalisation, and drugs treatment researchers Neil Hunt and Rachael Pizzey. It is due to hear on 29 October from veteran Dutch drugs worker John-Peter Kools, who has issued foil in the Netherlands. Both Holland and Spain issue foil through needle exchanges without any major problems.

    The full ACMD is to debate the issue in November and is expected to suggest setting up a pilot study on the effects of foil provision. It hopes to advise ministers of its views soon – possibly before the end of the year – on whether the law should be changed. Bridge said: "Smoking drugs is by no means safe, but is a great deal safer than injecting drugs – which is particularly associated with overdose, blood-borne viruses, drug-related litter, greater dependency, abscesses and vein damage.

    "The law has unintentionally put us in a strange position whereby we can give someone clean needles to inject with, but we face arrest for giving them aluminium foil to smoke with. Providing foil in this way is such a common-sense approach – with huge potential benefits and little opposition or potential costs – that we hope the law will change soon." Significantly, the Association of Chief Police Officers, which represents the country's most senior officers, is neutral on whether the law should be amended. But it would support a change if the ACMD recommended such a move on public health grounds, sources told the Observer.

    Harry Shapiro of Drugscope, which represents 800 drug projects, said: "It's important to do everything possible to discourage Britain's 300,000 problem drug users from injecting their drugs, and we should allow injecting heroin users to be provided with foil as part of a harm-reduction programme. As the law now stands users' health is being compromised and it would be better if section 9A was repealed."

    But James Brokenshire, the Conservative shadow home affairs minister, said: "I'm cautious about these sort of moves, which progress harm reduction rather than focus on getting people drug-free. In recent years there has been insufficient focus on getting people off drugs and too much on just maintaining people on drugs through methadone and other measures.

    "I would need to be swayed that there are clear and compelling public health arguments to make such a change [in the law]. I want to promote abstinence-based rehabilitation. There needs to be a greater emphasis in getting people off their drug habit rather than maintaining their addiction."

    Paul Hayes, the chief executive of the NHS's National Treatment Agency, which funds drug treatment, said: "Any way of using heroin is dangerous and likely to lead to addiction. However, injecting the drug is far more dangerous than other means of ingestion, such as smoking. Currently, the provision of foil is not legal. The NTA cannot advise drug treatment services to follow a course of action which is illegal and could have adverse consequences for provider services."

    Denis Campbell, health correspondent
    The Observer, Sunday 20 September 2009

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  1. Helene
    As mentioned in the above article, some exchanges have been making foil available to users for quite a while now. Exchange Supplies make specially designed foil for smoking heroin on, and quite a few exchanges across the country now stock it.

    Quoting from the Exchange Supplies website:

    Brown heroin is manufactured to be smoked, and smoking heroin is much less dangerous than injecting it.

    Smoking heroin is associated with lower levels of dependence than injecting, and every dose of heroin that is smoked rather than injected has no risk of HIV, hepatitis C, or hepatitis B transmission, and far less risk of overdose.

    For these reasons encouraging smoking heroin as a safer alternative to injecting has been a part of specialist needle exchange practice for years. With the continuing hepatitis C epidemic, and new evidence of a growth in the rate of HIV transmission amongst injectors it was clear to the field that providing foil alongside needle exchange has the potential to have a significant impact on injecting rates, and blood borne virus transmission.

    Exchange Supplies have arranged for the manufacture of unique foil packs [IMGR=][/IMGR]
    containing 50 sheets of high quality 100% aluminium foil, each interleaved with tissue, to help drug services encourage injectors to switch to smoking heroin as an alternative route of administration, and to encourage heroin smokers into early and regular contact with services.

    Being a handy portable size, having no cutting blade, and with harm reduction messages printed on the front they are perfect for the job, cost effective, and have none of the disadvantages and potential ambiguities of distributing kitchen foil.
    g manufacture, a thin coating of vegetable oil is used. However, the manufacturing process to make our foil does not use oil, so there is no need to 'burn off' before using it.

    Is it illegal?

    The provision of foil by drug services does constitute a technical breach of section 9a of the misuse of drugs act, but it is very, very unlikely to result in prosecution.

    The law

    Foil is not yet listed as being exempt from section 9a of the Misuse of Drugs Act which prohibits of the supply of 'articles to be used for the preparation or consumption of illicit drugs'.

    So, technically at least, it's illegal for drug services to supply it to drug users. However, section 9a exists to facilitate prosecution of drug dealers and has;
    Never been used against drug services; and has already been changed 3 times to add items supplied by drug services to reduce harm.

    Furthermore, we understand that the Legal Guidance section of the CPS online internal information service known as the 'CPS Infonet' is clear it would not normally be in the public interest to prosecute bone fide needle exchange schems for offences contrary to section 9A.

    Local agreements

    To reduce the (already tiny) chance of prosecution to zero, local agreements can be established with relavent agencies.

    Such agreements have been very succesfully used in the past to allow the supply of other paraphernalia that was illegal at that time, such as citric and VitC.

    A local agreement on the supply of foil will help to further protect drug workers and can ensure a sustainable and properly funded source of supply for service users.

    Examples of local agreements:

    We are collecting case studies of areas where foil has been introduced, describing the process of reaching agreement and reproducing relevent letters etc.

    Agreements have been reached in Manchester and Somerset, some areas have just gone ahead with supply of foil, but where a broader consensus and extra reassurance is needed, the bodies with whom an agency intending to supply foil could liaise include:
    The Drug Action Team;
    Police; and
    Service User Groups.
    Drug Action Team

    Circulating the briefing paper to members, liaising with people organisations in advance of the meeting and having someone at the meeting who understands the issues will help to ensure that discussion is constructive.

    The aim would be for the DAT minutes to record that interagency agreement was reached that:

    "the provision of foil to injecting drug users by needle and syringe exchange schemes is a desirable component of comprehensive services to reduce the harm to injecting drug users."


    The key people who you need to work with on this issue are:
    any police personnel you already have links with;
    the police representative on the Drug Action Team;
    the chemists inspecting officer (where there is one); and possibly
    the drug squad.

    In practice, the police are usually quite pragmatic about this issue - often being sympathetic to drug treatment/harm reduction and long aware of the difficult nature of enforcing sub-section 9A through shops selling paraphernalia for the use of cannabis.

    Crown Prosecution Service (CPS)

    Because they do not instigate prosecutions in the absence of a file from the police, agreement with the police is much more important than a written assurance from the CPS.

    In any event, the CPS are not in the habit of giving written assurances that they would not pursue a prosecution - as they understandably - reserve their right to look at each case on its merits. However, informal discussions with them will normally give reassurance of the position. Although it would help to get them to confirm in writing the principles by which they would judge such a case should it be presented to them, entering into negotiations with the CPS is so time consuming and unessessary that it can effectively sabotage the project.

    Service User Groups

    As with all aspects of service provision, discussion with service user groups should form part of the implementation process. Support from service users may be a powerful weapon in overcoming objections from people who oppose the provision of foil, it is also likely to maximise the positive impact (and uptake) of the new service.

    Paraphernalia and the law

    Paraphernalia supply has been a problematic legal issue in the UK since the inception of needle exchange. This page charts the history of the impact of the law on drug users, and how, why and when the law has changed.

    The two main legal issues have been around:

    A. The Misuse of Drugs Act 1971 has a subsection 'section 9a' which, at the time made it an offence for a person to supply any article - except a syringe or needle - in cases where 'the supplier believes it may be used by the recipient to administer an unlawful drug or prepare an unlawful drug for administration'; and
    B. the Medicines Act, because under the Medicines Act water for injections was a prescription only medicine. This meant that, in practice, it couldn't be legally supplied by needle exchanges.
    Section 9a was drafted to enable prosecution of drug dealers who sell complete 'kits' of drug and implements to take them, and/or are raided and although not found to be in possession of drugs, do have all the paraphernalia needed to take them.

    However, this obscure bit of law was virtually unknown in the drugs field, and was rarely used by the police for it's intended purpose, following the failure of a number of high profile cases of attempted prosecutions for sale of cannabis and cocaine consumption implements, in which defendants had used the "it's an ornament" defence.

    Changing section 9a of the Misuse of Drugs Act[imgr=][/imgr]

    However, in the late 1990’s the issue of section 9A of the Misuse of Drugs Act with regard to the supply of paraphernalia by needle exchanges also became an issue following a letter to the Pharmaceutical Journal on October 24, 1998 from a pharmacist in Somerset who questioned the legality of supplying citric acid to injecting drug users. In the wake of this, pharmacists up and down the country stopped selling citric to injecting drug users.

    While working for the drug service in Dorchester, Andrew Preston negotiated the UK’s first local agreement with Dorset police to enable pharmacists there to resume sales of citric, and other areas were able to use this model to negotiate further local agreements. Glasgow Drug Action Team received an assurance from the procurator fiscal for the Glasgow and Strathkelvin that no action was envisaged against “pharmacists who supplied citric acid, etc, in the interest of harm limitation as part of a recognised needle and syringe exchange scheme.”

    The Law and Ethics Committee of the Royal Pharmaceutical Society recommended that the RPS should make clear to pharmacists in the Glasgow area that it would support their professional decision to supply citric acid in appropriate circumstances.

    However, despite these local and professional body successes, the availability of citric and vitC continued to decline. As UK heroin can’t be injected without an acid, injectors began using lemon juice and vinegar and workers on our safer injecting courses from drug services up and down the UK began reporting eyesight problems and blindness caused by candidal infections from these acids.

    We tried to persuade a number of companies in the field to supply citric acid in single-use sachets but they were all too concerned about the legal problems that could arise. So, in the spring of 2001 we set about arranging the manufacture for ourselves.

    September 2001: citric sachets launched
    The sachets were launched in September 2001, and were supplied by drug services, many of whom used the Dorset agreement as a model for ensuring the supply didn’t put workers at risk of prosecution.

    The increasing number of services supplying citric, and the benefits it was having in terms of attracting users into contact with services, and reducing the harm associated with other acidifiers increased the pressure to clear up the anomaly in the law.

    Kay Roberts, a pharmacist managing the Greater Glasgow pharmacy needle exchange scheme, and member of he ACMD, put the issue on the agenda of the ACMD technical committee, and in late 2001 the committee recommended that the Misuse of Drugs Act be amended to permit the supply of certain additional items.

    In November 2002 the Home Office issued a consultation document requesting responses to the proposal to amend Section 9A.

    February 2003: vitC sachets made available
    In response to demand from drug users, we launched a (technically illegal) single use VitC (ascorbic acid) sachet, alongside our citric sachet.

    July 2003: citric, swabs, spoons, and filters made legal
    On 8th July 2003 a press release announced that the ACMD recommendations on paraphernalia supply had been accepted, and that 'The Government will be laying a negative resolution statutory instrument to implement changes to section 9A of the Misuse of Drugs Act 1971' with effect from 1/08/03.
    This will make legal the supply to drug users of '5 types of items':

    ampoules of water for injection;
    utensils for the preparation of a controlled drug (spoons, bowls, cups, dishes);
    citric acid; and,

    The change didn’t make legal the supply of VitC (ascorbic acid), which remained illegal to supply. However, the tone of the press release, and the fact that it was now clear that the intention of Section 9A was to allow the supply of items that could reduce harm, and many services continued to provide it.

    September 2003: launch of sterile water
    The change to the misuse of drugs act which removed the prohibition on supply of water for injections made no practical difference to the supply to injecting drug users because, like all injectable preparations, it remained a prescription only medicine.

    We therefore tried to find a way around this problem by supplying a single use 1.4ml ampoule of sterile water. Technically illegal under the Misuse of Drugs Act (because it wasn’t ‘water for injections’). The ampoules were available from September 2003 until June 2004.

    In June 2004 a complaint to the medicines regulator - the MHRA - by a competitor resulted in all of our stock being quarantined, and an order to stop selling it on the grounds that it was ‘presented as a medicine’ and therefore needed a medicines licence.

    We immediately began the process of applying for a licence, and a letter writing campaign was launched to persuade the MHRA to allow the resumption of supply, and to reclassify water for injections as soon as possible.

    October 2004: MHRA consult on changing the status of water for injections
    This campaign was very effective, and on the 19th October the MHRA consulted on changing the status of water for injections to enable it’s supply by needle exchanges.

    June 2005: Supply of water for injections made legal!
    On the 27/6/2005 the pressure to change the law, and the mass of responses to the consultation paid off. Statutory Instrument 2005 No.1507 The Medicines for Human Use (Prescribing) (Miscellaneous Amendments) Order 2005 was published on the HSMO website.

    The SI became law on 30th June 2005 and contained provisions for the supply, by drug workers, of water for injections to injecting drug users (without any pack size restriction, as proposed in the consultation) and with a limit on the size of ampoule that could be supplied of 2ml.

    Water for injections is still a prescription only medicine, and a prescription is still required for all uses other than supply to injecting drug users, but this change to the regulations meant that, at last, drug workers could legally dispense water to injecting drug users.

    Unfortunately, although this made the supply of water completely legal in terms of both the medicines act and the misuse of drugs act, the only 2ml licensed water for injections available in the UK was in a glass ampoule.

    We continued with our application for a licence for our plastic ampoule, but made little progress.

    October 2005: vitC made legal
    Meanwhile, The Advisory Council on the Misuse of Drugs (ACMD) advised government that the oversight regarding the omission of VitC from the section 9a exclusions should be corrected, and on the 12th October 2005 Under-Secretary of State Paul Goggins signed a statutory instrument - SI 2005 (2846) - adding ascorbic acid (VitC) to the list of items that it is legal for services to supply.

    January 2006: glass 2ml ampoule and ‘safe snap’ amp snapper made available
    In the autumn of 2005, with our licence application for a plastic ampoule stuck at the MHRA we reviewed all of our options, and looked again at the issue of glass ampoules which are readily available. Having discussed the problem, the idea of developing a device that could completely enclose the ampoule thus removing the risk of glass cuts emerged.

    We filed an application for a patent for the ‘safe snap’ ampoule snapper in October 2005 and immediately began the product development and testing. We negotiated a reliable supply from the UK’s biggest supplier of Water for Injections and ordered deliveries of ampoules through January, February and March to ensure continuity of supply.

    Manufacture of the safe snap began in early January, and the ampoule and safe snap were launched at the end of the month. Making this the first time a safe, legal supply of water for injections had been available in the UK.

    February 2007
    Exchange Supplies again push the boundries, and formalise the provision of foil as a reverse transition intervention with the first foil pack designed for drug users.

    As foil wasn't on the list of exempt items under section 9a, extensive guidance was again issued on our website to enable services to distribute it without fear of prosecution – in the same way that they have before for citric, vitC, and water. We expect the law to change to allow foil to be provided.. watch this space.
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