Comment
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?
More
questions
than
answers
20 | drinkanddrugsnews | December/January 2018
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.
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