Posts Tagged ‘addiction’


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. (

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).


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.


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”


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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 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).


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.


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