1.1. The provision of foil for the purposes of smoking controlled substances,
generally heroin and crack cocaine, is illegal under section 9A of the Misuse
of Drugs Act 1971. However, some drug services provide foil to heroin users
as a cited harm reduction measure. Evidence has been provided to the
ACMD that some drug intervention agencies supply specialist foil to drug
users to encourage smoking as a safer alternative to the practice of injecting.
The foil generally comes with a specified health warning1.

1.2. In most cases foil is provided in packs, in ready cut sheets. It is noted that,
for the user, kitchen foil is not discreet to carry and is often coated with
vegetable oil that is generally burned off before use.

1.3. The ACMD began its consideration of the issue of the use of foil as a harm
reduction measure in July 2008 after a growing body of evidence of its
potential benefits and also its distribution from drug services.

1.4. Evidence has been presented to the ACMD that the legislation (Section
9A of the Misuse of Drugs Act 1971) is broadly un-enforced; with respect to
drug services providing foil in apparent contravention of the Misuse of Drugs
Act 1971. The ACMD understands that there are various reasons for this: 1) it
is a low policing priority; rather than expend effort collecting evidence and
preparing a file for the Crown Prosecution Service (CPS) they would take a
crime prevention approach and inform those services that were providing foil
that they should stop; 2) it is reported that some forces are ‘supportive’ of the
provision of foil as a harm reduction initiative and have, upon request,
supplied ‘letters of comfort’ which clarifies that they will not produce a report
to the CPS for prosecution.

1.5. According to the Health Protection Agency (2009), there is some
uncertainty about the extent of injecting drug use in the United Kingdom. It
may be as high as 217,000 in England and Wales alone. What is certain is
that people who inject drugs are especially vulnerable to a wide range of
infections. These include viruses such as hepatitis C (HCV) and HIV and also
bacteria such as group A streptococci or Clostridium botulinum. High rates of
mortality and illness arise from these infections so public health and
protective behaviour interventions among injecting drug users (IDU) are
important.

1.6. In its 2009 report The primary prevention of hepatitis C among injecting
drug users, the ACMD estimated that:

1 Details can be found at:
http://www.exchangesupplies.org/needle_exchange_supplies/foil/foil_intro.html

“There are 120,000 to 300,000 (mid estimate 190,000) people that have
been infected with HCV in England and Wales, and about 50,000 in
Scotland. 85% became infected through injecting drug use.”

The report concluded that “Ultimately we need to stop injecting to reduce the
risk of HCV”.

2. Background to the evidence underpinning ACMD’s previous
considerations and recommendations regarding
paraphernalia [under section 9A of the Misuse of Drugs Act
1971]

2.1. The ACMD first considered sterile water for injecting (WFI) in 1991 and
other drug paraphernalia in 1995. The issue was raised again at an ACMD
meeting in November 1998. Concern had been expressed that drugs workers
were putting themselves at risk of prosecution when supplying paraphernalia
in breach of the law.

2.2. A number of reports and studies were discussed at the November 2000
ACMD Technical Committee meeting:

2.2.1. A report by the Royal Pharmaceutical Society of Great Britain
(RPSGB) had recommended that section 9A should be amended to
permit the supply of injecting paraphernalia by pharmacists to drug
misusers.

2.2.2. A report of the Police Foundation’s Inquiry into the Misuse of Drugs
Act 1971 (Police Foundation, 2000) had also recommended that
section 9A should be repealed.

2.2.3. A paper by Sheridan et al. (2000) examined the supply of syringes
and other injecting equipment by needle exchange schemes in
South-East England. The researchers collected data from
approximately 400 community pharmacists and needle exchanges;
the responses had indicated that 83% of needle exchanges supplied
swabs and 6% supplied filters.

2.2.4. Research by Crofts et al. (2000) found detectable levels of hepatitis
C virus on injecting equipment other than needles or syringes – which
suggested that infection could be transferred to syringes (and
individuals) through sharing paraphernalia. The virus had been
detected on 70% of syringes, 67% of swabs, 40% of filters, 25% of
spoons and 33% of water samples.

2.3. The ACMD considered a paper on the supply of drugs paraphernalia at its
meeting in November 2000. The ACMD considered drug paraphernalia and
WFI at its meeting in May 2001 and subsequently the use of filters in May
2003.

2.4. In May 2001, the ACMD made its recommendation to amend the misuse
of drugs legislation to permit the supply of swabs, bowls, spoons, stericups,
citric acid and WFI. In May 2003, the ACMD recommended the inclusion of
generic filters in the legislation. These recommendations were accepted by
government.

3. Current legal position and background

3.1. Section 9A(1) of the Misuse of Drugs Act 1971, below, makes it an offence
to supply any article used for administering a controlled drug unlawfully (i.e.
without a doctor’s prescription).

“A person who supplies or offers to supply any article which may be
used or adapted to be used (whether by itself or in combination with
another article or other articles) in the administration by any person
of a controlled drug to himself or another, believing that the article
(or the article as adapted) is to be so used in circumstances where
the administration is unlawful, is guilty of an offence.”

3.2. Section 9A was inserted in the 1971 Act by the Drug Trafficking Act 1986.
The purpose was to outlaw the supply of cocaine kits (razor blades, foil and
lemon juice) that were being marketed in the mid-1980s. An exception was
made for sterile syringes and needles to permit the supply of clean injecting
equipment to drug users because of their significant harm reducing benefits,
including reducing the spread of HIV, hepatitis B and hepatitis C and other
water and blood-borne diseases.

3.3. The ACMD was previously asked to consider whether the supply of
additional items of paraphernalia should be lawful. (It had become clear that
some pharmacists and drug workers in needle exchanges were supplying
such other items contrary to Section 9A in the belief that they were effective in
reducing the harms associated with injecting drug use). In May 2001, the
ACMD concluded that certain items had significant harm reducing benefits
and recommended that the supply of swabs, utensils for the preparation
(spoons, bowls, cups and dishes), citric acid and ampoules of water for
injection (when supplied in accordance with the Medicines Act 1968) should
be lawful, but only if medical practitioners, pharmacists and persons
employed in the lawful provision of drug treatment services supplied them
and, from 2005 onwards, a supplementary prescriber. Whilst rejecting them in
2001, the ACMD subsequently recommended that the supply of filters should
be lawful in similar circumstances. Cross Government agreement was sought
by the Home Office and changes were made by secondary legislation –
Regulation 6A of the 2001 Regulations – in August 2003. (The ACMD
rejected the inclusion of tourniquets, concluding that the risks outweighed the
benefits). Following evidence that users injecting crack or freebase cocaine
tend to use ascorbic rather than citric acid and following the ACMD’s
recommendation, the 2001 Regulations were further changed in 2005 to
incorporate ascorbic acid.

2 According to the findings of an online survey conducted by the National Needle Exchange
Forum (NNEF) between October and November 2008.

3.4. In accordance with section 9A, the supply of any other article is prohibited
where the supplier believes that it will be “used in circumstances where the
administration [of a controlled drug] is unlawful”, but not otherwise. It is a
matter for the police and the crown prosecution service respectively to assess
what policing priority should be given and whether prosecution is in the public
interest where a drugs worker supplies articles in contravention of section 9A.

3.5. Despite the current legislation 15%2 of UK services have for some time
contravened section 9A by providing foil. Yet there are no cases of a service
being charged with an offence (Pizzey and Hunt, 2008).

3.6. The ACMD considers that any advice provided to ministers regarding
changes in respect of the Misuse of Drugs Act 1971 would need to fulfil two
criteria:

. for there to be evidence that the intervention reduced drug related harm;
and,

. the intervention would not encourage use of illegal drugs, especially
heroin.

4. Evidence presented to ACMD regarding the use of foil as a
harm reduction intervention

4.1. Two key studies provided evidence of how the provision of foil might reduce
harm among injecting drug misusers in the UK. A published study (Pizzey and
Hunt, 2008), provided an evaluation of results from an intervention in South
West England using foil packs to promote a transition away from heroin
injecting to inhalation. The study analysed data from four needle and syringe
programmes (NSPs) and interviews with injecting drug users (IDUs) in one
NSP. A Turning Point report (Boid and Waldock, 2008) described a trial
scheme entailing the introduction of aluminium foil to Sydney Street needle
exchange and Sharp Action needle exchange in Sheffield.

4.2. The report by Pizzey and Hunt (2008) showed that foil packs were taken
when available (out of 320 attendees, 54% took the foil packs). Over the
period of the evaluation, NSP transactions increased by 32.5% from 1,672 to
2,216.

4.3. The findings from the Pizzey and Hunt (2008) study suggested that
distributing foil packs could be a useful means of engaging needle and
syringe programme (NSP) attendees in discussions about ways of reducing
injecting risks – thereby reducing harms to users and providing a mechanism
of engagement to reduce overall use. It could also reduce injecting in settings
where there was a pre-existing culture of heroin chasing.

4.4. The study called for further research, to evaluate whether the study findings
(Pizzey and Hunt, 2008) could be reproduced in other cultural contexts and
evaluate whether the observed behavioural changes were sustained and led
to reductions in harm including blood-borne infections and overdose.

4.5. The Turning Point report (Boid and Waldock, 2008) details a trial scheme,
with feedback, where foil was provided at both a site based needle exchange
(423 packs provided) and an action van (304 packs provided). Whilst the
feedback received was not analysed it was apparent, from self reported
results, that the provision of foil reduced injecting behaviour and promoted
less risky alternatives.

4.6. The National Needle Exchange Forum (NNEF) undertook an online
questionnaire between October and November 2008, the results of which
were analysed by Liverpool John Moores University. The questionnaire
produced 445 responses from across the UK, these included responses from
managers, commissioners, service users and workers. The results of the
NNEF questionnaire (Chandler et al., 2009) found that 15% of services
provided foil while 67% of services had no provision due to the current legal
status. 92% of respondents felt that foil would help reduce harms and 81%
felt that foil would encourage drug users not to inject. Overall the
questionnaire indicated that respondents were supportive of foil being
supplied through needle exchange programmes. The NNEF recommended
that Aluminium Foil should be added to the current list of exemptions in
Section 9A of the Misuse of Drugs Act. The NNEF further requested a more
detailed assessment and review of Section 9A.

4.7. In February 2009 the Association of Chief Police Officers (ACPO) Drugs
Committee wrote to the ACMD to highlight that ACPO Drugs Committee
members had been aware that, during the last few years, a number of local
service providers had taken part in harm reduction initiatives and had
supplied foil to intravenous drug users in order to encourage a change in their
consumption habits. The ACPO Drugs Committee cited a scheme operating
in Somerset Drug and Alcohol Action Team (DAAT) which had received
prominence following its evaluation in 2008.

4.8. The ACPO Drugs Committee requested clarification of the legislative
framework provided to all parties involved in these schemes so that local
health professionals and police do not expose themselves to breaches of the
law. This is a difficult area since the ACMD is aware that on a local level
individual forces are providing ‘letters of comfort’, where requested, to needle
exchanges and services. These letters do not have any legal standing, but
are a statement that effectively turns a blind eye to the provision of foil by
services.

4.9. Release provided a submission to the ACMD in March 2009 that supported
an amendment to section 9A to include foil in the exempted paraphernalia list.
Release recommended that:

. There should be an immediate review of section 9A and how it
impacted on the development of harm reduction initiatives;

. Consideration to be given to a new system led by medical opinion
whereby those working in this area could dispense equipment if it
could be shown to have an effective impact in reducing harm and/or
acting as a tool for engagement.

4.10. A study by Exley (2008) tested the hypothesis that aluminium foil could be
a significant source of aluminium in users of heroin who were ‘chasing the
dragon’. These experiments used the same ‘batch’ of street heroin. While
there was evidence of an increase in bio-available aluminium from heroin
vaporised off aluminium foil this would not account for the elevated urinary
excretion of aluminium in heroin users. According to a case study aluminium
had been found as a contaminant of heroin; e.g. 42 – 2280 µg aluminium g-1
heroin (Bora et al., 2002). The study also measured the aluminium content of
‘street’ heroin and found; 48.0 . 19.6 µg aluminium g-1 heroin (n=9). In
comparison the aluminium content of tobacco has been found to be; 600-
3700 µg g-1 (Exley et al., 2006) the aluminium content of heroin is generally
too low to account for the high urinary excretion of aluminium from heroin
users.

4.11. A presentation on the Dutch experience (Kools, 2009) provided an
overview of the supply of foil in the Netherlands. The Dutch aim was to
promote a move away from drug administration by injecting towards less risky
methods, a practice known as ‘route transition’. It described autonomous
trends among opiate and stimulant users from injecting towards non-injecting
drug consumption in the early 1990s. This trend in the drug using community
was initially recorded in 1992 and became the basis for a range of health
interventions to promote a shift away from injecting.

4.12. In the Netherlands, the provision of a combination of a full range of health
interventions (Opiate Substitution Therapy – OST), NSPs, consumption
rooms, community outreach, peer support, social marketing etc.) led to
significant individual and public health benefits.

4.13. Currently within the Netherlands foil is available in all needle and

syringe exchange programmes (NSEP) and consumption rooms (CR). It was
highlighted that a success recorded from the intervention had been a
significant reduction of blood-borne viruses (BBVs) (Kools, 2009). In
Amsterdam during the last decade “HIV prevalence had fallen from 8.5 per
cent to virtually zero, and the number of fatal overdoses had also drastically
decreased” (Kools, 2010).

4.14. The ACMD heard that provision of aluminum foil within NSEPs and CR

had not encouraged new users to take up illicit drugs.

4.15. In Scotland, Glasgow Addiction Services have proposed a foil exchange

pilot scheme. This followed encouraging results from a recent service user
evaluation. In October 2009 an anonymous service user questionnaire was
developed and distributed to service users to evaluate the service and
establish their views on foil provision. The key findings regarding foil were that
83% of service users said they would like foil to be offered as part of the
service and 59% said the provision of foil would encourage them to consider
smoking rather than injecting.

5. Consideration of the evidence

5.1. In all studies the benefits ascribed to the use of foil and the aims of
providing the foil were multi faceted. They included:

. To reduce injecting related harms (blood borne viruses, infections, vein
collapse);

. To reduce the risks of overdose;

. To reduce injecting drug use;

. To engage users to discuss options with a view to reduce harms,
injecting and ultimately drug use;

. To reduce drug related litter; and,

. To reduce drug related crime.

5.2. However, from the present studies it is difficult to specifically quantify the
reduction in injecting related harms since studies are not constructed to
measure this. Most of the studies to date have been qualitative in nature and
have been self-reported.

5.3. In the ACMD’s report on the primary prevention of hepatitis C (ACMD,
2009) it was noted that there was only weak evidence for the effectiveness of
many interventions in reducing HCV among IDUs. The key finding was that
there is emerging epidemiological evidence (supported by preliminary studies
in the UK) that the combination of opiate substitution therapy (OST) and NSP
is the most effective way of reducing HCV (and HIV) incidence among active
IDUs (NSP or OST alone may not be sufficient to prevent HCV). Transposing
the findings of the ACMD report (2009) it is likely that the provision of foil
alone, unless a total substitute for injecting behaviour, would not make any
significant impact on the incidence of blood borne viral infections.
Nonetheless, foil provision may have an important role within a programme of
interventions (like other paraphernalia) if it can be used to enforce harm
reduction messages on the dangers of injection.

5.4. The National Institute for Health and Clinical Excellence (NICE) Public
Health Guidance 18 Needle and syringe programmes: providing people who
inject drugs with injecting equipment recognises the importance of NSPs in
providing a gateway for IDUs to commence OST as a mechanism for
reducing harm. In this report is was also noted that from fieldwork findings of
participants who worked at Needle and Syringe Programmes:

‘They were disappointed that the draft guidance did not address the need
to provide foils and crack pipes to help people who inject to stop.’

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