Emerging Perspectives on Substance Misuse

Willm Mistral

• Publisher: Wiley-Blackwell
• Year: 2013
• Print ISBN: 9781118302125, 9781118306642
• eBook ISBN: 9781118306628
• Edition: 1
• Topic: Psicologia
• Subtopic: Dipendenze in psicologia

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Emerging Perspectives on Substance Misuse addresses theoretical, practice and policy issues with regard to the problematic use of alcohol and illegal drugs.

 

• Comprises chapters from some of the most internationally well-known academics and practitioners representing a range of different specializations and perspectives in the field
• Presents a wide range of emerging evidence-based perspectives
• Includes content relevant for researchers, practitioners, and policy makers who work with individuals or policy related to drug and alcohol misuse
• Areas covered include -  gender and substance use, working with children and families of substance misusers and  the emerging recovery movement

1
Changing Perspectives on Problematic Drug Use¹

Richard Velleman

What is Drugs Policy?

Drugs policy can be said to comprise the various ways that governments and societies try to deal with substances that many people consume for pleasure or medicinal purposes but which can also have negative consequences for users, their families, or wider society. The difficulty with this view of drugs policy is that it includes so much – not only laws regulating the substances but also programmes for dealing with those who fall foul of the laws or who develop problems with substance use, and also programmes for prevention of use, or safer use. All these require efforts across a large number of sectors including policing and law enforcement, health, education, customs, ‘homeland security’, and community organizations. This is a very large canvas, and this chapter will look at only a part of it – primarily the overarching government policies that various countries have adopted, how these have changed over time, and challenges to these policy directions.

History

Societies have used, and attempted to control, intoxicating or psychoactive substances as far back as records go. In Western societies, alcohol was the substance mainly used, and correspondingly controlled, for most of recorded history. Although other substances were occasionally used (usually hallucinogens such as ‘magic mushrooms’), this was relatively rare and it was not until a range of different intoxicants became more available that use increased, and society felt the need to control that use. Although policy responses have varied, there are some main ways that large-scale societies and governments have conceptualized the issues, and these have determined the policies applied.

Conceptualizations of Drug Use

Societies and governments have variously taken the view that issues surrounding drug use are:

• economic: some substances ought to be freely traded;
• moral: people are weak and so substance use needs to be prohibited, and users need to be reformed and/or punished;
• health: some substances cause addiction and dependency, so use needs to be prevented or users need to be treated;
• criminal justice: many behaviours, including drug use, need to be controlled, forbidden or punished.

Countries usually utilize different or overlapping responses, depending on factors such as the status of the majority of the users, and whether or not use is associated with social disruption.

The United Kingdom

The experience of the United Kingdom is an interesting example. Up until the middle to late 19th century, because drugs other than alcohol were not seen as a problem, there were no drug policies, no laws, and no regulations. Instead, the government's approach was centred on an economic concept: drugs were commodities that could be traded in and with other countries, with resulting economic benefits to the United Kingdom. As Babor et al. (2010) state:

…psychoactive substances were an obvious choice; once the demand for them has been created, it becomes self-sustaining. Thus psychoactive substances became a favourite commodity from which to extract revenues for the state… The most notorious of such cases were the Opium Wars that Britain fought with China in the 1840s and 1850s to force the opening of the Chinese market for Indian opium. (p. 203)

As a result of this aggressive marketing, smoking opium became very common in 19th-century China, and a great deal of money was made by the British. However, while this economic model was applied abroad, the position taken with regard to the ‘home market’ was somewhat different. Many sailors, traders, employees of the East India Company, and others associated with the opium trade, returned to the United Kingdom, and a market for opium started to develop across Europe. At first this was relatively unproblematic but, around the same time as the opium wars, the active ingredient within opium, morphine, began to be produced on a large scale within Europe and became the basis of many popular patent medicines, including laudanum. As very many people purchased these products without understanding the potential for overdose, calls arose for legislative control. This led in Britain to the Pharmacy Act of 1868, which is highly important for two reasons.

First, it established the policy of limiting availability of dangerous drugs, a policy then followed by other European nations. Second, it placed central responsibility on a health-related profession, the Pharmaceutical Society established in 1841, to oversee the Act's provisions. Thus as well as aiding public health by having dangerous drugs sold or dispensed by individuals knowledgeable about their qualities, the Act also provided a significant boost to the status (and profitability) of a health profession. This created the conditions for a very long-standing approach (which became known as the British System) of placing health professionals at the heart of the governmental and policy responses to the control of drugs.

The impact of the Pharmacy Act was that the vast majority of people who used opiates did not become dependent on them (as opposed to in China, where the British trade in opium meant that over a quarter of the male population were regular consumers by 1905). In fact, recreational or addictive use in nations where opium was not so aggressively marketed remained rare until the early 20th century, with very many recordings of high praise for the drug. Nevertheless, some people did become dependent, especially once the more potent form of morphine, heroin, was developed in 1874 (and marketed from 1897 as a nonaddictive morphine substitute and cough medicine for children). However, the large bulk of those dependent were either members of health-related professions (who had ready access to morphine and heroin), or people who had become dependent following initial use of a heroin- or morphine-based medicine.

When the problem of what to do about these people became sufficiently pressing, the government set up the Rolleston Committee, which reported in 1926. , which remained largely unchanged for the next 40 years, the central position of which was maintenance-prescribing for dependent users of heroin (MacGregor & Ettorre, 1987; Velleman & Rigby, 1990). This Committee laid down guidelines for appropriate maintenance prescribing:

Persons for whom, after every effort has been made for the cure of the addiction, the drug cannot be completely withdrawn, either because (i) complete withdrawal produces serious symptoms which cannot be satisfactorily treated under the ordinary conditions of private practice; or (ii) the patient, while capable of leading a useful and fairly normal life so long as he takes a certain non-progressive quantity, usually small, of the drug of addiction, ceases to be able to do so when the regular allowance is withdrawn. (Rolleston Committee, 1926)

These guidelines gave control over prescribing to general practitioners, who could use their discretion on the treatment/maintenance of dependent individuals. This centrality of prescribing, and the discretionary powers of doctors, confirmed the primary orientation for dealing with heroin use as within the health sphere. Prescribing was of course not the only plank of government policy, enforcement has always been included in the system of controlling drug use in the United Kingdom, but it was the primary focus. This system was the practice until the 1960s (Velleman & Rigby, 1990) and then followed by another health-oriented approach focused more on short-term prescribing of reducing amounts of opiates, leading to abstinence. It was not until the 1980s that the long-standing health orientation shifted towards a more confrontational, crime and enforcement approach, swayed by an increasingly USA-influenced United Nations and international ‘war on drugs’.

The United States

While the main conceptual basis of British drugs policy was originally economic, followed by health, drug policy within the United States developed very differently. First, both medicine and pharmacy remained essentially unorganized in the United States until the First World War. Although the American Medical Association was founded in 1847, and the American Pharmaceutical Association in 1851, both remained small and nationally unrepresentative groups for the next 60–70 years; and crucially, both lacked the authority to license practitioners. As Musto (n.d.) states:

Licensing of pharmacists and physicians, which was the central governments' responsibility in European nations was, in the United States, a power reserved to each individual state …. any form of licensing that appeared to give a monopoly to the educated was attacked as a contradiction of American democratic ideals. (para. 5)

Thus within the United States, with respect to drugs policy, there was

• no practical control over the health professions;
• no control on the labelling, composition, or advertising of compounds that might contain opiates or cocaine;
• no representative national health organization to aid the government in drafting regulations, and
• no national system of developing laws or regulations relating to drugs (because the form of government adopted in the United States, a federation of partly independent states, was a conscious attempt to prevent the establishment of an all-powerful central government characteristic of Europe).

The result, unsurprisingly, was no drug policy at all with most states making little attempt to control addictive substances until quite late in the 19th century. Opiates were used in abundance for almost every ailment, with hypodermic syringes even advertised to consumers in the Sears Roebuck catalogue (Musto, 1973).

The second difference between the United Kingdom and the United States related to who became addicted. In the United States there was a large population of Chinese immigrants, especially on the West Coast, many of whom were already dependent on opium. United States' policy then, fragmented and with no lead from the health lobby, began with the stigmatization of Chinese immigrants and opium dens across California, leading rapidly from town ordinances in the 1870s to the formation of the (United States'-focused and led) International Opium Commission in 1909. During this period, the portrayal of opium in literature was squalid and violent, and purified morphine and heroin became w...

Table of contents

• Cover
• Table of Contents
• Title
• Copyright
• Contributors
• About the Editor
• Preface
• Chapter 1: Changing Perspectives on Problematic Drug Use
• Chapter 2: Formulating Effective Alcohol Policy: Not as Simple as it Sounds
• Chapter 3: Binge Drinking: Consumption, Consequences, Causes and Control
• Chapter 4: A Picture Tells a Thousand Stories: Young Women, Mobile Technology, and Drinking Narratives
• Chapter 5: Exploring Emerging Perspectives on Gender and Drug Use
• Chapter 6: Embracing Children and Families in Substance-Misuse Treatment
• Chapter 7: In Their Own Right: Developing Confidential Services for Children and Young People Affected by Parental Alcohol and Drug Use
• Chapter 8: Screening for Alcohol Use Disorders
• Chapter 9: From Comorbidity to Multiple Health Behaviour Change
• Chapter 10: Counselling in Intensive Structured Day Treatment: The Co-production of Recovery
• Chapter 11: Movements Towards Recovery
• Chapter 12: How Current Drug Laws Impede Research and Clinical Treatments
• Index
• End User License Agreement