Addiction Debates

Hot Topics from Policy to Practice

Catherine Comiskey, Author

• Publisher: SAGE Publications Ltd
• Year: 2019
• Print ISBN: 9781526495761
• eBook ISBN: 9781526498366
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Addiction Debates explores the tumultuous landscape of addiction research, policy and practice. Covering all the ?hot topics? of the day in a balanced and informative manner, Comiskey provides international perspectives on each topic, stimulating debate and discussion via the different approaches taken globally.

Considering the complexities of debates around legalisation, rehabilitation, abstinence, harm reduction, and the current opioid epidemic, this SAGE Swift also looks into the health and social concerns related to drug consumption. Less-often debated topics include the ageing population of people who use drugs, the rights of the child of parents who use drugs, and the pressure these unique factors put on public health and associated services. A relevant text for a range of disciplines and people, sure to inform, challenge and continue the debate.

1 The Motions for Debate

Introduction

The global debate on the failure of the so-called ‘war on drugs’ is raging. The United Nations Office on Drug Control’s (UNODC) annual World Drug Report 2018 highlighted the international crisis in the misuse of prescription drugs from fentanyl in the Americas to tramadol in Africa and Asia. Overdoses from opioids were responsible for over three-quarters of all drug deaths internationally (United Nations Office on Drugs and Crime, 2018). The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is bracing itself for a possible epidemic and is strengthening its defences with improved early warning systems and rapid risk assessments of novel psychoactive substances. Countries with well-established prevention, treatment and intervention services are questioning their approaches, and emerging economies are looking for guidance on best practices from these very services.

Within this turmoil, policy makers led by elected politicians are struggling with the old philosophies and traditional approaches. They are demanding that current research tells them what works, for whom, where, and will our voters support this? Researchers are challenged. Does the evidence support the move from medical marijuana use to decriminalisation to legalisation? What will be the impact on young people? What about big business interests? What have we learned from alcohol use? Is it better for research within a treatment centre which supports a person who uses drugs to ask them if they have children or not? What about the so-called potential hidden harms to these children? If a client has a child will we let them use a drug consumption room? If our research supports the use of naloxone for overdose by a member of the general public will we ever be funded by medical foundations again? These are just some of the debates raging within addiction research.

The aim of this book is to pose these difficult motions for debate. The objectives are to provide an international perspective on the nature of these challenges; present the seminal prevailing research evidence; and stimulate discussion and development of these arguments for policy and practice.

To illuminate the background to the debates, this chapter provides a brief overview of the prevailing addiction philosophies and how they have evolved historically and globally. It introduces the overarching theories of addiction and discusses how these philosophies and theories influence international drug treatment policy and service provision to date. It presents a summary of the global epidemiology and hence challenges now facing addiction research policy and practice. It ends with posing seven motions for international debate. The debates to be addressed relate to society, policy and broad practice issues. The evidence to inform these debates stems from current international research and best practice.

Defining Addiction

The EMCDDA, in a discussion of models of addiction, reviews an array of international theories of addiction, which range from those that focus on addiction as a brain disease, which implies it requires treatment, to those that focus on environmental and social forces and the fact that addiction involves a continuum and that many individuals ‘recover’ without treatment. The EMCDDA proposes the following definition of addiction: ‘A repeated powerful motivation to engage in a purposeful behaviour that has no survival value, acquired as a result of engaging in that behaviour, with significant potential for unintended harm’ (EMCDDA, 2013: 27). This definition is deliberately chosen as it does not mention the reputed cravings, loss of control or withdrawal symptoms which, while they do exist, can vary for each individual. This definition focuses on avoiding or prejudging any underlying mechanisms.

Overview of Addiction Philosophies

Addiction philosophies, as with philosophies of belief, vary greatly from continent to continent, region to region or person to person. While it may be thought that consideration of the underlying philosophy of addiction held by a nation, a region, a policy maker or a practitioner may simply be an academic or a private consideration, a prevailing philosophy of addiction will influence the research undertaken, the policy developed and the practice delivered. Often, however, the prevailing philosophy has not been outwardly articulated and is simply left unsaid, yet it is inherently understood and maintained throughout, and within, the political, social and healthcare system within which it resides. If a community is to debate its current policies and practices, a basic understanding of the prevailing philosophies is required. It must also be acknowledged that prevailing philosophies can change over time, as research provides evidence of the efficacy of one philosophy over another in relation to the current addiction challenges. To conclude, there is a scale of addiction philosophies that may be summarised in distinct but often overlapping beliefs. These range from abstinence-based philosophies and prohibition policies, to freedom of choice and unregulated market policies.

An abstinence-based philosophy, will, as the term suggests, support abstinence from the use of drugs and alcohol. The American Society of Addiction Medicine (2013) defines abstinence as ‘Intentional and consistent restraint from the pathological pursuit of reward and/or relief that involves the use of substances and other behaviours’. Prevention and treatment approaches based on this philosophy will reflect this. Perhaps one of the best-known phrases of the abstinence-based prevention approaches was the ‘Just say no’ campaign of the 1980s and 1990s by Nancy Reagan (First Lady and wife of President Ronald Reagan of the United States) (accessed via History.com, 2017). This campaign was followed from 1998 to 2004 by a national anti-drug youth social media campaign supported by the United States Congress and the Partnership for a Drug-Free America. The campaign was designed to be a wide-scale social marketing effort that aimed anti-drug messages at youths aged 9 to 18 years, their parents and other influential adults. Advertisements were produced for television, radio, websites, magazines and cinemas. It was intended that, on average, a youth would see 2.5 targeted ads per week. The adverts fell into three broad categories: resistance skills and self-efficacy; normative education and positive alternatives, addressing the benefits of not using drugs; and negative consequences of drug use, including the effects on academic and athletic performance. Most adverts were developed on a pro bono basis by individual advertising agencies working with the Partnership for a Drug-Free America. Research by Hornik et al. (2008) has demonstrated that this campaign spent almost one billion dollars but was not effective.

Treatment for substance use based on abstinence-based philosophies will often involve a detoxification phase followed by a longer supervised period of abstinence and possibly social rehabilitation (Helena Kennedy Centre for International Justice & Phoenix Futures, 2017). While there is little evidence to support the long-term effectiveness of detoxification there is increasing evidence to support the effectiveness of abstinence-based treatments if they are of sufficient duration (Holt et al., 2002). The effectiveness of treatment modalities shall be explored in greater detail in Chapter 3.

The rapid increase in the number of deaths and the spread of HIV and AIDS and hepatitis C globally from the 1980s to the present day among people who inject drugs (World Health Organization, 2017) fuelled the debate on the need to move away from the abstinence-based philosophies and move towards a more harm-reductionist ethos and philosophy. Dole and Nyswander (1965) in their seminal work proposed a new approach to the treatment of heroin addiction, one that substituted the use of heroin with methadone supported by a comprehensive range of additional supports. Within this work the harm-reduction philosophy was born.

The harm-reduction philosophy is promoted globally by the International Harm Reduction Association which defines harm reduction as ‘policies, programs and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families and the community’ (Harm Reduction International, 2019). Harm reduction targets the causes and the harms and seeks to address these root causes at a population or individual human rights-based level as opposed to targeting the substance use of the individual. The philosophy is embedded in a public health and human rights-based approach of the 1948 United Nations, Universal Declaration of Human Rights. Article 25(i) of the declaration clearly sets out the right to appropriate medical and social care for an individual and Article 1 sets the tone of the declaration by stating that all human beings are equal in dignity and rights (United Nations, 2019).

While the harm-reductionist philosophy has been lauded as being respo...

Table of contents

• Cover
• Half Title
• Acknowledgements
• Title Page
• Copyright Page
• Contents
• Figures
• Table
• About the Author
• Foreword
• Publisher’s Acknowledgements
• 1 The Motions for Debate
• 2 Prohibition, Decriminalisation or Legalisation The Cannabis Conundrum
• 3 Towards Treatment and Harm Reduction, or Recovery and Rehabilitation
• 4 Medically Supervised Safe Injecting Facilities, Drug Consumption Rooms and Local Communities
• 5 Hidden Harms and the Children of Parents Who Use Substances
• 6 Ageing, Chronic Illness and Caring for People Who Use Drugs
• 7 Trade Wars The Opiate Epidemic, Overdose and Naloxone
• 8 The Future of Addiction Research, Policy and Practice Challenges and Opportunities
• 9 This House Concludes and Presents a Conceptual Framework for Future Development
• Index