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New Era for Drugs Policy

There has been a lot in the news recently about the ineffectiveness of the current prohibitive stance taken by the first world countries, and the resulting “failure” of the war on drugs. Again there have been many reports on the Portuguese Model, and the fact that this model may be the way forward for drug services many of the reports suggest that this is a new model, and it is revolutionary, and
Soon and so forth.
This model is indeed revolutionary, you can see this just by the way the model has increased the
Number of those in treatment and accessing treatment. You can see how successful the model is
When you see the reduction in BBV transmission and a rise in the numbers of those in treatment,
All these facts quite rightly highlighted in the various press articles and reports.
However as with everything that is reported, there are parts of the process which are not so readily or so enthusiastically reported by the media.
For example, the media have omitted to inform the public that this strategy is not just about changing the concept of drug use from a criminal justice issue to a health one, it is also about Social Change.
From the early 20th century, indeed probably from the time of Rush and Trotter the medical professions have tied to ” cure” addiction, by utilising various cures and social reinforces such as licensing legislation, the professionalisation of treatment processes, and medicalisation of the
Condition.
Also many countries have started to look at how to control drug use within their populations by embarking down a parallel route of enforcement and control, linked to the “cure” paradigm of the medical model, in effect criminalising and stigmatising the very populations they are supposed to be helping. Within this drive to control substance accessibility within the population, the Professionals who originally conceived the medical model as a way to break free from the moral model and its pejorative language and solutions, started to assert a more sinister form of Social Control, by pedaling the myth that there was no cure per se, but only the route of on going
Treatment for this disease of the mind, and the acceptance of the new mantra of abstinance as the only way to maintain your “normally acceptable behaviour”. These groups of professionals also started to build an impenetrable myth around this act of taking substances by introducing
medicalised terminology and concepts, one can only assume to mystifies the whole idea of a Disease that not only affects a person’s psyche, but also can be physically and morally dangerous. It is the ingrained concepts and beliefs of these widely accepted and held myths that allow the Media to sensationalise what is in the eyes of most academics, and drugs workers, an almost logical next step in the life of the construct that is addiction. The Portuguese model that has been sensationalised in the majority of the right wing press, is a very simple idea that could be argued has its roots in the development of the Harm Reduction movement started in Britain and Europe In the wake of the discovery of HIV in the eighties. When countries like the UK, led the way in
The development of services which are now the backbone of modern addiction and harm reduction services. The whole concept of the model is to facilitate the drug user into treatment, and to this end the Portuguese Authorities, allowed the police and enforcement services to in effect de-criminalise the small fish, the everyday drug user, and allow them to utilise the resources which would have been spent on chasing up the lesser offenders, putting them into custody, and treatment programs whilst there. Something a lot of the reports touched on, but were ambiguous about the reasons why they chose this route… The press also spent lots of time suggesting that his process of decriminalisation would allow drug use to rage through Portuguese Society, and bring in undesirables into the country as drug tourists, which would turn the Family Holiday destination into some kind of modern Sodom and Gomorra. Unsurprisingly this didn’t happen, in fact none of the
Dreadful social fallout that was predicted did, instead, the rampaging epidemic of blood borne Virus, criminality, and substance use itself actually declined, the streets of Lisbon were not turned Into avenues of vice fueled by ever increasing crowds of drug seeking criminals. The costs of maintaining an enforcement based policy, was transferred into maintaining a treatment system that now offered hope instead of writing people off, a system that put recovery at the heart of treatment instead of criminality, and a system that offered treatment as a viable option instead of incarceration or criminal justice solutions. In effect, what the policy implementation in Portugal means is now rather than spending money on incarcerating and caring for ever increasing numbers of petty offenders, the drugs enforcement apparatus can now spend funds on targeting the criminal networks who supply and import the substances, and once they seize their assets, these can also be utilised to facilitate the dissemination of services, and delivery of services, in the short term effectively turning enforcement into a self-sustaining process. In the long term however Portugal has to decide whether this model, which goes against the European love for enforcement will form the bases of a long term strategy.
Although Europe is humming and hawing with regards to the concept of decriminalization, and if when and how to implement this revolutionary new model, a worldwide movement is gathering strength, condemning the so called “war on drugs”, and calling for less prohibitive legislation, and a more liberal treatment based framework, citing Portugal and various other radical harm reduction interventions such as Drug Consumption rooms and peer led intervention centers as the blueprint for future policy developments in policy.
This movement has also pushed the idea of the prohibitive legal and criminal justice system, set up to protect us from the all-consuming drug criminality that is powerful enough to affect nation states, as being an arm of international foreign policy, and of targeting so called failed states, to prevent them from becoming havens for the evil drug cartels. After all, Great Britain, one of the greatest empires next to the Roman Empire, peddled drugs, which allowed us to gain territory in China (Hong Kong), and take land from indigenous populations, for a bottle of whisky (Maori’s, Aborigines’, Native Canadians), in fact this policy of subduing native populations with alcohol, continued into the times of the United States of America, defenders of the free.
The new wave of awareness and understanding about drug use and the issues which cause it, are indeed changing the face of drugs policy, but we still have to be fully aware of how current foreign policy is linked inextricably to drugs policy, we also have to be aware of how financial crisis can alter perceptions of what is a good drug and a bad drug, this is no more evident in the US of A where a number of states have now legalized, or decriminalised cannabis in order to cash in on its popularity, how long will it be till we see the same process in the UK, cannabis4U coming to a high street near you”, once the politicians see how much cash can be generated from the selling of licenses, and the setting up of legal cannabis farms, and the whole infrastructure that goes with it, it may come to the UK sooner than we think. It is indeed a new era for drug laws, and the defining of drug related criminality.

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Anyone who knows me will know that I am committed to voting yes on the 18th September.

I am a socialist with nationalist leanings, and I think that I am probably like the majority of socialists in Scotland.

I moved my allegiance from Labour to the SNP after the devolution vote in the

1990’s, after having a deep and philosophical discussion with a family friend, who invited me to listen to her vision for not only at that time a newly devolved

Scottish parliament and its potential, but ultimately what an independent state

called Scotland may look like The passion and eloquence of the vision and the

concrete belief that Scotland’s only way forward was now independence got me thinking, which then led me to research all of the political arguments, and look at the facts. I am not going to go into these arguments, as they are more than adequately covered by the two main protagonists in the campaign; instead I am

going to give you the more personal reasons that have resulted from this

research and observations of our current state of affairs.

Scotland first of all ,in my humble view is fundamentally different as a nation from the rest of the UK, our psyche is basically socialist in hew, we can look back

through history and trace a lot of these differences to the” Scottish

Enlightenment” when great intellectual figures like Adam Smith and

David Hume to name but two of many, basically re defined society, politics, and philosophy, the shadows of which can still be seen in modern society,

interestingly Adam Smith also wrote in his great work the wealth of nations,

a warning about allowing government and business to monopolise the development of policy, sound familiar. We can also see from history, the direct result of this radical academic and philosophical movement when we look at the trade union movement and the beginning of this in Lanarkshire, Messer’s James Wilson and Keir Hardie. The trade Union Movement has helped further the lot of the common man, it has improved Working conditions, pay and was instrumental in

developing the conditions we all take for granted, again an intesting fact you discover when you read about all this was Kier Hardies’ belief in universal suffrage, long before it became fashionable in the south of Britain, he was pushing for

this as early as 1892.We also have produced greats like Alexander Fleming,

who discovered Penicillin, Charles Macintosh who we have to thank for waterproofing, McAdam and McAlpine who built roads, William Murdoch who invented gas lighting, and importantly James Dewar without who picnics would be

radically different, what did he invent, the thermos flask. The list goes on, and if you look in most areas Scots were instrumental in developing a lot of the

modern world. All of these people illustrate the impact the enlightenment had,

the search for empirical evidence, and the development of the scientific process which allowed us to convert ideas to actual items or theories came from this

period. We can move much closer to our time, and there are plenty of examples of this endogenous philanthropic, streak, you see it in the supermarkets when

people buy extra for food bank donations, you see it in the nurse who pays for a bag of food stuffs to give away at support groups, you see it in the way members of the public give the guy selling the big issue slightly more than the asking

price then tell them to keep the change, Scots are different. So why am I voting yes, because I have dared to dream, not about how rich we can be, or about how our standard of life will be better, and that bills may be cheaper, I have dreamed about what we can give the world, we are responsible for inventing building, producing and making what we see today, not just the material things

like the car, but the other things like health care, bridges, the thermos flask,

financial systems, maps of and places on continents, why am I voting yes ,

because we can and will create a better country, we have already started, we

are one of the very few nations to seek independence without resorting to

physical violence, we are already looking after the poor, we have and already

are standing up to tyranny, the poll tax, and the bedroom tax, that is why I am

voting yes, because we can lead the way again as we once did and have done , we can have new Kier Hardies’, and James Watsons, new Adam Smith’s and

David Hume’s, new Mary Slessor’s and Alexander Fleming’s, all we have to do

is vote Yes.

I am also voting yes because we shouldn’t have food banks, our welfare state

should be able to provide for the basic needs of our poor, without prejudice or

stigma, I am voting yes because government and business have influenced

policy for too long and by doing so have created the political elite Adam Smith, warned about, and Keir Hardy and James Wilson fought. I am voting yes

because we need true universal suffrage, and we have the right through this to choose a government we want, not a government of political elitists who commit ideological rape in our name, with a political mandate we didn’t vote for.

To coin a phrase this is not about the SNP, this is about a once sovereign nation regaining what was lost. This is about regaining independence from a state

that manipulated and forced Scotland into financial crisis, then forced an act of union through financial manipulation backed by a political elite, sounds familiar doesn’t it.

Introduction:

To answer the above question, I am first going to briefly examine what is meant by the terms substance use problem, Criminal Justice Intervention, Public Health Intervention and Harm Reduction. I am going to examine what is meant by contemporary society by the phrase substance use problem, how this concept then defines and drives what are the current thoughts around Criminal Justice Interventions, and public health interventions, and then I will examine what is meant by Harm reduction and how this may or may not compliment public health and criminal justice interventions.

What are Substance Use problems?

The common  contemporary concept of substance use being a social evil, is relatively new, and if you examine social history, and read commentators such as ( Anderson & Berridge 2000),(Barclay et al  2000 ) & (Gossop 2007)  you can see from their research and resultant books, that substance use has been a integral part of society from early times. In many historical pieces, many academics discuss how substances such as cocaine, opium , and alcohol were all used in various commercially available products without any recourse prior to 1820(Anderson & Berridge 2000).

With the advent of the pharmacology act of 1820, the rise of professionalism amongst the new scientific professions such as medicine and pharmacology, the adoption of a new “Medical Model “of viewing substance use issues, or addiction and the rise of temperance, due to the public and social drive against drunkenness and all of its resultant evils, the common concept of what a substance use problem were, gradually began to perfuse into societies psyche. Over the various decades, more prohibitive laws have been passed, each time the laws becoming more prohibitive, until after world war two, the modern landscape of prohibitive legislation was finally developed and ratified by several global position statements by the United Nations. First the 1961 Declaration on narcotics,(UNODC 1961) which ratified the concept of all member nations being drug free, and basing their drug policies on evidence,  and the 1971 convention on Psychotropic  Substances, which called for psychotropic substances to be placed into Schedule one or two dependant on Harm, and banning all use except for medical and research practice. (UN 1971) These two documents also reinforced the concept of the “drugs war”, which had began with the branching out of the enforcement authorities into enforcing social and racial stereotypes based on cultural use of alien substances by ethnic and disenfranchised groups(ref)  which  with the repeal of the Volstead act, which  was the catalyst for the prohibition years from 1920-1932, enabled  the law enforcement apparatus originally set up to enforce prohibition enact a new role as guardians of society  against the insidious march of deviant and immoral drug use as alcohol became a legal substance once more. This new role brought with it the need for a more robust legislative and social framework to control these “immoral substances” and as such a new paradigm acceptable to the public to allow the enforcement and development of new legislation.

This was achieved by not only classifying the sale and use of these substances as illegal acts out with medical and scientific use, but was also fuelled by the development of the scientific model of addiction as a “disease of the will”, an idea first vocalised as early as the 1600’s by men like Trotter, Rush, Levine, & Huss, who all initially discussed alcohol, but the ideas of this “disease model” were quickly applied to all substances. With the advent of the 12 step model, which was “scientifically” endorsed via research and study by E.M Jellinek .published in 1960?

The decision of the United Nations both in 1961, and later in 1971, to endorse these concepts within their individual conventions, introduced this concept of drug use as a form of criminal behaviour perpetrated by criminals to supply clients with substances to ensnare them in a disease process, which then drove them to more crime to facilitate their ever increasing craving for their substance of choice.

Therefore substance use problems can be seen as criminal behaviour caused by the use of illegal substances which by their very nature have medically related problems, such as mental health issues, and physical health issues which are in the long run detrimental to the drug user’s health and social wellbeing.

Criminal justice Interventions:

Within the substance misuse arena, the term Criminal Justice Intervention refers to any of the interventions delivered due to a service user breaking the relevant part of the legislation.  The whole idea of drug interdiction and the reduction of supply all of which are parts of the criminal justice system, as noted above, come from the moral model of addiction, which is based on the belief that the use of drugs and alcohol is morally wrong, and that by preventing use you prevent substance mis use. The most effective example of this was as discussed the Volstead act which ushered in the era of prohibition within the US, strongly supported by the temperance movement, this however is also held up as an example of how the criminal justice approach can cause a rise in criminality, and offers an environment for organised crime to flourish. (Buchanan & Young 2000)

Within the UK we have also had our criminal justice system influenced by this movement, one of the many legislative bills which can be traced to these movements, especially here in Scotland was the 1913 Temperance Act (Scotland) which was an attempt to control licensing, this is sometimes over looked by all of the prohibitions passed with the defence of the realm act, which was intended to control substances, specifically alcohol, and the access troops had to it.

 

The main legislation in respect to this in the United Kingdom is the misuse of drugs act 1971, which has tariffs attached to various acts involved in drug use, and has also a classification system based on how harmful the drug is, and each drug is categorised as A, B or C dependant on perceived harm. (http://www.legislation.gov.uk/ukpga/1971/38/contents)

This legislation also gives courts and enforcement agencies the power to hand out custodial sentences, the tariff for which depending on the class of drug, and the part of the legislation the offence is committed under.
In Scotland at this point in time, there are several  criminal justice interventions utilised which can also be linked to Public Health Interventions which are prison based  opiate replacement therapies, Drug Treatment and Testing orders. There are also others, e.g. Probation and community service orders, which may also have public health elements within them.

Within this essay, we are going to focus on two of these interventions, prison based opiate replacement programmes, and drug treatment and testing orders, due to the way they can be linked to public health through the blood borne virus and sexual health framework.

Public Health Intervention

Public health interventions are interventions which look at the health of the general population initially, then specific groups deemed to be vulnerable or at risk specifically within that general population.

As with Criminal Justice Interventions, as outlined above, Public Health Interventions have their  core concepts based within a model of addiction. The model of addiction that public health takes its main concepts and schemas from is the medical model, as briefly discussed previously. This model suggests that addiction is the result of a disease process, and as a result the various issues that are associated to this disease concept such as the cravings, and associated medical problems such as liver damage, blood borne virus and the social issues such as crime and some degree poverty can be abated by people “just saying no” or by facilitating people who use drugs into treatment. The public health model also looks at abstinence, as does the moral model, as the ideal, and to this end most interventions are geared towards a drug free life(Scottish Government 2008,).

Public health interventions rely more on policy than legislation, to guide and facilitate their delivery, and examples of this for substance use  directly related to our two interventions would be the Road to Recovery (Scottish Government 2008) the sexual health & blood borne virus framework (Scottish Government 2011) , both of which discuss in detail substance use/misuse and the governments expectations of what services should offer.

Public Health interventions, especially around blood borne viruses and their prevention, tend to be delivered alongside harm reduction techniques, which are the polar opposite to the models discussed as the focus tends to be on the reduction of harm with abstinence being of secondary concern, this often causes tension between drug services and public health services, as drug services are being seen to condone drug use (Lloyd & Hunt 2007). On the other hand drug services tend to look at harm reduction as one of the many tools on a continuum towards abstinence, but another difference is that drug services are also pragmatic and realise that the concept of abstinence is not suitable for everyone, and with most harm reduction services the role is completed with some clients by just ensuring someone turns up at the clinic is using the correct injecting technique and knows how to react in an overdose situation.

Harm Reduction Approach:

As outlined above, Harm reduction approaches focus on reducing harm, this approach is more centered on thebehaviour change model as described by Prochaska & DiClemente in 1980, but also uses elements from Bandura’s theories around learned behavior, and also to some extent Skinner’s work around operant conditioning. (Ghodse 1995, Rasool 2009)

Harm reductionists believe in facilitating change, by providing choice, and by influencing factors such as mentorship and peer concepts, and this can be seen actively at work in the various peer support models used throughout the current drug services. This idea is at odds with the interventions based on the more traditional viewpoints as outlined previously. These concepts focus on facilitating the service user to enter into treatment and then whilst in treatment, maintain their sobriety, with the ultimate aim to be to facilitate and maintain abstinence. The tension arises with the way that this is done, and how the problems are perceived.

As previously stated, Harm reduction is about choice, with the emphasis being put on personal responsibility, the other two models are about removing choice, the disease model could be said to absolve personal responsibility due to the concrete belief that addiction is a disease, therefore any “addict” or “alcoholic” is at the behest of a disease process which causes the sufferer to have cravings, and ensures that once they use their substance of choice they continue to use until they are intoxicated or causing physical/psychological harm to themselves. Within the Criminal Justice Model, again choice is removed from the service user, as they are either incarcerated, in which case they are removed from their supply, or through DTTO’ given a tariff that also involves forced treatment options on the pain of imprisonment when and if they do not comply(Rasool 2009) there is also the issues around the harm reduction agency facilitating an illegal act by facilitating the use of illegal substances, this argument can be seen in the various papers surrounding the setting up and running of “drug consumption rooms” and introducing needle exchange in a prison environment.

Do the two models compliment a harm reduction approach ?:

On initial examination the two models would seem to be at odds to a harm reduction approach, but to answer this question, we need to examine in more depth areas where all three of these concepts intersect, and the easiest topic to do this with is the current delivery of Blood Borne Virus Services within an addiction related context.

Blood Borne Viruses especially Hepatitis C and HIV have been an issue within the drug taking communities and the prisons that are more often than not a main fixture within their existence since the 1980’s.

The topic has been and continues to be an area of  research within academia, and in her book “ Aids in the UK : The making of policy 1981-1994: Virginia Berridge discusses how the issues around this encouraged the prisons within the UK to adopt  Opiate Replacement Therapy as a main tool to fight infection and reduce high risk behavior within the prison system in the 1980’s and 90’s, and the text from this era also indicates that injecting practice, and other high risk behavior was prevalent, which increased the risk of cross infection within the prison estate, with some of the respondents admitting in open questionnaires that they had indulged in risk behaviours whilst incarcerated. (Berridge 1996, WHO,1998).

This research and further discussions with the prison authorities led to Opiate Replacement Therapy being chosen as the main intervention to reduce these risk behaviours.

As with Prisons, and those incarcerated, HCV has also been an issue within the community with the incidence of HCV on the increase, especially within the drug using population. This issue has been deemed a priority by the Scottish Government who have produced two strategies to develop services Hepatitis C Action Plan (Scottish government 2006) which then developed into the Sexual Health and Blood Borne Virus Framework (Scottish Government 2011), which looked at all of the actions needed to deliver containment of what is a growing public health problem (Scottish Government 2006, 2011), inclusive of a section that was specific about Prevention,. In this section, it specifically looked at expectations around provision of services, and the expectation that services should complement each other.

The main thrust of these documents was to decrease risk behaviour in the community and increase access to preventative strategies including needle exchange and related therapies such as Opiate replacement therapy.

To achieve this various strategies were developed, which included the re-orientation of needle exchange to incorporate easier access to sterile equipment, more accessible testing processes, education about the issue and one of the few interventions that has spanned across all three areas without much disagreement has been that of using peers to deliver health, and harm reduction related messages, as well as Opiate replacement therapy.

Recent research has now highlighted that the combination of targeted prevention messages, and information on testing, has reduced transmission rates, and Peer education initiatives (Dolan et al 2004, Allman et al, 2006, Fisher et al, 2013, Moro et al 2013, Lianping et al 2013Weeks et al 2006), has been successful in delivering the relevant messages to target populations and reduced risk behaviour. Opiate Replacement Therapy has also been highlighted as an intervention, with roots in Harm reduction philosophy that has had a major impact on clients in both Public Health, and Criminal Justice environments, as it allows the service users to reduce risk by changing behavior around that risk, e.g.  sharing non-sterile equipment, by eliminating the risk taking.

Recent research suggests that ORT has been so successful in preventing onwards transmission of BBV within the prison environment that in the reports conclusion it suggests that there may be no need for needle exchange programs within Scottish prisons, it also suggests that this result is also due to other harm reduction strategies. (Taylor et al 2013). This trend of ORT and other Harm reduction strategies reducing ongoing transmission through high risk behaviours has also been witnessed in the general community, the NESI study & others indicated that a similar trend in the community of injecting drug users, suggested that ORT was one of the main contributors along with other strategies. (NESI 2012, Turner et al 2011).

Summary:

The question that was to be considered was Do criminal justice and/or public health interventions compliment a harm reduction approach to substance use and problems, and in order to do this we had to examine how and why we as a society view substance use the way we do, how this ultimately affected how we saw the problem , and as a result how this was developed into the conceptual ideas of the moral model and medical model to describe why people with substance use issues behaved in a certain way. We then examined how historically these concepts or models influenced the development of not only two distinct models, the disease model, and the moral model, but also how these models began to influence not only social concepts of addiction/ substance use, but also informed political and policy development in the western world. We then looked at how these historical ideals through globalisation led to the world acceptance of these concepts, and how this acceptance through the United nations conventions and declarations led to not only a prohibitive form on control through the development of legislation like our own Misuse of drugs Act 1971, but also how this “war on drugs” also led to, supported and normalised the continued medicalisation of drug use issues which has led to abstinence based policy statements like the road to recovery(Scottish Government 2008).

The next step of our exploration of the question examined how these two models viewed the harm reduction approach, and this concept and what it means in relation to the prohibitive and moral stance point of the medical and moral models, we also looked at how their is inherent tension between the traditional models and harm reduction due to the focus of harm reduction being on and this was explored looking at the issue of blood borne viruses, and how certain harm reduction approaches have been identified and utilised to control the spread of this condition, within the paradigms of the two traditional models, and their related interventions. We also briefly examined the research that has suggested that these identified harm reduction approaches, namely Opiate replacement therapy, and targeted prevention education utilising peer educators, has been seen to be as effective inside the criminal justice intervention that is incarceration, and also within public health where they are targeting substance use sub populations to facilitate total abstinence.

Conclusion:

Therefore when considering the question Do criminal justice and/or public health interventions compliment a harm reduction approach to substance use and problems, we have to suggest that in some cases these two  forms of intervention can complement the harm reduction approach, as outlined above, however we also have to concede that the two approaches that advocate criminal justice interventions and public health interventions i.e. the medical model and moral model, although fundamentally trying to do the same thing as harm reduction approaches, that is to protect the population from harm, are fundamentally different in outlook and design. We also have to concede that the two abstinence based models also in their own ways remove responsibility from people who use drug, and therefore by default remove ownership and responsibility for actions and behaviours as well. This again is a major difference that can only add to the tensions previously discussed, and this is evident when you examine the current debates around the introduction of drug consumption rooms in the community,( Lloyd & Godfrey 2010,Lloyd & Hunt 2007, Patel, 2007, McKeagney 2006, Rhodes et al 2006) or needle exchange programs within the prison (Taylor et al 2013). Therefore in conclusion it can be strongly suggested that some harm reduction approaches are complimented by Criminal Justice and Public Health Interventions, with the caveat that these harm reduction approaches can be effectively said to be within the letter of the law, i.e. are not encouraging the illicit injecting of illegal substances, or are not condoning use of illegal substances.

This discourse is well represented in research literature, (Lloyd & Godfrey 2010, Lloyd & Hunt 2007, Patel, 2007, McKeagney 2006, Rhodes et al 2006) and most famously was commented on by the Joseph rowntree trust in their 2006   paper “The Report of the Independent Working Group on Drug Consumption Rooms”

References

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Barclay et al, Royal College of Surgeons ( 2000) Drugs, Dilemmas and Choices, London Gaskell

 

Berridge V (1996) Aids in the UK: The Making of policy 1981-1994: Oxford University Press

 

Bloor M and Wood F. (1998) Addictions and Problem Drug Use: Issues in Behaviour, Policy and Practice,  London, Jessica Kingsley Publishers.

 

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Department of Health(England) and The Devolved Administrations(2007):Drug Misuse and dependence: UK Guidelines on Clinical Management London: The Department of Health (England),the Scottish Government, Welsh Assembly Government, and Northern Ireland Executive.

Ghodse H.  (1995): Drugs and Addictive Behaviour : A guide to treatment  2nd  Edition London Blackwell Science Ltd

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Hunt N. And Stevens A. (2004): Who’s Harm? Harm Reduction and the Shift to Coercion in UK Drug Policy, Social Policy & Society Vol 3 . (4) pp333-342

Independent Working Group (2006) : Drug Consumption Rooms, summary report of the Independent Working Group, Joseph Rowntree Foundation

Jellinek, E. M. (1960). The disease concept of alcoholism. New Brunswick, NJ: Hillhouse Press

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University West of Scotland et al. (2012) Needle Exchange Surveillance Initiative (NESI): prevalence of HCV and injecting risk behaviours among people who inject drugs attending injecting equipment provision services in Scotland, 2008/2009 & 2010.

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http://www.legislation.gov.uk/ukpga/1971/38/contents  Accessed on  8th May 2014 @ 20.13

 

To discuss  “Which type of treatment works best in treating those with substance use problems?” we first have to examine what is meant by treatment, and then look at what is currently used, and evaluate what if any of the techniques “work best”.

 Treatment within substance use, can be broadly split into two distinct phases, intervention, and  recovery maintenance. Intervention being the initial phase utilising assessment, intervention delivery and continuity planning including relapse  prevention/management, and  recovery maintenance encompasses the  process of recovery itself, relapse and if needed condition management if mental/physical health issues are identified.

 Intervention:

 Intervention for substance use issues are varied, and range from pharmacological Interventions for substance use related issues,(Barbor et al 2010) such as Methadone Replacement Therapy and Buprenorphine for opiate use to Disulafram and Campral for dependant alcohol use, to Cognitive Behavioural based interventions e.g. Health Behaviour Change and Motivational interviewing, and most often  both forms of intervention are utilised together initially (Rollnick et al 1999). The majority of these  are delivered within a “medical model” requiring assessment, and then some form of prescribed treatment plan which is controlled by the prescribing  or referring medical practitioner which has been described as social control (Naidoo & Wills 2000, Berridge 1999, Peele 1998). The underlying concept within this process is that of abstinence being the ultimate goal for treatment, reflecting back to the “Treatment works” statements from the treatment effectiveness review from the 1990’s (Berridge 2012). These interventions are all time limited, by the clients interaction with the treatment agency, traditionally only focusing on the short term contingency planning provided by practitioner who engaged with the client, which focused on problem solving, and basic cognitive behavioural work and possibly pharmacological input to prevent drinking (disulafram,) or block cravings (Accamposate).Once the engagement time came to an end the client was referred back to his or her GP, with contact information for mutual aid societies.The service would then “discharge” the client, and encourage them to utilise third sector, or 12 step recovery support networks..

Recovery Maintenance

Recovery, and it’s associated theories of personal development can be traced back to the idealology of the temperance movement, and the idea of the “inebriate” being controlled by the disease of Alcoholism, and that abstinence is the only cure.(Berridge 2012). The current concept can be directly traced to the Mental Health Recovery movement and Models such as the “Tidal Model”  (Barker 2005), and the government paper “Road to Recovery” (Scottish Government 2008) which looks at building capacity and helping service users move on from addiction, through personal development supporting the development of relapse prevention skills encouraging abstinence, and providing more of the long term support and behaviour change through Cognitive Behavioural based work, and group therapies. .
With the general acceptance of this concept, and the indication of government  acceptance of the concept as a way to deal with substance use(Scottish Government 2008) there has been growth in the third sector especially of recovery support organisations who advocate twelve step style models, with or without higher power involvement.
The development of community based rehabilitation , and recovery orientated systems of care, have further developed the treatment process, encouraging  the recovering substance user to ”re-define their identity” (SRN 2007)  on their journey to social re-integration.

Critique of current treatments:

 The close relationship to the use of the medical model in the intervention stage reinforces the age old paradigm of addiction/substance misuse as a disease, a torch which zealously reinforces the twelve step recovery model and is utilised by advocates of the model to forward their own process of recovery. This process is embroiled in a dichotomy of needing the treatment services to supply their members for their organisations, but decrying the importance of treatment in the overall journey for the client.

Many research papers have however suggested that the process utilised by twelve step based support is no more successful than similar psychosocial interventions, and indeed one paper in particular(Goebert & Nishimura 2011) suggests that Americans of ethnic origin, actually utilise other services such as marriage counselling, to gain the same insight into their substance related issues, and tend not to favour twelve step model services when moving into recovery, instead relying on their own social circles.

Assessment is one of the many pillars modern treatment is based upon(Department of Health 2007), the utilisation of  assessment tools which assess both substance use and social inequalities can be found within most services, however Shewan and Dalgarno (2005), suggested in their paper that the discourse between service use and clinician, can be one of reinforcement of the social structure both people find themselves in, so this piece of work as well as other research into addiction as a social construct .( Peele,1998, Davies 2008) suggests that assessment may be flawed for this reason, and may not be an accurate reflection of substance use problems.

Few researchers disagree with the fact that at one point in the service users treatment plan they may need some form of intervention, and again researchers also agree that in some cases involving alcohol use/ especially at the dependent level of use, pharmacological intervention is needed to safely detoxify the person from alcohol. What does however cause discussion is the role recovery services have in dealing with those who spontaneously recover (Sobell & Sobell 1996), and those who wish to continue reduced drug use during and throughout recovery.

Standard belief systems within treatment and recovery are based on the client wanting to become, and stay abstinent, and needing help from clinicians, and recovery support networks to maintain that abstinent state via mechanisms such as sponsorship, and devolving responsibility to higher powers. These systems do not allow for natural recovery and often refuse to engage with the idea that it exists.

Research has suggested that spontaneous recovery is indeed a more normal state of affairs than twelve step groups would have you believe (sobell & sobell 1996), and that one thing it has in common with supported recovery networks are robust social networks which allow the service user to move away from their substance using past, as well as a change in circumstance and expectation behind the initial substance use, (Zinberg 1986).

Conclusion:

In order to answer the question “Which type of treatment works best in treating those with substance use problems?” I have briefly examined treatment and its two constituent parts, looking at the research which has critiqued the current thoughts and theories behind intervention and recovery maintenance, and how some research actually highlights weaknesses within the current paradigm. I have however to offer a balanced view, and if you read the research around the use of recovery networks, and the recovery movement, it does indicate that recovery is sustainable, it also indicates that treatment as a whole needs recovery and person centred care to be at its centre.(SACDM 2008).

Research also suggests that both medicalised treatment and psychological treatments need to be considered in deed several government documents state within their text that psychological and medical treatments should be considered part of the overall pathway for treatment of substance use problems, (Department of Health 2007, SACDM 2007) also highlighting that the “focus of the clinician treating the drug misuse is on patients themselves” (Department of Health 2007,)

When seeking to answer the above question, it appears that not one size fits all as it were, if you examine the current treatment provision there are many different treatment pathways available to people with substance use issues. In fact within the text of “Alcohol, No Ordinary Commodity, research & public policy “ it is stated that “there are more than 40 therapeutic approaches” for dealing with alcohol problems,(Babor et al 2010) .With so many treatments being available, it would be impossible to decide which specific treatment works best, however, after looking at the research, and the various reports on the value of community support (Miller, Meyers &  Hiller-Sturmhöfel, 1999) and balancing the research and evidence, one theme  seems to be common throughout successful treatment, and that is the use of social networks, or recovery capital. Another main theme in the literature seems to be the suggestion that personal responsibility is also a considerable aid in completing treatment successfully. (Prochaska & Di Clemente 1986)

I therefore submit that in answer to the question “Which type of treatment works best in treating those with substance use problems,” I would suggest that any treatment that is inclusive of behaviour change ideas, focuses on facilitating a person’s own journey into recovery, and accesses evidence based interventions relevant for that clients specific needs based on a holistic assessment should be deemed an effective treatment.

References:

Babor T et al (2010): Alcohol, No ordinary Commodity: research and public policy 2nd Edition Oxford University Press Pan American Health Organisation. 

Barker, P.; Buchanan-Barker P. (2005). The Tidal Model: A Guide for Mental Health Professionals. London: Brunner-Routledge

 Barker P.; Barker, PJ (2008). “The Tidal Commitments: extending the value base of mental health recovery”. Journal of Psychiatric and Mental Health Nursing 15 (2): 93–100. 

Berridge V (2012): The rise, fall and revival of recovery in drug policy: Lancet. 2012 Jan 7; 379(9810):22-3

Davies J.B (2009): The Myth of Addiction 2nd Edition Routledge London

Department of Health (England) and the devolved administrations (2007): Drug Misuse and Dependence: UK Guidelines on Clinical Management. London

Goebert D, Nishimura S. (2011): Comparison of substance abuse treatment utilization and preferences among Native Hawaiians, Asian Americans and Euro Americans: Journal of Substance Use April 2011: No 16(2) pp 161-170

Gori G.B. (1996): Failings of the Disease Model of Addictions. Human Psychopharmacology Volume 11  pp S33-S3

Gossop M. (2007) Living with Drugs 6th Edition  Ashgate Publishing Ltd.

Merril J.C , Menza M. (2002): Treatment of Drug Dependence in the Context of Traditional Disease Treatment Models. Psychiatric Services, Volume 53, No 12 pp1632-1633

Miller W.R , Meyers R.J  &  Hiller-Sturmhöfel S,(1999) : The Community Reinforcement ApproachAlcohol Research & Health Vol.23, No 2. P 116-120

Naidoo J & Wills J (2000): Health Promotion: Foundation for Practice Second Edition  Balliere Tindall Edinburgh

Peele S (1998) The Meaning of Addiction: An Unconventional View (1998 edition). San Francisco: Jossey-Bass,

Prochaska, JO; DiClemente, CC (1986). . Toward a comprehensive model of change. In: Miller, WR; Heather, N. (eds.) Treating addictive behaviors: processes of change. New York: Plenum Press

Rollnick S, Marson P, Butler C (2000) Health Behaviour Change : A guide for Practitioners: Churchill Livingstone Edinburgh

Sobell L.C, Cunningham J.A, Sobell M.B (1996):Recovery from Alcohol with or without Treatment: Prevalence in Two Population Studies:The American Journal of Public Health, July 1996 Vol.86 no.7 pp 996-972

Scottish Advisory Commision on Drugs Misuse (2008): Essential Care: a report on the approach required to maximise opportunity for recovery from problem substance use in Scotland

Scottish Government (2008) The Road to Recovery: A new Approach to tackling Scotland’s Drug Problem, The Scottish Government Edinburgh

 Scottish Recovery Network / NHS Education Scotland(2008)  Scottish Recovery Learning Materials

Shewan D, Dalgarno (2005): Evidence for controlled heroin use?  Low levels of negative health and social outcomes among non treatment heroin users in Glasgow (Scotland): evidence for controlled heroin use ? : British Journal of Health Psychology Vol. 10 No 1  pp 33-48

Wildholm J.J (2010): Extinction as a Model of Drug Treatment and relapse; A Behavioural Overview. The Open Addiction Journal No3 pp57-62

Zinberg , N (1986) : Drug ,Set And Setting: The Basis For Controlled Intoxicant Use  Yale University Press.

 

 

Introduction:

Within this essay I am going to critically examine the evidence supporting the concept of the disease model, and I am also going to examine the research which counter acts this evidence. I am going to initially explore the development of the disease model of Addiction , then examine the process which allowed this model to dominate the area of drug use, and explore some of the arguments, social control, social construct, and the discourse that enforces these concepts which have been used to counter and discredit this model and how one of the most important factors “Spontaneous Recovery” calls the core concepts of this model into question.

Addiction: The Definition of a Disease.
For the purposes of this essay I am going to use the definition of Addiction as first muted by Benjamin Rush (1745-1813) and Thomas Trotter (1760-1832) who suggested that “alcoholism” & Substance Use could be viewed as a disease rather than as an issue which had its roots in loose moral fibre and weakness as the previous moral model of addiction had suggested.
Rush and Trotter suggested that drunkenness was a process of disease, a mental illness and as such displayed specific symptoms and was not a character flaw. Further weight was added to this concept of a disease of the will by Magnus Huss (1807-1890) in his book Alcoholismus Chronicus, or Chronic Alcohol Illness. A Contribution to the Study of Dyscrasias Based on my Personal Experience and the Experience of Others, in which the phrase alcoholism was first used, when in it he also highlighted symptoms of this new disease. According to the model “inebriety” (Courtwright 2005) has several main characteristic of this “disease of the will” and these were “loss of control”, or “craving”, and a progression of the disease, leading to an irreversibility of the problem which led to the person becoming addicted to a substance which made them an addict with a chronic condition that once treated, would always run risk of re-occurring. This model also suggested that the addict was different from the normal person, in a way that was reminiscent of the moral weakness that afflicted the drunkard of the moral model. Rush suggested abstinence was the only realistic cure to this disease, and this Disease concept, also relied on the “alcoholic” to see the need for change, and embrace the abstinence that would allow this change to happen. Rush suggested this could be achieved in “Sober Houses” or institutions where alcohol was banned.

The Development of the Disease Model
To understand the development of the disease model, we have to step backwards and briefly explore the moral model, and the influence it had on society.
This moral model perpetrated by the church suggested that alcohol was directly responsible for the ills of society, and the movement which grew out of this model, the temperance movement, advocated abstinence as the main treatment for this issue. This model also gave birth to the concept of the “Work Ethic” which was pushed by the church and the newly developing industrialists as the ideal, and that those in society should aspire to achieve this, stigmatising those who drank or used other drugs to extreme. Those who drank too much or utilised other substances, were deemed to be criminals and deviants and were treated as such. This work ethic which was the result of a redefinition of the traditional social order which had existed pre industrial revolution, where the relationship between society and substances was less prohibited acted as a social control on the use of substances, and the stigma around drunkenness, and in turn this social control also served as a social enforcement. The treatment with regards to this model was to repent the behaviour and the cause of it alcohol and embrace total temperance whilst promising not to drink again, on the pain of eternal damnation.

The Aetiology of the Disease Model

The disease model concept was developed when Physicians like Rush Trotter and Huss, began to feel that the traditional Moral Model and the concept of alcoholism being a sin perpetrated by the devil was not the answer. They also felt if alcoholism/addiction was a disease then it could be treated, and if it could be treated then and also as with other diseases it could be understood, and prevented. The new professionals utilised the process of scientific enquiry, to look at this issue, and identify what were the factors causing the disease, Huss being a good example of the use of this process, by utilising his research and observations from other physicians to coin the phrase alcoholism, and publish his work, All of this research identifying the core characteristics outlined above with all of the theorists suggesting the only treatment for the disease process of “inebriety” was abstinence, because the alcoholic would always be at the mercy of the need to drink, and the inability to control this drinking behaviour.

With the acceptance of the Disease Model the 19th and 20th centuries heralded the adoption of stricter prohibitionist legislation, which utilised this idea of an incurable illness to forward the introduction of the said legislation, and develop the concept of the drunk as being deviant and in need of treatment. This legitimised medical treatment, and also allowed the substance misuse to abdicate personal responsibility as they suffered a disease and as such any behaviour or misdemeanours were as a result of this disease process and not the person themselves. By the very nature of their social standing and the existing class system the new medical professions were inevitably supporters of the temperance message along with the temperance ideal and embraced this condition and used the spectre of addiction and “loss of control” to target other substances and ensure that their professions were the only ones qualified to treat this disease. The new medical based professions, Pharmacists and Physicians also used this new disease and the introduction of the dangerous drug acts (1920) for example which targeted the sale and prescription of opium ( Berridge 1999) to professionalise the concept of addiction, and introduce the idea that substance misuse, and the resulting bad behaviour could only be treated legally by them, in effect beginning medicalization of this issue, a concept of addiction which society still uses today. Whilst in Britain the temperance influence produced strict regulatory apparatus, in the United States the temperance movement used this model to forward the Temperance cause so successfully that in 1920 the use of alcohol was banned nationally in the US resulting in the prohibition of alcohol from 1920 To 1933.This period allowed the concept of the disease of addiction to be further ingrained into the general populations psyche, by the demonisation of addiction, alcohol in particular and its use, although the concept of addiction being a disease, and the idea of drug induced addiction was beginning to take on a more racist base, with cannabis(marihuana) and opium in the US and UK respectively, being linked with immigrants , and the spectre of drug use and addiction being used to demonize and marginalize immigrant populations. This process was also used as a vehicle to to introduce more prohibitionist legislation, the Harrison Act (1914) and the Defence of the Realm Acts (1915) (Gossop 2007) The media was also used to reinforce and further disperse the desired image of the addict as being a diseased person who can’t control their behaviour when confronted with their choice of drug by creating a moral panic utilizing the press and film industry, publishing story lines playing on the fears of the WASP majority, scape- goating the targeted populations and making films which added to the already growing myth around addiction as a disease which afflicted those who were different.
In Britain, stories were rife in the press suggesting that Chinese immigrants were responsible for the corruption of single females, and the proliferation of “opium dens”, a topic backed up by “Fu Man Chu “ stories, which were incidentally made into films in the fifties and sixties , with the undercurrent of the “yellow peril” still unaltered in the modern adaptations.

With the repeal of Prohibition in 1932, and the resumption of normal drinking patterns, but without the increase in “Alcoholics”, The temperance movement were forced to re evaluate the disease model, and EM Jellinek with funding from Marti Mann and the help of members of Alcoholics Anonymous carried out research in 1946 which resulted in his book in 1960“The Disease Concept of Alcoholism” in which he further reinforced the concept of alcoholism as a disease by his classification of the types of alcoholic identified in his 1946 study. This book also started to separate Alcohol as a substance from that of other drugs (Ref) and slowly began the process of moving the 12 step process into the realm of treatment provision, and began to perpetrate the modern concept and discourse of what addiction is, but more importantly what the concept of recovery within addiction was.

Again as with Rush and Trotters concept, within this version of the model Abstinence was the only true treatment, but this time with the use of the added support of peers, as provided by AA, the AA movement also suggested that the “alcoholic “ would always be an alcoholic, and this very statement began the discourse, and reinforced the construct of Alcoholism being a disease with its own specific mysticism, and process that only alcoholics could understand, further reinforcing the concept of the alcoholic being different from other “normal people “adding to the already common belief that the disease was an entity in its own right.
There was also a more concerted move by the authorities, towards the inclusion of other substances into the model, and the concept of drug induced addiction, or the one hit and your addicted concept began to gain more acceptances in the eyes of the general public. This move by the apparatus that originally was set up to police prohibition, mainly driven by Henry Anslinger also began to utilise the concept of ethnic minorities and the relationship of these populations with certain drugs to perpetrate the concept of race related addiction , with the stereo types already mentioned previously, and this became a form of covert social control, utilising a similar process of demonization,and the resulting moral panic to force further prohibition as the moral model had used religion and the threat damnation to advance social control centuries earlier. With the added development of the expert addict, and the discourse that this provided to the public backing up the ideas of Jellinek and the disease model as a whole was beginning to resemble what today we see as the condition of Addiction.

As outlined in the brief history above, the concept of addiction as a disease arose at the beginning of the 19th century, and can trace it’s routes through to E M Jellinek in the 1940’s as well as the research into discovering a genetic cause for addiction, which could be said to be the modern arm of the existing disease model.
These differing versions of the model, all have one major factor in common, and that is the main core concepts of the model, which subscribe the process of addiction being caused from within the addicted person. They also all suggest that addiction is a discrete commodity, as previously touched on and I would suggest that the modern day compulsion to explore the human G-Nome for genetic markers for all sorts of diseases, inclusive of the search for a definitive causal gene for addiction is a direct extension of this centuries old concept of an addiction disease process. This eugenic approach, is very similar to the older concept of inebriety in such that, it aspires to remove the locus of control from the addiction sufferer, and put it squarely in the realms of medicalised treatment, in effect removing all emphasis from the actions of the substance user, and laying the blame for their subsequent actions and behaviours onto a disease process, which they are susceptible to because of their genes, which has predisposed them to suffering from, or caused them to become addicted. So is it any different from the disease of inebriety, and moral weakness?

Addiction as a Disease : Proof of a Myth

There are many factors which have led to this concept being one of the most popular explanations, and we can also see that over the years, many agendas and professions have spawned from the concept of addiction being a disease. These concepts with some revision have becoming all encompassing, Initially the research from the 18th & 19th centuries, which posed the concept of inebriation, and Rush’s disease of the will, backed up by the writings of Huss and then E M Jellinek and his research in the 1940,s all produced a more scientific explanation for the disease of Addiction by utilising research practice to identify the progressive nature of the disease. This concept of an internal disease process, backed up all of the thoughts and reductionist ideals of 18th, 19th and early 20th century medicine as the scientific inquiries focused on finding a central cure for the problem of substance misuse. The expert patient, testimonies backed up by the recovering “alcoholics” and substance misusers from Alcoholics anonymous, and other peer support/12 step based groups only added weight to these scientific inquiries. This is the basic concept on which modern disease theory is based, it portrays alcoholism, as a chronic disease, ideas that are backed up by researchers such as White et al (2008), and policy documents such as the road to recovery( Scottish Government 2008) all of which in their own ways reinforce this idea within the public domain. These ideas have very close resemblance to the original ideas of the 12 step movement, and preach abstinence as the only solution, the document “Road to Recovery” actually talks about “moving towards an approach to tackling problem drug use in Scotland based firmly on recovery.” and about guiding substance users “towards a drug-free life” phrases that hint towards the ultimate goal of a drug free society, which can only be achieved through abstinence.

The concept of abstinence being the only cure for addiction, and the equally popular concept of drug induced addiction, are the disease models down fall.
The disease model relies on the core elements as highlighted at the beginning of the essay which are “loss of control”, “craving”, the progression of the disease, leading to an irreversibility of the disease, and the idea of addiction in some way being intrinsic to the sufferer. All factors whose validity has come under scrutiny from behaviourists and sociologists who suggest that the disease model is more myth than fact (Peele,1998 Szaz 1996, Alexander,2002, Schaler 1991 , MacAndrew & Edgerton 1969 & Gori 1996).They all in fact suggest that this model is no more than a social construct, or a form of Social Control.

The first of the many areas of research that have cast doubt on the model was the studies of MacAndrew and Edgerton into drunken comportment in 1961. This study was a large scale study, which looked at drinking culture across a number of societies, inclusive of primitive and industrialised ones. The study concentrated on how a society interpreted the concept of intoxication, and how they acted whilst being drunk. This study suggested that the common perception of the drunk being seen as a deviant, and alcohol being responsible for criminality within society was proven not to be as common as was indicated by the disease model. MacAndrew and Edgerton observed that the behaviour of the intoxicated person was governed by how society expected them to behave, and inevitably in society where expectations were negative, then the resulting behaviour was negative, it was also noted by the study, that in most societies the expectation of the society and the resultant acceptable behaviour when intoxicated fell within that societies idea of normal drinking behaviour. So the idea of intoxication and addiction through drug use, was deemed to be an exception rather than a norm. Stanton Peele has also suggested in many articles that addiction rather than being a disease was more to do with the persons experiences and life themes, which also included the ability to spontaneously recover from excessive substance use and maintain controlled drinking which indicates the usefulness of harm reduction within addiction, concepts which are totally at odds with the core concepts of the disease model, irreversibility and uncontrollable drinking as advocated across the previous three hundred years by addiction treatments. His work also discusses the validity of denial as part of the overall disease model, and likens it to “a web” (Peele 1996) which only acts as a reinforcement of the model, which suggests that the very discourse involved in the disease model, as touched on earlier, which is specific to twelve step models is self fulfilling in that it “brainwashes” the subject into believing that they are incapable of dealing with their addiction without the support of the other “brothers” in recovery.
Davies in his book The Myth of Addiction (2009) also discusses the use of discourse within the disease model of addiction , suggesting that the very nature of this discourse, and the way it is used between practitioners and clients, reinforces the specific roles of the of the two opposing groups. He suggested that substance users learn the specific language of the disease model, and they also learn how to manipulate this language to maintain their identity as addicts. This is supported by the practitioners who prime the substance users by asking specific questions, expecting the learned responses from the user, which then adds validity to the whole exchange. This suggests that the whole disease model of addiction is a construct between two individual groups, which legitamises the treatment and stigmatisation endured by one of the groups, and reinforces the concept of the addicted person being different from the general population, the suggested discrete entity of addiction, which is part of the core concept of the disease model.
The idea of professional constructs has also been voiced and championed by Thomas Szasz,(1920-2012) who consistently suggested that the idea of the disease of addiction as part of the trend for the medicalisation of bad habits, suggesting that the concept of a disease that is addiction is a way of utilising social control, and that the disease concept basically allows governments to enforce treatment , and this treatment paradigm allows for the creation and support of the treatment industry. He also suggests that addiction is a form of scapegoating utilised to maintain social control, a similar idea to the use of peer support to maintain the concept of recovery amongst 12 step societies. He also constantly refers to the inability of researchers to identify the cause of the uncontrollable excessive use an idea which has been explored by Gori (1996) in a paper which looked specifically at the failures of the disease model. Within this paper Gori discusses the ambiguity of the definitions as used by the world health organisation, and the moral attachment of the language in the definitions from WHO and how this allows treatment to be loosely prescribed, which in turn can be “subject to Social & moral Sanctions,” hinting at the religious overtones of treatment, and the disease model itself.

Conclusion:

Within this essay I have explored the idea of addiction as a disease, exploring the model from its beginning through to its modern incarnation. From the ideals of forward thinking professionals, to the voices of a few of the many critics of the idea of addiction as a disease. I have attempted to show how the ideas of commentators like Szasz , Peele and others have attempted to highlight inconsistencies, and dangerous assumptions within the model, and how the core concepts can be explained by other means. The one idea that has been constant through out this essay has been the idea that the disease model is a construct utilised to explain the condition of addiction. We have seen how traditionalist medical model users such as Trotter, Rush and Huss utilised it to try and explain addiction in a more understandable way than the previous moral model had. I also feel that they were trying to de stigmatise the idea of addiction and find a way to help those afflicted. We then saw how this model then developed into a tool for social control, with the use of scientific enquiry and the perpetration of the myth around the core concepts of the model and how organisations and governments manipulated the ideas of society towards addiction, and the resultant stigmatisation of those who become addicted high lighting how the disease model is in deed a modernised version of the moral model, with a new lexicon allowing a new set of professionals to take over from the original perpetrators of social control, the churches and the industrial complex.

References:

Alexander B.K (2000) The Myth of Drug Induced Addiction sourced on 20/12/2012 from
http://www,parl.ga.ca/content?SEN/Committee/371/ille/presentation/alexendar-e.htm

Anderson T.L. (1993) Types of Identity transformation in Drug-Using and Recovery Careers.Sociology focus Volume 26, No2.

Davies J.B (2009): The Myth of Addiction 2nd Edition Routledge London.

Courtwright D.T.(2005):Mr.ATOD’s wild ride: What do Alcohol, Tobacco and Other Drugs have in Common?: The Social History of Alcohol and Drugs No 20m, pp 105-40

Gartner C.E., Carter A., Partridge B. (2012) : What are the public policy implications of a neurobiological view of addiction: Addiction No 107, pp 1199-1200

Gori G.B. (1996): Failings of the Disease Model of Addictions., Human Psychopharmacology Volume 11 pp S33-S3

Gossop M. (2007) Living with Drugs 6th Edition Ashgate Publishing Ltd.

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Hyman S.E (2007) The Neurobiology of Addiction: Implications for Voluntary Control of Behaviour: The American Journal of Bioethics, No 7(1), pp 8-11

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Merril J.C , Menza M. (2002): Treatment of Drug Dependence in the Context of Traditional Disease Treatment Models. Psychiatric Services, Volume 53, No 12 pp1632-1633

Peele S (1998) The Meaning of Addiction: An Unconventional View (1998 edition). San Francisco: Jossey-Bass,

Scottish Government (2008) The Road to Recovery: A new Approach to tackling Scotland’s Drug Problem, The Scottish Government Edinburgh

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“Can a person spontaneously recover from Heroin Addiction?”
An interesting question!
Spontaneous recovery from substances misuse appears more common than many people initially think, but acceptance of whether this concept exists is dependent on whether you believe that addiction is based in a purely medical/disease model, or whether your are more inclined to believe that addiction is a sum of many parts as it were, i.e. it is a manifestation of greater psycho-social issues that affect the individual collectively.
Medical/Disease Model:
If you subscribe to this model, then spontaneous recovery will not exist. The medical model relies on Addiction being seen and accepted as a disease, and at the very core of this model is the almost zealot like belief that addiction is a disease and as such has symptoms and a prognosis. Also embedded in this conceptual framework, is the belief that once the person has succumbed to the ravishes of addiction, they are always an addict, and at the mercy of this disease.
Advocates of this conceptual construct would also suggest that the only treatment for this “disease” is a medicalised one, and the only real “treatment” is abstinence.
It is therefore not surprising that followers of this particular construct would be more than happy to argue that the concept of “Spontaneous Recovery” as it is almost heresy to suggest that an addict can “cure” themselves.
A believer would argue that this concept of “self-management” hence “self-treatment” & “self-cure” is near impossible due to the all encompassing “cravings” that the addict suffers from which makes them unable to refuse, or stop taking their substance of choice even when their health both mental and physical depends on stopping.
They would also suggest that the very real nature of this “craving” & its resultant threat to successful medical management of the symptoms resulted in the development of replacement therapies such as Methadone Replacement Therapy, and pharmacological interventions such as Disulafram, Campral and Suboxone. These interventions, which have incidentally all been scientifically tested via years of clinical trials, and have been proved by researchers to do as they say on the box as it were, that is to help addicts/service users negate “cravings” provide scientific proof that addiction is a disease. Therefore “spontaneous Recovery” does not, cannot exist.
Some proponents of this model would also go as far to suggest that those who claim to have suffered from an addiction, and to have “spontaneously recovered” are not “really suffering from an addiction” and are not real “addicts” so their opinions and stories are not “valid”.
All convincing arguments, but we must also consider the wider picture around this argument.
It is well known, and written about by academics like Berridge that the Disease Model has its roots in the earlier Moral model. Like this model, the disease/medical model relies on utilising and informing public opinion. These opinions allow the model to be sustained and legitimised which combines to form an almost evangelical layer to its use by the public and politicians.
From this legitimacy has sprung treatment centres, pharmacology research and development, and specific professions in an ever expanding industry. All good reasons not to examine or think about an anomaly called “spontaneous recovery.”
Psychosocial Model
Earlier I mentioned the Psychosocial Model, and indicated that followers of this school of thought may view this model differently, and it is my suggestion that they would argue almost as religiously for “spontaneous recovery” as the “medicalists” would against it.
Psychosocialists would argue that as their construct for addiction looks upon the issue as a life choice, all be it a bad one, which is influenced by society, environment and the psychological makeup of the substance user, then the inclusion of this concept into their construct is fundamental.
Psychosocialists believe that addiction is a choice which is made by the individual. This choice is then influenced by the subjects psychology, environment, social discourse both personally and societal, and other factors such as physical / mental health, developmental abnormalities and learned behaviour.
All of these issue are relevant to the development of addiction; therefore psychosocialists accept the concept of a natural limit to an addictive episode exists and that “spontaneous recovery” is the proof of this concept.
They also argue that learned behaviour, especially within close knit sub cultures can explain why you have families who seem to be “blighted” by addiction, the argument being that within a family were drug use is normalised, and accepted, that family will inevitably be part of a larger sub group that is isolated by a concept of deviance(behaviour outside the host societies accepted norm)then there is a lack of positive reinforcement , that is found in normal society which may negate the negative behaviour(drug use). The argument is that this learned behaviour would mimic genetic disposition, “alcoholism is genetic, sons of heavy drinkers are heavy drinkers themselves”, especially in the family group as described.
So back to the question, can a person recover spontaneously from a heroin addiction?
Yes is the answer.
People change for various reason but what seems to be most effective is if they change for themselves. As a young staff nurse ,fresh out of the wards, I was advised by my first addictions charge nurse, that folk who change because they are told to, or “for others” will inevitably relapse, however those who change for themselves or for a reason that is personal to themselves will inevitably always succeed. This is apparent when you look at Prochaska & Di Clemente’s model of change or Rollnick’s thoughts on Motivational Interviewing, the central concept in both is based on the person developing their own personal discourse on change and accepting it.
So I would suggest that a person with an opiate addiction, as with any other, can recover naturally if their internal discourse is personal and relevant to them.
This personal discourse also has to offer the client a powerful personal “buy in” which in the case of a client with a heroin addiction could be the result of criminal justice proceedings or violent injury.
This “buy in” however has to offer the person some validation of the change they want to make, and is valued and desired by the person, and this discourse is maybe the thing that is missing in the person who is being coerced into change by the belief that they are doing it for an external person thing or reason.

Question: Is Drug Policy Evidence Based ?

Introduction:

Drug Policies are a common feature of public health programmes world wide, and the question I have chosen to discuss in my essay is “Is Drug Policy Evidence Based”.
Every nation in the world will have some kind of drug policy, designed to protect their population from the harm that can be associated by the use of drugs either illicit or licit. This world wide  movement can be traced back to the emergence of the concept of capitalism in the 16th Century , just as western nations were taking their first tentative steps at colonisation and imperial expansion.
King James 1 with his “counterblast against Tobacco” could be cited as being the first attempt in Britain at controlling a substance with a policy of taxation (Barclay et al 2000), although within the Muslim world, alcohol had been controlled for centuries due to religious ideologies.
If we look at Britain specifically, there then followed a raft of substance control legislation , from the Gin Acts 1729  and 1736 (Barclay et al 2000), through the Pharmacy Act 1868 , Defence of The Realm Act 1914,and the Dangerous Drugs Act 1920 (Barclay et al 2000 and Rasool 2009) up to the recent Misuse of Drugs Act in 1971. All designed to control how the population used substances, and introduced to prevent substance related problems.  Globally, a Prohibitive Policy Structure has been followed since the inception of the United Nations Single Convention on Narcotic Drugs in 1961 which effectively declared a “war on drugs”, encouraging all member states to adopt a prohibitive stance within their local drug policies. This stance was further compounded by the Convention on Psychotropic Substances in 1971 and an amendment to the original 1961 convention in 1972.

We then need to ask, were these policies and legislation research based, and the evidence scientifically scrutinised, or were the legislation, and the policies that followed a way of forwarding another agenda.

Prohibition Vs  Decriminalisation/Legalisation:

Various nations have their own interpetation of the UN policy, and more locally, the UK uses the Misuse of Drugs Act 1971 as it’s main stay in the attempts to prohibit the use of controlled and illicit substances, (Barclay et al 2000), in effect criminalising the use of drugs which are used and accessed outside state control in line with the original 1961 UNDOC convention which looked to “limiting such drugs to medical and scientific use” (UNODC 1961)
In order to examine the question “Is Drug Policy Evidence Based ? “ we have to examine and contrast the two opposite stances, and as no country world wide has yet legalised the use of psychoactive substances we have to look at countries like Portugal who decriminalised all drugs in 2001 and Holland who has a more liberal attitude to drug use  and compare these policies with the UK who has a more prohibitive policy in place. To compare theses policies, we have to focus on a specific area, and examine the research followed, and how this research is transferred into policy.

Drug Consumption Rooms

Policies whether liberal, or prohibitive effect the population that they are used to protect and guide. Prohibitive policies are no different.

It could be said that whilst a prohibitive drugs policy designed to reduce consumption by preventing supply by using legal and social sanctions, it can at the same time isolate and marginalise sections of the population it intends to protect and all policies can have unintended outcomes as well as the intended ones.

In 2004, an Independent Working Group was established by the Joseph Rowntree Foundation, to look into, and gather evidence for the use of Drug Consumption Rooms, and their effects on the Drug Related Deaths due to overdose. The working group investigated, and visited sites throughout Europe, Australia and Canada, and looked at the current research, and published their findings, which were passed to the UK government, who rejected the findings “ for a number of reasons including lack of evidence , legal concerns, likely media and public hostility”. (IWG 2006)
The findings that were reported to the government at the time, included evidence that the introduction of these rooms would reduce the number of deaths, increase access to services, and lead to a decrease in blood borne virus cross infection.
Which were all issues which linked in to the “increasing emphasis within the Government drug policy on reducing harm” (IWG 2006 )

This seem s to be an interesting stance, when initially at the outset of the HIV epidemic in the early eighties, the UK government was among the first to encourage the use of Harm Reduction to combat the spread of HIV/Aids, and pioneered the introduction of Needle Exchanges, which has been instrumental in preventing an epidemic of HIV in the UK, but the same governmental apparatus seems to be resistant to the next “rational and overdue extension to the harm reduction policy.” (IWG 2006)

The more liberalised policies of some countries may be seen as allowing the move towards DCR’s , but as the IWG pointed out, the issues raised by the government for not adopting this policy were dealt with within the report, and the process used to gather information to formulate the findings. (IWG 2006)

As touched on previously, the historical context for drug control has always been that of prohibition, with the emphasis slowly shifting from a “voluntary “concept of control, prior to 1862, to a more coercive framework. This has been evident from the dawn of “New Labour” , who began to change terminology, to the point where “drug policy discourse of the New Labour Government largely focused on  drugs as an engine of crime” ( Hunt & Stevens 2004), this policy shift could maybe explain why the above issues have mainly fallen on deaf ears as it were.

The moral dimension of UK Policy

In a paper by Trevor Bennet and Kate Holloway, the two authors of the paper undertook a study looking at the above question,” Is drug policy evidenced based “but principally concentrating on current british policy & strategy and they studied case studies drawn from the four main strands of the current drug strategy to evaluate whether the strategy had its roots firmly in scientifically researched information. Out of the four main strands, almost all of three out of the four, had been grounded in , and could be linked to research around the subject, although on some of the flagship policy areas, there were some disparities on the way the research was used.  In the reclassification of cannabis, the government had basically based the decision on good strong reliable evidence, where it fell down was on how it had reported the findings of the evidence. (Bennet & Holloway 2010)
It was also apparent in some of the other case studies that some of the policy decisions were made prior to the publishing of the evidence “cited in the policy”. (Bennett & Holloway 2010)

Looking at this document, and taking into account the four main streams of strategy that the authors talk about, which are 1.  Protecting Communities through enforcement, 2. Preventing Harm to children, young people and families, 3. Delivering new approaches to drug treatment, and 4. Implementing public information campaigns, only one of the objectives nearly met all of the criteria, and this was the case study looking at cannabis re classification, and interestingly the other top scoring objective was objective 3 which looked at Dedicated Drug Courts. Interestingly enough both objective case studies were related to the coercive approach, of utilising criminal justice services to enforce policy, namely the enforcement of the re-classification of cannabis by the Misuse of drugs Act 1971, and the enforced treatment of repeating offenders with drug related criminal activities. This again hinting at a more hard-line doctrine within the government and policy producing apparatus. Therefore it could be argued that the government did not base the decision not to use Drug Consumption Rooms purely on the evidence in front of them but on an ideological stance as prescribed by previous governments.

Decriminalisation:

As we have seen , the UK at present prefers to use a prohibitive policy  stance when looking to protect our population from the harms of drugs, and as discussed, the majority of countries within Europe also subscribe to a prohibitive policy of drug control, there are however two exceptions to this , namely Portugal and the Netherlands. 
Both countries have embraced decriminalisation, The Netherlands in a limited form (mainly cannabis), and Portugal, almost exclusively.

The Netherlands & Cannabis.
The Netherlands has had  a unique policy, for many years. This is mainly due to the  way that the Dutch have distinguished between “Hard Drugs” & “Soft Drugs” , and the policy relationship built upon these definitions.
In the late 1970’s, the Dutch government formed a commission to inform, and advise on drug policy, called the Baan Committee, then published a report in 1976, which suggested that the definition of hard drugs and Soft drugs should be specific, this report was used to develop amendments to the Dutch opium act of 1919. The new amendment split the drugs available into schedule 1 and schedule2 drugs, based on the level of harm to health.  Schedule 1 covering substances such as heroin and cocaine, and “Hemp products such as Hashish and marijuana or “Soft Drugs” on Schedule 2 (Bloor et al 1998). This change in legislation, also increased the ease with which enforcement agencies could track and prosecute large scale importers, and with the addition of recognising the “expediency principle”  in effect decriminalised cannabis at street level, for recreational users as prosecutors would only pursue prosecutions that were in the public interest,(Bloor et al 1998) e.g. large scale traffickers not small time recreational users.
This model throughout the world at present is now held up as a possible alternative to total prohibition.

The UK and Cannabis

Interestingly, a similar approach was taken by the UK in 2004 when the then government re-classified cannabis to a class C drug on recommendations from the ACMD which led to the substance being reduced to category C within the Misuse of Drugs Act 1971. This was after the police commissioner in Brixton, had announced that his officers would no longer be arresting people for possession for personal use in 2001, and after the then Home Secretary David Blunkett had backed the “decriminalization” of  amounts for personal use This was when it was noted that 75% of drug arrests for possession were for possession of Marijuana. (King & Mauer 2006). Blunkett also went on to comment in further discourse “ this policy will permit Britain to concentrate efforts on the drugs that cause the most harm” (King & Mauer 2006).
As with most democratic states, the person in charge usually changes, as was the case when the prime minister at the time  moved on, and the Deputy Prime Minister, Gordon Brown took over the reins of power, this led to a renewed debate around the classification of this substance in 2007 based on its perceived dangers, and links to psychosis. A committee was established in December 2007 to examine all the evidence around the areas in discussion at the time, e.g. “ The Gateway Theory, Links to poor mental health, and potency to name a few.
“The outcome of the report was that the committee found “no compelling new evidence which would require the ACMD to alter its recommendation in 2006 to keep cannabis classified as Class C.” (UKDPC 2008), however Gordon Brown did follow through with the reclassification of the drug, in a very public way, against the advice within the report, with some of the media suggesting he was taking a “moral stance” against the drug.

Conclusion:

The question “Is Drug Policy Evidence Based?” may initially seem an innocuous, and simple question, but when you look deeper, it becomes evident that there is more at play when developing a drug policy than just discussing conceptual ideas around societies needs and the resulting protection of that society from spectres and monsters in the form of society destroying illicit substances.
When you examine in a micro way two or three initially straight forward seeming policy decisions, you see that political idealology also plays a big part in policy making as does the personal attitudes of the politicians.
Within this essay I have discussed several examples of policy decisions, made with the assumption of the general public, on good scientifically presented evidence, but under scrutiny, you see that in some cases, specifically with the example of the Drug Consumption rooms, and with the declassification then the reclassification of Cannabis, you can see a certain pattern of disinformation, arising when the information goes against the overall prohibitive stance taken by the government.
The United Nations Convention of 1961 was a prohibitive statement, but built within the convention is article 38, which allows the ratifying governments to “take all practicable measures for the prevention of abuse of drugs and for the early identification, treatment, education, after-care, rehabilitation  and social reintegration of the persons involved”, underlining the crucial  role of health and social interventions.”( UNODC 1961) This policy also enshrines the concept of policies designed around scientific research to enable the signatories to have fit for purpose  policies to protect their populations, and it could be suggested that in recent years, due to the influences of historical and artificially heightened public opinion around illicit drugs, and the use of combatitive language with regards to the policy of the “war on Drugs”, that in some way, this over arching concept of a policy fit for purpose has been lost in the quagmire of political and in some cases personal moral crusades against drug use and the population that uses the substances.
This is evident in the examples of policy decision cited in this essay, firstly drug consumption rooms, and the lack of enthusiasm for the UK government to accept and push forward in the words of the reporting commission “ a rational and overdue extension to the harm reduction policy.” (IWG 2006), again this is interesting due to the ground breaking policies in HIV harm reduction piloted by the UK in the eighties and then Cannabis re-classification debate of 2004-07 and the blatant disregard for the report by the UKDPC which backed up the classification of cannabis remaining at Class C when the Prime Minister of the time upgraded the classification , not only for what would appear to be personal moral reasons, but to reinforce a policy stance inherited by him from his predecessor. These facts in conjunction with many other instances which have not been discussed here, like the use of minimal pricing on alcohol, and the large cost of enforcing interdiction for small return, all suggest policy does not follow evidence based research, therefore drug policy could be deemed not to be principally based on evidence gathered by research, unless it fits in with already preconceived policy ideas e.g.  The coercive treatment approach as previously discussed within this easy.

References

Anderson S. and Berridge V. (2000): Opium in 20th Century Britain: Pharmacist’s regulation & the people, Addiction Vol.95 (1)

Barclay et al, Royal College of Surgeons ( 2000) Drugs, Dilemmas and Choices, London Gaskell

Bennet T. and Holloway K. (2010): Is UK Drug Policy evidence based ?, International Journal on Drug Policy  Vol. 21 pp 411-417

Hunt N. And Stevens A. (2004): Whose Harm? Harm Reduction and the Shift to Coercion in UK Drug Policy, Social Policy & Society Vol 3 . (4) pp333-342

Independant Working Group (2004) : Drug Consumption Rooms , summary report of the Independant Working Group , Joseph Rowntree Foundation

King R.S and Mauer M. (2006): The war on marijuana: The transformation of the war on drugs in the 1990’s: Harm Reduction Journal Vol 3 (6)

Rassool G.H., (2009): Alcohol & Drug Misuse: A handbook for Students and Health
Professionals,  Abingdon: Routledge

Bloor M and Wood F. (1998) Addictions and Problem Drug Use: Issues in Behaviour, Policy and Practice,  London, Jessica Kingsley Publishers.

United Nations Office on Drugs and Crime (UNODC) (1961): Single Convention on Narcotic Drugs 1961(amended in 1972), United Nations New York

Bibliography

Buchanan J and Young L ( 2000): The War on Drugs-A war on drug users?. Drugs :education, prevention & policy Vol.7 No4

Des Jarlais D.C (1995) :Editorial: Harm Reduction-A Framework for Incorporating Science into Drug Policy, American Journal of Public Health Vol 85. No 1