More questions than answers

As he prepares to leave the substance problems field, George Allan poses a few questions and fires some parting shots.

Has the recovery movement been beneficial?
Recovery as the model for service delivery has dominated the discourse for the last decade – but has this been a good thing? There is much on the positive side: it has challenged the negative mantra that substance problems are ‘a chronic relapsing condition’, it has encouraged the emergence of support networks and attendant activities and it has been a driver for incorporating reintegration into mainstream services.

Aspects of the recovery agenda have, however, had a detrimental influence. An alliance of treatment ideologues – politicians for whom evidence appears to be irrelevant and celebrities determined to persuade others that what has helped them is right for everyone – has promoted an anti-treatment, abstinence-only narrative. Harm reduction has been side-lined in some areas and this has had consequences.

While it would be simplistic to blame the rise in drug deaths on recovery (the ageing cohort of vulnerable users was always going to be a challenge), the anti-OST agenda hasn’t helped. Far from many being ‘parked on methadone’, there is clear evidence that people are often not staying on OST long enough and dropping out of services too quickly to ensure stabilisation, with the attendant increased risk of overdose.

As this becomes more evident, a rebalancing is in the offing. Scotland is looking to a ‘seek, keep, treat’ model to reduce drug deaths. Can we avoid the mistakes of the past by making the shift to addressing the needs of the most vulnerable without losing the gains which recovery has brought to those who feel able to move on?

Why do we pay so little attention to ‘endings’?
In the light of the need to retain some people in treatment for longer, it is alarming that we give little attention to dropout and the wider processes of ‘endings’, both planned and unplanned. A plea to the research community – let’s look more closely at endings in all their shapes and forms.

Whatever happened to controlled drinking?
Around 1980, as the dust settled on the Mark and Linda Sobell affair and the controversies surrounding research that suggested some people with significant problems with alcohol could achieve harm-free consumption, some services began to provide controlled drinking as an option. The agency I was working for was one of these. It had clear guidelines regarding suitability and a controlled drinking programme aimed to help the person to achieve non-problematic use. Few now talk about controlled drinking. There is plenty of guidance on brief interventions, whose goal is nudging risky drinkers towards moderating their consumption. But what about rigorous, individualised controlled drinking programmes? Are they still going on out there under the radar?

How can we enable people to regain a stake in society?
Reintegration means different things to different people but, for many, obtaining paid employment remains just an aspiration. There are many projects preparing people through volunteering and ‘job ready’ programmes, but few which open the door to actual jobs. There are shining examples, including some social enterprises, but the numbers gaining employment are small. One way to increase volume could be to engage with large scale employers who would provide training and subsequent jobs, with substance problems agencies supplying personal support over an agreed timescale. The employer bears the training costs but, in return, has the reassurance, as does the person themselves, that any difficulties will be addressed: a win for all. Piloting such a model on a significant scale is overdue.

Is stigma ever helpful?
The effects of stigma are well documented: it reinforces a negative self- image, erodes self-confidence and can serve to militate against change. But is it always counterproductive? Neil McKeganey was shouted down in the pages of DDN when he suggested that it wasn’t. Far be it for me to defend him, but the critics missed his point. At a societal level, we define what is acceptable behaviour by stigmatising what is unacceptable. The trick, of course, is to censure certain actions (eg public drunkenness; sharing needles) while trying to avoid defining the individual solely by their behaviour – a subtle distinction nigh on impossible to maintain in the real world. Stigma is also about the use of language, of course, which takes me to my next question.

Can we please get rid of the word ‘alcoholic’?
After nearly 50 years linked to the field, I still don’t know what it means. It seems to suggest that there is a group of people who are somehow different in kind, as opposed to conceptualising problems as being a continuum. Worryingly, it plays into the hands of the drinks industry which has a vested interest in maintaining the fiction that there is a group of irredeemably dependent drinkers who will drink come what may, while the rest of us can imbibe with impunity. Is there a better word? How about the phrase ‘person with an alcohol problem’?

Why are governments so resistant to change?
Is it just fear of tabloid headlines? Certainly some politicians are only prepared to emerge from the trenches once they retire. This resistance is not only to legislative change; there is a reluctance to back service options for which there is supporting evidence, such as heroin assisted treatment (HAT) and drug consumption rooms (DCRs). HAT has a lengthy history in the UK; from the original ‘British System’, through the work of Dr John Marks to the RIOTT trials, the lifesaving and stabilising virtues of HAT for carefully identified individuals is well evidenced. From Switzerland to Canada, examples of well-run DCRs demonstrate that they reduce a range of harms and can draw people into other services. Why, then, are the national and devolved governments so coy?

Should we support changes in the law?
And finally, this takes us neatly to different legislative models of control. In the current political climate, the government is unlikely to revisit the Misuse of Drugs Act anytime soon. This is a pity, as lessons from elsewhere tell us that some models of decriminalisation, linked to a health-based approach, have considerable merit.

Such developments are a long way from the more radical reforms advocated by some. It is ironic that the effective legalisation of cannabis in certain countries and states in the US comes at a time when we are beginning to understand the nature and extent of mental health problems associated with it.

While prohibition remains the cornerstone of drug control, laissez faire continues to characterise the approach taken to alcohol, particularly in England. Is this paradox sustainable?

In the minefield of social control, it is a truism that greater availability leads to more widespread use and a rise in health problems, while proscription leads to less use at a societal level but increased criminality. However, there are lessons to be learned from tobacco control. Consistency of policy across successive governments of differing political hues has led to price increases, restrictions on availability for children, the elimination of advertising and the provision of cessation services, and combined, these have achieved a remarkable public health success story. Smoking remains a drug epidemic but one which is in serious decline: a positive note to end on.

Some of the challenges the field faces are changing, many remain the same; I wish those working in services the best of luck in meeting them. And to readers grappling with their own problems I would like to say: ‘if it works for you, it works for you, and don’t let anyone tell you otherwise!’

George Allan is outgoing chair of the Scottish Drugs Forum. He is the author of Working with Substance Users: A Guide to Effective Interventions (2014; Palgrave)

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