Therefore, often as an alternative to imprisonment a drug misusing offender within the criminal justice system will automatically be given priority to access treatment. “Drug Treatment and Testing Orders made under Section 1A (6) of the 1991 Criminal Justice Act required offenders to attend drug treatment as a condition of a probation order.” (Hough et al, 2003, P.6).
This may cause problems because when faced with a prison sentence or a treatment programme the majority of people would most likely choose the latter even when they do not want help for their drug problems. Ironically, someone who is serious about getting help for their drug problems and has not broken the law will usually be placed on a long waiting list for treatment. Although, Tackling Drugs Changing Lives (2005) state that the average national waiting times for treatment have fallen almost three quarters since 2001; (from 9.1 weeks in December 2001, to 2.3 weeks in June 2007). However, this still could possibly result in non offenders slipping through the net especially since the most common referral route into treatment is self referral (NTA, 2006, P.7). Thus possibly resulting in them not getting the treatment or support they require at that time. Therefore whilst they remain on the waiting list for treatment social workers have a responsibility to give advice on minimising harm associated with drug misuse. Government policy has prioritised criminal costs of drug use King (2007) states that the wider issues that surround drug misuse such as the effects on communities, families and health are not taken into account. Therefore advocates a harm reduction policy by saying:
“Given that drugs may, and often do, cause significant harm to individuals, their family, their friends and their communities, the main aim of the law should be to reduce the amount of harm that they cause.”
In response to the 1998 drug strategy The Royal Society for the encouragement of Arts, Manufactures and Commerce (RSA), (2007) comment, through its Commission, that drugs are a matter of health and not just crime. The Commission argues that addiction to drugs and other substances should be treated as a chronic health condition and a social problem, not just a crime or cause of crime. In addition to this they also recommended that the primary aim of the new drugs policy should be to reduce harm. The review of the National Drug Strategy in 2008 argued that the previous drugs policy did little to help the problematic drug users and to mitigate the impact on drugs in society. Professor Anthony Kings the Chairman of the RSA Commission explains that in their view drugs in society are not just about crime. They criticised the previous strategy by saying there was too much emphasis on crime and that there needed to be a shift from crime reduction and the criminal justice system onto an understanding of the more varied and complex social problems. For example the social consequences of drug use can include social exclusion. People may lose their friends and family because of the stigma that surrounds drug misuse resulting in isolation. In addition to this drug use can have an impact on living standards and may result in homelessness for example if their drug use is given priority over their household outgoings such as rent. Therefore King (2007) suggests that there should be wraparound services which include individual social needs such as employment and housing as these problems often come hand in hand with chaotic drug use.
The work of Professor A King has informed the new Government drug strategy and prior to the 2008 drug strategy being unveiled it was suggested by Prime Minister Gordon Brown that the new strategy would adopt a more holistic approach when working with drug users and there would be more support for people undergoing treatment. However, when the Government's new 2008 10-year drug strategy was revealed there were proposals to shake-up the welfare system, effectively punishing drug abusers who fail to get “clean”. The Press Association (2008) highlighted that benefit payments to drug users may be reduced if they drop out of treatment. This could possibly result in people not accessing treatment for the fear of dropping out and having their income reduced. Therefore the new strategy gives no consideration to relapse. Drug relapse is a process that begins when an individual slips back into old behaviour patterns and as identified by Regan (2003) as being the most damaging characteristic of drug taking. Relapse may occur because drug users are often stereotyped and may find it hard to reintegrate back into society. Therefore this proposal may not be very effective. In addition to this if a drug misusing parent’s benefits are cut and they are faced with buying food, for their children, or drugs that they are dependent on they may not necessarily be capable of making a rational decision. Cleaver et al (1999, P.245) lends support to this by stating:
“Family income may be used to satisfy parental needs. Purchasing food and clothing or paying essential household bills may be sacrificed.”
However it is recognised that parental drug use may not always affect the parent’s capacity to look after their children well. The British Medical Association (1997, P.88) highlights that:
“Drug use itself by parents need not constitute a risk but neglect or abuse may be associated with problem drug use and should be addressed appropriately.”
However, long term drug misuse could impact on the families’ living standards and possibly result in a requirement for Social Services to intervene under section 17 of The Children Act 1989. In addition to this people may resort to crime so they can afford the drugs they are dependent on. Critics of the new drug strategy say there should be more focus on treatment and less on punishment (, 2008). Therefore better strategies need to be introduced to encourage drug users into treatment. An improvement to enable this could be not giving General Practitioners the choice to avoid providing drug treatment. This would allow people to be seen straight away by their General Practitioner and not placed on long waiting lists with other agencies.
All drugs, hard or soft, illegal or legal can cause social problems to some degree. Although, it is suggested that many drugs are thought to cause problems merely because they are illegal. However, The British Medical Association (1997, P.385) highlights that:
“Both the Green and White Papers, Tackling Drugs Together, rejected any arguments for legalisation or decriminalisation on the grounds that wider use and addiction are very serious risks which no responsible Government should take on behalf of its citizens.”
In contrast to this view Mullis (2003, P.3) argues that all drug laws should be abolished. The legalisation of drugs would mean that people could buy drugs but only through legal sources, thus removing a major criminal resource and reducing crime levels. The British Medical Association (1997, P386) also suggests that crime would be significantly reduced if drugs could be purchased legally and money spent on law enforcement could be spent on treatment and education. On the other hand there is evidence that drug users commit crimes for other reasons and not just to finance their habit. Many drug users are involved in crime even when they have access to drugs on prescription such as methadone. (Graham and Bowling, 1995, P.49). Therefore the social background of the drug user may also contribute to why they commit crimes. However, even if crime was not considerably reduced, people buying drugs through legal sources would know the strength and quality of what they were using thus possibly reducing the risk of overdose. If drugs were legalised there is no evidence to indicate that crime levels would reduce. People would still need money to purchase drugs from legal sources and as highlighted by Robertson (1998, P.209) it is uncertain that legislation would significantly reduce the cost of drugs. In addition to this alcohol and nicotine are highly addictive drugs that hold legal status. King (2007) suggests that the Misuse of Drugs Act (1971) should be repealed and replaced with a Misuse of Substances Act which includes alcohol and tobacco. As well as being addictive they can also cause major health problems. For example smoking can cause chronic lung disease, coronary heart disease, strokes, and various cancers.
“Some doctors have even reported that nicotine is just as addictive as heroin or cocaine, which indicates quite clearly as to how people become hooked so rapidly and stay hooked for so long.”
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Heavy drinking is linked to suicide, murder, fatal accidents, and many fatal . It can increase chances of developing cirrhosis of the , and it has been associated with many different types of cancers. However, the NHS Direct (2008) underline that drinking a moderate amount of alcohol will not do any physical or psychological harm. In a recent survey Lifeline publications (2007) highlighted that approximately 114,000 people die every year from smoking tobacco. About 40,000 people die from using alcohol and the least amount of deaths occur as a result of all illegal drugs put together and is about 2,000 people. This clarifies that:
“Although drug misuse poses risks to the user and others, from a health perspective it still remains a small problem in relation to the medical harm caused by alcohol and nicotine.” (The British Medical Association, 1997).
Therefore it is evident that the reason why some drugs are illegal is nothing to do with dangerousness. If drug classification is based on the harm that specific drugs may cause to individuals, families and communities. (NHS Health Scotland, 2004, P.10) then unquestionably nicotine and alcohol would both be classified. However, consideration needs to be given when looking at the above figures because more people may use alcohol and/ or tobacco because they are socially acceptable and hold legal status. If all drugs were legal, or the same amount of people who smoked used illicit drugs, then drug related deaths may significantly increase. However King (2007) suggests that the majority of people who use drugs are able to use them without harming themselves or others. Which means, according to King, the use of illegal drugs is not always harmful anymore than alcohol use is always harmful. Although it is paramount that people are still aware of the risks involved when using legal or illegal drugs. For example high impact adverts explaining the effects on all drugs as well as warning messages on alcohol similar to the messages on cigarette packets. Although King suggests that illegal drug use is not always harmful, heroin has been ranked the most dangerous drug by researchers The Lancet (2007). These finding were based on three factors which were: physical harm; potential for dependence and the impact on society such as costs to health care. Heroin dependency is an increasing problem in the UK which causes high social and criminal costs. (Stimson, 2003, P.1) Therefore, some view prescribing the drug as a way to reduce drug-related crime and others emphasise the advantages of heroin prescribing as a way of reducing health problems, for example blood borne viruses. However prescribing heroin may have risks as well as benefits. Prescribing might attract more people into treatment. More heroin users might get help as they would be identified thus resulting in fewer untreated heroin users in the community. In addition to this prescribing would stop or reduce illicit heroin use. This would undercut the black market in illicit heroin possibly helping to phase out drug dealers. BBC News (2002) also highlights that the idea has gained favour amongst some senior police officers, who believe it could reduce the amount of drug-related crime. However General Practitioners worry that prescribing heroin would maintain the level of dependency reducing any motivation for a person to stop using the drug creating an “addict for life. Therefore this may not necessarily be the best response to drug misuse.
Since we live in a drug taking society it is paramount that there are interventions available to substance misusers to help minimise any potential harm. Under the National Occupational Standards social workers have a duty to manage risk to individuals, families, carers, groups, communities, self and colleagues. Social workers can help to reduce risks by implementing harm reduction strategies.
“Harm reduction policies, programmes, services and actions work to reduce the health, social and economic harms to individuals, communities and society that are associated with the use of drugs.” (UKHRA, 2005)
Harm reduction has a very high profile in drug treatment programmes it aims to focus on issues such as needle exchange schemes and the risk of infection. The strategy is led primarily through the NHS and influences the Drug Action Teams (DAT). However, the strategy mainly focuses on minimising harm associated with intravenous heroin use. The NTA (2006, P.7) highlights that:
“Heroin was identified as the main problem drug for over two thirds (67 per cent) of clients receiving drug treatment.”
Nevertheless, the strategy accepts that people are drug dependent and therefore consideration is given on how best to reduce harm this includes access to information and clean injecting equipment. However, information needs to be widely available, written in relevant languages, and produced in an accessible format. Without any focus on harm reduction there are issues with blood borne viruses such as Human Immunodeficiency Virus (HIV) and Hepatitis C that could be overlooked. Hepatitis C is a viral disease that destroys liver cells and can lead to cirrhosis and liver cancer. Balkin (2004) identifies that:
“Most new cases of Hepatitis C occur in people who use contaminated needles or injecting equipment for drug use.”
Therefore although there are harm reduction programmes available for dug users they may not be easily accessible. For example, an intravenous heroin user who needed clean needles is not likely to travel a few miles by bus to collect them. This could result in the person using, or sharing, dirty needles which increases the risk of blood borne viruses. With this is mind it may be useful to establish if there are mobile needle exchange services available to especially in rural areas where people are often more isolated and may be less likely to travel long distances for clean needles. The advantages of this service could be that because the service comes to the people who need it, clean injecting paraphernalia is more likely to be used therefore helping to reduce the risks of blood borne viruses. However, there may be some users who might be worried about using, or not want to use, a mobile needle exchange service. This could be because of the stigma attached to drug use and they may be worried about neighbours finding out that they have a drug problem. Another service that may possibly help drug misusers to minimise harm is drug consumption rooms. However this service is currently not available in the United Kingdom.
“Drug consumption rooms are places where dependent drug users are allowed to inject drugs in supervised, hygienic conditions. There are approximately 65 drug consumption rooms in operation in eight countries around the world but there are none in the UK.” (, 2006)
Drug consumption rooms may help to minimise blood borne viruses and fatal overdoses. They would also help to take drug use off the streets and reduce numbers of discarded needles in public places.
“Drug users who congregate in public areas or open drug scenes are often homeless and marginalised, and lack access to social and health care services. Studies suggest that severe health risks are linked to street-based injecting.”
(Klee, 1995; Best et al., 2000).
Additional services within the drug consumption rooms can include needle exchange, safer injecting advice, Hepatitis B vaccines, safer sex information as well as counseling, showering and washing facilities. However, as highlighted by Drugscope (2004), there are some areas of controversy concerning drug consumption rooms. For example could the Government justify providing a service that enables people to engage legitimately in activities that are both harmful and illegal? Since drug users will take drugs regardless of there harmfulness and legality the Government should take into consideration that drug consumption rooms have potential benefits. However, if these rooms were available in the UK they might encourage people to use hard drugs or increase drug related problems in the areas where they were located. In addition to this support from communities and local services such as police would be required if the consumption rooms were to be work in communities. New or amended legislation may also be necessary since under the Misuse of Drugs Act (1971) drug possession for personal use is an offense. However if drug consumption rooms were legal then would drug possession be legal? If this was not the case then there would be a contradiction between the two. Other services available within the United Kingdom for drug misusers include voluntary agencies such as drug support agencies, counselling, rehabilitation and aftercare services. Services available need to be both accessible and available to people who require them.
There are many different models that can be used when working with people with addictions. However:
“When working with substance misusers it is helpful to consider two different models, the ‘disease’ model and the ‘wheel of change’.” (Goodman, 2007, P.103).
In the 19th century the first disease concept was established. This model considered that alcohol and drugs were evil and people who misused them were labelled victims. Therefore, alcohol and drugs addiction was starting to be seen as a disease that required treatment. In the 20th century the second disease concept evolved and alcohol consumption was once again socially acceptable. Only a small minority of individuals developed a problem with excessive drinking. However, alcohol and drug addiction was still considered as an illness that required treatment and support. Goodman (2007) highlights that the disease model works for some and is supported in self help groups such as Alcoholics Anonymous. He goes on to explain that people accessing the programme are told that they have a disease which prevents them from controlling their drink or drug problem. Consequently they need to avoid former drinking associates or drinking situation. However this model has implications as the nature of the disease has never been identified. It also suggests that a person with drug or alcohol problems has no choice or control over their decision making thus taking away their personal responsibility. Dick (2006) lends support to this by saying:
“Drug misuse is not a disease; it is a decision, like the decision to step out in front of a moving car. You would call that not a disease but an error of judgement.” In addition to this by following the disease model there is no consideration given to other factors such as psychological, cultural and family factors which may influence why someone may misuse substances. Therefore it does not adopt a holistic approach when supporting the service user. However according to National Institute on Drug Abuse (2008) drug addiction is a brain disease and highlights that:
“Although initial drug use might be voluntary, drugs of abuse have been shown to alter gene expression and brain circuitry, which in turn affect human behaviour. Once addiction develops, these brain changes interfere with an individual’s ability to make voluntary decisions, leading to compulsive drug craving, seeking and use.”
However, although this model will work for some people it may restrict social workers with their intervention because the model requires complete abstinence. Therefore there would be no harm reduction strategies needed such as needle exchange. The model also contradicts the General Social Care Council Codes of Practice (2002) as it does not work in an anti-oppressive manner. For example, by following the disease model approach the service user is not treated as an individual with individual needs and choices but as a person with no choice, control or autonomy over their situation because they are labelled as having a disease. In addition to this because the model does not adopt a holistic approach factors such as housing, employment and education are not taken into consideration. Although this model works for some consideration still needs to be given to the wider problems that surround drug misuse.
The second model, the ‘wheel of change’ was designed by Prochaska and Diclemente (1994). It was produced from work they had done with people wishing to change their smoking behaviour, it soon became evident that their theory was helpful for all addictive behaviours. It is a holistic approach and looks at areas such as housing and financial issues when supporting someone throughout the different stages of their alcohol or drug problems. Since the model is holistic it also allows social workers to work in partnership with other agencies such as housing. As far as social work practice is concerned this model is the value base of the codes of practice as it works within a positive framework promoting anti oppressive practice. In this model there is a cyclical process. It starts with a period of pre-contemplation when the service user does not know or feel that they have a problem. For those who are thinking about change they are at the contemplation stage. This is when the service user acknowledges the risks and problems caused by their behaviour and recognise the benefits of changing their behaviour. This may be when services are accessed, such as drug treatment agencies, for support. Following the period of contemplation service users who feel that change is desirable and possible begin preparing for the change. This stage of the cycle involves setting goals and making plans. Social workers can help service users by using motivational interviewing. This emphasises the empowerment of the service user and seeks to involve them in the work of changing their behaviour. It is non-judgmental, non-confrontational and non-adversarial. The approach attempts to increase the service users awareness of the potential problems caused, consequences experienced, and risks faced as a result of the drug taking behavior. However a great deal of commitment is required from the service user for this model to work. Once the goals have been established the changes need to be implemented. If plans are clear and goals are realistic they are more likely to be long lasting because service users may feel they can reach their aim. Strategies to deal with problematic situations that may arise, such as relapse, are also very important, as are rewards for success and ongoing support. Adapting to this new behaviour is a difficult period where huge support is required, such as positive encouragement, to enable the service user to move into a period of maintaining the change. However service users need to believe in the possibility of change otherwise this model will not work. For example, someone who had committed a crime for a drug related offence and chosen treatment over prison may not identify their drug use as a problem. Therefore this model would not work because they have not even pre contemplated change.
The wheel of change model links with the social model and allows social worker more flexibility when working with service users who misuse substances because it is predominately about empowerment and it involves the service user. This approach helps people recognise the risks involved with their behaviour and allows them to do something about it.
Conclusion
Drug misuse in Britain is a substantial and growing problem. It is not only a problem for the individual but for the Government and society. Problems for the Government could include increased crime resulting in financial costs and overcrowded prisons. Problems for the individual include social exclusion, physical and mental health problems, finance and legal issues and relationship problems. Problems for society include increased crime and increased cost on resources for example treatment and rehabilitation, police and social service involvement. Therefore treating the individual would benefit society and the Government. Policies to help treat individuals should include wraparound services which include issues such as housing, legal and financial issues and should also offer good aftercare treatment. However the new 2008 10-year drug strategy focuses more on punishment than on treatment and does not take relapse into consideration. Therefore new strategies need to be introduced to encourage people into treatment. In addition to access to treatment should be made easier for non offenders because at present problematic drug users who commit offences get preferential treatment over those who also have problematic drug problems but have not committed any offences.
Society place different values on drugs and although alcohol and nicotine are highly addictive drugs they hold legal status and are socially acceptable. However, although legalising all drugs may be unrealistic and could possibly encourage drug use it would allow drugs to be bought from legal sources. Therefore crime levels may reduce and people would know exactly what they were buying thus possibly preventing overdose.
There is a large emphasis on harm reduction strategies, which mainly focus on heroin misuse, and although interventions such as needle exchange services are available for drug misusers they are not always easily accessible. Introducing drug consumption rooms to the United Kingdom has advantages as well as disadvantages. It is a controversial subject and has many contradictions regarding the law. However provided they were supervised and people used them the advantages outweigh the disadvantages.
The disease model allows social workers limited flexibility when working with service users who misuse substances as it does not adopt a holistic approach. It also links with the medical model as the individual is regarded as a victim. It suggests that a person with drug or alcohol problems has no choice or control over their decision making thus taking away their personal responsibility. In addition to this it does not take into account harm reduction as the aim of the disease model is complete abstinence. Whereas the wheel of change model takes into consideration the possibility of relapse when working with drug misusers and respects the autonomy of the service user to make their own decisions. It allows social worker more flexibility because it is predominately about empowerment and it seeks to involve the service user changing their behaviour. It adopts a holistic approach when working with people with addictions of any kind and therefore social workers work in partnership with other agencies or professionals to help support the individual with additional problems that link to their substance misuse. The wheel of change model takes into account both physical and psychological factors again allowing social workers more flexibility with their intervention.
Although the disease model can work for some individuals it requires limited intervention from social workers whereas the wheel of change model adopts a holistic approach which gives social workers more flexibility when working with service users who misuse substances.
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Shirley Craik
Social Work and Drug Use
