Cultural attitudes and government policies toward opiate use in Britain have shifted markedly over the past two centuries from acceptance to criminalization, the latter helping to stoke the so-called "heroin epidemic" of 1980s and 1990s and almost leading to a national outbreak of HIV/AIDS among these groups. This period saw the government reach a new depraved low as it ran its “Heroin screws you up” campaign (see image, below).

In this final article, we examine that particular time, when the Thatcher government was forced into being the first in Britain to employ harm reduction measures alongside criminalization, before looking at how the UK could learn from the success of others who have reformed their drug policy -- notably Portugal -- if they are to end the dangerous stigmatization and marginalization of opiate users.

Heroin Epidemic

Through the late 1970s and 1980s heroin use in Britain became increasingly concentrated among the lower socio-economic class as an economic recession took hold across the country. In the five years from 1978-1983 the number of people addicted to heroin nationwide rose three-fold, while overall drug use rose to 27 percent above the national average in coal mining towns, areas that were among the hardest hit by the recession. Places that disproportionately experienced rises in unemployment -- Glasgow, Manchester, Bradford, Edinburgh and the Welsh valleys -- were the center points of the UK's so-called heroin "epidemic" in this period.

"For those of us in practice at the time, it was very visible," Dr Roy Robertson told the Scotland Herald in 2012. Robertson was working as a GP in Edinburgh in the 1980s and was chairman of the National Forum on Drug-Related Deaths. He estimated that there were roughly 250 heroin users in the late 1970s, yet just one decade later there were as many as 4,000 in Edinburgh. "People were injecting this thing called smack because their friends were doing it and didn't know what it was. There was an epidemic of heroin use but also of hepatitis B, hepatitis C and HIV," he continued.

In the 1980s young people were particularly affected, and mid-way through the decade over one million youth were on benefits. “These outbreaks [of heroin use] involved a minority of 18-25 year olds who were predominantly unemployed and lived in deprived urban areas,” concluded a Home Office report in 1998.

Explaining why people suffering from socio-economic marginalization turn to opiate use is, of course, not straightforward. However, a good place to start is by understanding that, above all else, heroin is an analgesic and offers people at least a temporary escape from a reality of hardship.

Heroin use in the 1980s and economic decline became such defining moments in British culture that they were popularized, most notably in Irvine Welsh’s Trainspotting which captured with empathy the essence of the “junky” stereotype. As Matthew Collins wrote in his book Altered State: The Story of Ecstasy Culture and Acid House, Trainspotting was “a narrative of incandescent brilliance tracking the blind hope and crazy dreams of a group of Edinburgh youths: junkies, people with AIDS, ravers, brawlers, boozers and losers … Trainspotting was the cult text of the nineties not just because of Welsh’s literary talent, but because it struck a deep chord with anyone who had been immersed in drug culture."

Geoffrey Pearson conducted extensive research into heroin use in Northern England in the mid 1980s -- what was widely recognized as “the Trainspotting generation." He found that for the poor in particular, “dependence on heroin, quite literally, imposes its own rigid time structure involving a necessary cycle." Between prison and any possible stay in a rehabilitation center, users may “come off” heroin for shot periods, but rarely rid themselves of addiction for long.

The proliferation of crack cocaine in the late 1980s among economically marginalized opiate users pushed these people further into a vicious cycle of dependence and increased their stigmatization among a largely unsympathetic British public. Home Office research (conducted in 2002) showed that the initial uptake of crack was largely by habitual heroin users. Crack counters the sedative effects of heroin and traps the user in an impulsive cycle of extremes. Extensive interviews by Max Daly and Steve Sampson with dealers for the book Narcomania, found that they commonly and very intentionally pushed crack alongside heroin to maximize user dependence, and so their profits too. The combined effect of the drugs on users was cataclysmic.

HIV/AIDS & the Beginning of Harm Reduction

Through stigmatizing intravenous drug users (IDUs) and pushing them to the fringes of society, Britain unwittingly stoked a health crisis among these communities, with HIV and hepatitis taking hold. Erin O’Mara, founder and editor of the now discontinued Black Poppy magazine, described to The Independent her predicament as a user: “The wooly image of the slightly vulnerable but untouchable heroin addict was an illusion: in reality you're feared and distrusted. I got into prostitution; I thought work gave me a bit of control; it allowed me to pay for heroin when I wanted it. You need three or four hits a day, a little bit more if you can get it. It was 1995 when I was diagnosed with HIV.”

HIV prevalence among IDUs has never been high historically in Britain, but in the mid 1980s there was a very real concern that this could change dramatically. In Edinburgh, for example, the rate of HIV among IDUs was a shocking 50 percent or more in 1986, according to research, largely as a result of needle sharing. This forced the administration of Margaret Thatcher to act in what is described by Daly and Sampson as a “defining moment in British narco-politics;" in 1986, the country's first ever clean needle exchange program was put in place.

As Mike Trace, chair of the International Drug Policy Consortium (IDPC) and former deputy drug czar to Labour, says in Narcomania: “Through a combination of this fear of the unknown, and the vision and understanding of key ministers at the time, the UK became one of the first countries in the world to embrace what we now refer to as 'harm reduction'."

The new policy successfully halted a national HIV epidemic among IDUs, and harm reduction policies have been increased further since that 1986 milestone. Despite this, the number of crack and heroin users continued to grow, peaking in 2005-2006 at a little over 332,000. This has since fallen to under 300,000 in 2010-2011, according to figures from the National Treatment Agency for Substance Misuse (NTA).

“However,” the NTA reported last year, “behind this positive picture, an older and vulnerable population of users poses major challenges for local treatment systems.” We are still seeing the effects of the most destructive periods; "These people became addicted to heroin during the epidemics of the 80s and 90s. Some … have entrenched use that presents a significant issue for treatment services, not least because of the sheer numbers in treatment who are aged over 40," said Paul Hayes, chief executive of the NTA in 2012.

The treatment services now on offer have evolved tremendously in the past three decades. However, the continued criminalization of opiate users -- combined with the way in which these people are viewed by the general public and rabid elements of the media -- means not all will necessarily seek the treatment they need. According to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), opiates were mentioned on the death certificates of 83 percent of drug-related deaths between 2008-2012, and the rate of hepatitis C among IDUs stood at just under 50 percent in 2012.

The circumstances under which these people died and/or contracted a disease of course vary enormously, but one must imagine that if a more compassionate approach were adopted, a significant number would have been avoided.

Looking Forward

"The current campaign for … 'regulation' of some illegal drugs is based either on grave ignorance of the issues, or upon deliberate dishonesty," wrote Peter Hitchens in The War We Never Fought. While prohibitionists such as Hitchens often attack those advocating drug policy reform for being "ill-informed," it is, in fact, these very people who suffer from ignorance of the issues at hand. Through defending heroin and other opiate use, this series has not sought to promote it. Rather, it has hopefully laid out the complete irrationality in pursuing criminalization and just how destructive such a policy has been for those affected.

A good place to start when looking for alternatives to the UK's current policy is Portugal which decriminalized the possession of all drugs for personal use in 2001 partly due to the alarming rates of HIV/AIDS and hepatitis among IDUs. In the years following reform in Portugal, the number of newly diagnosed cases of HIV among IDUs fell dramatically -- from over 1,000 registered cases in 2001 to less than 100 in 2012 -- as did the number of drug-induced deaths.

From the Portuguese experience, it is clear that vulnerable groups are far better protected when offered support without the continued threat of punishment, and addiction is viewed as a health issue not some moral choice of the afflicted.

Until state and society firmly breaks from the view that problematic use is simply suffered by someone who has made "the wrong choice," and acknowledges the complex social and economic factors involved, many opiate users will remain on the fringes of society, dangerously exposed to the harms associated with the drug. Paul Hayes, chief executive of the NTA, warned in 2012 that periods of economic recession "[provide] fertile territory for the next drugs threat to take hold. Young people who are at risk of unemployment, whose prospects are limited, are much more likely to become addicted than people who have a stake in society and can actually see themselves making progress long term."

The historical shift from one extreme to another -- 19th century widespread availability of opiates and acceptance of their use, to current restrictions and condemnation -- in Britain is, to a degree, understandable given the timeframe covered in this series. As we begin to experience another global paradigmatic shift with the increasing calls for reform, the UK would be doing a great injustice to those suffering from problematic drug use if it refuses to address the issue with evidence-based policies. If the country insists on keeping its head in the sand, stigmatization and marginalization will sadly remain the norm.

Read Part I in this series here

Read Part II in this series here