The one sure way to reduce prostitution: heroin prescription

We are at a point in the drugs policy debate now where it is no longer heretical to critique conventional wisdom; that is, to critique a policy which bears virtually zero relation to medical and sociological evidence. How many more women have to beaten, raped, or murdered before we finally see sense?
Stuart Rodger
5 January 2012

In late 2006, the whole of Britain watched in horror as five vulnerable female prostitutes were, one by one over the course of one and half months, picked up off the streets of Ipswich and taken to their deaths. The last victim, Paula Clennell, was even seen on television stating that, despite news of the murders and despite being alerted to the fact a killer was on the loose, she would continue working the streets as she ‘‘needed the money’’ to fund her drug habit. The killer was eventually identified as a Mr Steve Wright. In February 2008, Mr. Wright was found guilty of all five counts of murder and sentenced to life imprisonment. But the truth is that all five deaths were preventable. Preventable, that is, for want of some political courage on the part of our leaders.

In response to the murders, there was, of course, a wide and varied national debate about policy on prostitution, and how to make these vulnerable women safer. Criminalization of demand, legalization, brothels – all were considered and discussed. Although these are urgent and legitimate areas for debate, one simple way to keep vulnerable women away from ‘‘the oldest oppression’’ as some feminists prefer to call it, was ignored: heroin prescription.

But before explaining the rationale for this, it’s worth describing in more detail the risk that women put themselves in when they enter into prostitution. Here are a few shocking, striking facts: a Home Office study from 2004 found that 60 prostitutes had been murdered within the last ten years; more than a quarter report attempted rape; and over 50% of women start in prostitution before the age of 18. And let’s not forget: prostitution, by its very nature, involves having sex with someone you do not want to have sex with – a fact too often overlooked. 

And here’s yet another astonishing statistic: according to the Fawcett Society, 63% of women in prostitution report that they are doing so in order to fund a drug habit – the drug, in most cases, being heroin. The immediate response is, of course, to call for rehabilitation services to be enhanced, broadened, and improved. Now, rehabilitation programmes have their place, and it is imperative that the health service try to wean people off drugs entirely, but to think this is the only way of dealing with the problem misses one hard, crucial fact: rehabilitation of hard drug users have a very low success rate. Even the swishest, swankiest form of residential rehab only has a success rate of 50% at best, according to research by Dr David Best, chair of the Scottish Drug Recovery Consortium. For a significant number of addicts rehab, sadly, doesn’t work. It is, as the medical research refers to it, a ‘chronic relapsing condition’.

The solution for this group of remaining addicts is to provide a safe, clean supply of heroin (otherwise known as diamorphine), prescribed by a medical professional, allowing them to hold down a stable, unchaotic life, where they no longer have to burgle or prostitute themselves to fund their ineradicable habit. 

Many of you may be reading this and thinking: what ‘safe, clean supply of heroin’? But the truth is that unadulterated heroin is, in reality, a relatively safe drug: the only consequences being addiction itself and a bit of constipation. It may seem shocking at first, riddled as the British press is with misinformation about drugs, but the distinguished investigative journalist Nick Davies has conducted a detailed study into this, highlighting large scientific studies of unadulterated heroin users. He states: ‘The Oxford Handbook of Clinical Medicine records that a large proportion of the illness experienced by blackmarket heroin addicts is caused by wound infection, septicaemia, and infective endocarditis, all due to unhygienic injection technique’. (But, given that street heroin has a purity of between 20-90%, it’s probably wise not to go near it).

Interestingly, he gives a few historical examples of well-functioning heroin addicts, including the children’s novelist Enid Bagnold, who died quietly in her bed at the of 91, having spent twelve years her life after a hip operation consuming up to 350 mg per day. Two others of note include Dr William Stewart Halstead – widely regarded as the most pioneering surgeon in US history – and Dr Clive Froggatt, Margaret Thatcher’s health advisor (now an avowed champion of heroin prescription on the NHS).

Of course, many people reading this will be familiar with the heroin substitute methadone - a bright green gloop consumed orally - which has been the principal drug used in harm reduction strategies for problematic heroin addicts for well over a decade. The problem is that, while it works to some degree, methadone is in many ways more dangerous than heroin, and unpopular among recovering addicts, meaning they are not successfully driven away from the illicit heroin trade. As the epidemiologist Dr Ben Goldacre demonstrates in his detailed analysis of the scientific literature, it is a profoundly unpleasant drug to take, causing tooth decay, nausea, vomiting and so on. But more alarmingly: it has a higher mortality rate than heroin; this, despite the fact that there are a higher number of heroin users to methadone users in the UK (some scientists have put this down to its longer half-life – a fact used to justify its use in preference to heroin).#The real reason for the choice of methadone over heroin is, I suspect, one of price: pure heroin is almost 8 times more expensive than methadone. This can, however, be easily dealt with by dismantling the monopoly the company ‘Evans Medical’ has on the drug.

A comprehensive 2006 study conducted by the Joseph Rowntree Foundation found that Drug Control Rooms – supervised clinics where heroin addicts could turn up at any point, day or night, to shoot up – had been a stunning success: places where drug deaths fell to literally one – one! – and levels of HIV infection collapsed from 50% to 2%#. Once addicts have a safer, cleaner supply of their drug – where they can, of course, be slowly weaned off it, inch by cautious inch – the need to deal to fund vanishes: the Global Commission on Drug Policy highlighted that under a heroin-prescription policy the number of new users fell by a spectacular 80%, thereby ending the most vicious of vicious cycles. Don’t be deceived by the seemingly low levels of success by the National Treatment Agency (the body responsible for delivering harm-reduction treatments) in ending dependency entirely; this is, in the words of the NTA’s Director of Communications ‘like measuring a school's GCSE success by counting the number of A grades as proportion of the total school population’. Remember: heroin addiction is a chronic relapsing condition.

Up until the 1960s, this was common practice in the UK, and so successful it was replicated throughout the world as the famous ‘British method’, only ending in the wake of Richard Nixon’s global ‘war on drugs’. Returning to this model would mean fewer families unnecessarily torn apart, and, crucially, far fewer women having to enter to prostitution, keeping them safe from disease, destitution, and death.


So what is the current government’s policy? Pre-election, drug policy reformers had reason to be cautiously optimistic: David Cameron sat on the Home Affairs Select Committee in 2002, co-authoring a report which was sympathetic to legalisation. Although upon becoming PM Cameron initially looked like he’d caved-in to the utopian, senseless, cold-turkey approach of his colleagues, the government has since back-tracked: the money for the National Treatment Agency has been ring-fenced, with Ken Clarke providing a sober voice of reason, pointing out that withdrawal was clinically dangerous. They have not, however, signalled a change from methadone to heroin, so for Cameron to continue with a policy he knows full well increases disease, destitution, prostitution, and death, is nothing short of a disgrace. Only public pressure – by the medical establishment in particular but with the backing of the public – will make him change course. 

Of course, heroin is not the only hard drug addiction to which will drive women into prostitution – there’s also crack, the stronger, microwaved form of cocaine. I hold back from advocating crack prescription, given the lack of epidemiological literature on the subject, but I think it would be wise to think a similar dynamic works again: either prescribe, or they find new users as a reliable income stream. Crack is, however, one of the key products of what the campaigner Richard Cowan calls the ‘iron law of prohibition’: criminalize a substance, and its use intensifies. As he explained in his famous 1986 essay, ‘How The Narcs Created Crack’: ‘it is good business to minimize the bulk of contraband. Smuggling beer and wine was less profitable than rum running. Tiny pieces of crack are easier to carry than cocaine powder, which in turn is far less bulky than the coca leaves that are used legally by the Andean Indians. Heroin replaced opium for similar reasons. Obviously, the bulkiest illegal drug, marijuana, will lose out in the supply channels to cocaine and heroin.’ #This theory fits the facts: in Glenn Greenwald’s key CATO Institute study into the experience of Portugal’s experiment with decriminalizing personal possession of drugs in 2001, he found that while use of cannabis among older teenagers increased somewhat, use of heroin declined considerably.

We are at a point in the debate now where it is no longer heretical to critique conventional wisdom on drugs policy; that is, to critique a policy which bears virtually zero relation to medical and sociological evidence. We need to seize this moment. Make a noise. Get it on the agenda. Pile on the pressure on the politicians. Educate and inform: too many people are still misled by newspaper misinformation and irrational tabloid hysteria. Afterall, it’s an urgent cause, as the experience of Tania, Gemma, Anneli, Annette, and Paula - the five women murdered in Ipswich in 2006 –and countless other faceless, nameless victims show. How many more women have to beaten, raped, or murdered before we finally see sense?

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