Working with Substance Users

A Guide to Effective Interventions

George Allan

• Publisher: Bloomsbury Academic
• Year: 2014
• Print ISBN: 9781137278043
• eBook ISBN: 9781350314009
• Edition: 1
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

Social care and health professionals encounter people with drug and alcohol problems on a daily basis, but many feel ill-equipped to respond. Although people working across different professions will approach substance users from various perspectives, the knowledge and skills needed to intervene effectively are the same for all. With a strong emphasis on the core skills needed for practice, this up-to-date and accessible text provides a complete guide to working with substance users and their relatives. It covers the nature of problematic use and introduces theories as to why people experience substance problems and why people change. The book moves on to examine a number of effective interventions and how they can be applied, including assessment and care planning, pharmacological treatments and cognitive behavioural therapy. Distinctively, in addition to chapters on working with specific groups such as adolescents and involuntary service users, it also addresses the implications of parental problems for children and explores ways of helping adults affected by a relative's substance use. Supported throughout by case examples and activities to help apply theories and concepts to practice, this comprehensive text equips readers with the knowledge and skills needed to work with substance users.

PART I

Context and Theory

CHAPTER 1

Defining and Experiencing Substances

KEY THEMES

It is important to use language precisely as it influences both how we view people experiencing difficulties with substances and society’s efforts to devise strategies to reduce the harms.

Dependency and addiction are central to our understanding of substance problems but are difficult to define. Many concepts surrounding substance use remain contentious.

Psychoactive substances can be categorised by their different effects on the central nervous system.

Phenomena such as tolerance, withdrawals and overdose can be explained to a great degree, but not entirely, from a physiological perspective.

The chemical properties of a drug alone do not account for how a person experiences it. This is predicated on a complex interaction between the individual, the environment and the substance itself.

The language maze

Addiction and dependence are difficult to define but, as concepts, they tend to mould our understanding of what problematic use of substances is. In the public mind, substance problems are often synonymous with ‘addiction’, but this is an example of language shaping – and limiting – our perception because people can experience problems with substances, irrespective of whether they are addicted or not. The term ‘alcoholic’ is used to describe the dependent drinker, a person who appears unable to stop when he starts and who uses most of the time. This stereotype has come to define what problem drinking is, thus minimising the risks inherent in bingeing or regular heavy use. Two examples illustrate the problem. I remember Mitch Winehouse, the father of the singer, Amy, saying that, initially, he was not overly worried by his daughter’s heavy alcohol use. He did not think she was an ‘alcoholic’ as she did not drink all the time – a good example of how a word can influence understanding. At that time, for Mitch, a drink problem constituted persistent, dependent use and no other pattern. In a similar vein, Ward, Henderson and Pearson (2003, p. 30) describe how a group of care leavers dismissed concerns about their drug use by measuring this against the idea of ‘addiction’: ‘Addiction was the point of reference that many of these young people used in defending the extent to which they used drugs, justifying their continuing use on the grounds that they were “not addicted”.’

The problem is not confined to how people make sense of their own or other people’s use on an individual basis. The drinks industry has a vested interest in presenting Britain’s alcohol problem as residing with a small minority of irresponsible or ‘problematic’ drinkers rather than being a wider public health issue involving excessive consumption by a significant proportion of the population. Such a view can then influence political decisions regarding what measures should be put in place to reduce the harms.

Words used to define specific concepts within the substance problems field have spilled over into common parlance to refer to unrelated ideas. Thus we have the media describing politicians as ‘being in denial’ over the outcome of their policies. Within the disease model, ‘being in denial’ is a characteristic which ‘alcoholics’ are deemed to possess – a controversial concept; however, we think we know what it means. Problems with language can become absurd. Detoxification refers to a specific process of ridding the body of poisonous substances and is used primarily to refer to alcohol and drugs. What are we to make of a company advertising ‘corporate detox solutions’ and a book entitled Detox your Finances: The Ultimate Book of Money Matters for Women (Trueman, 2009)? It is little wonder that concepts, which are both difficult to define in the first place and contentious within the substance problems field, become further muddied through imprecise use.

Words can reinforce stigma which, in turn, may militate against a person’s recovery. ‘Junkie’ conjures up the idea of a hopelessly dependent individual living a squalid existence in a shadowy subculture with nothing to contribute to society. The phrase ‘person with a drug problem’ invokes a very different image. A junkie is not one of us, a person with a drug problem is.

If we are to make sense of substance use and substance problems, we need to use language with care.

Central concepts

Drugs, addiction and dependence

Drugs are consumed in most societies. Vast, complex industries, both lawful and illicit, surround their production and marketing. They are used for medical and recreation purposes. They can be defined by their effects on the central nervous system or by their legal status. But what are they? Gossop argues that cultural significance and methods of use are as important as chemical properties when struggling to define ‘a drug’, a notion he considers to be a ‘social artefact’ (Gossop, 2007, p. 2). Most people would agree that heroin is a drug, but when it comes to solvents, the response might be ‘in particular circumstances only’. In respect of the non-medical use of substances, we are primarily referring to those which are psychoactive, in Edwards’ words ‘mind-acting’- they alter mood and cognitive functioning (Edwards, 2005, p. xvii). Even this is unsatisfactory; steroids may affect mood but that is not why people take them.

If the concept of a drug proves hard to pin down, addiction and dependence present even greater difficulties. Addiction is commonly used as a pejorative word to describe an unhealthy preoccupation. Dependence is often used to mean the same thing. However, there are two separate but overlapping phenomena at work here:

Physical dependence. Persistent, heavy consumption of some, but not all, substances leads to adaptions in the functioning of the central nervous system. When this occurs, more of the substance is needed to achieve the same effect: this is tolerance. If the person then stops using abruptly, the central nervous system reacts until it has readjusted to the absence of the drug: this is withdrawals. Raistrick, Heather and Godfrey (2006, p. 128) argue that ‘physical addiction’ can be a confusing term for these processes of neuroadaption but it is hard to find another phrase that makes the concept clearer. What is important is that physical dependence is a physiological process which anyone who takes certain drugs will experience if he consumes regularly and heavily. Psychological factors need not come into the equation. For example, a person prescribed morphine to control pain over a period will become physically dependent and withdrawals will occur if he suddenly stops; however, he may feel no desire to use beyond wanting to ward off the discomfort of withdrawal. With regard to tolerance, it is not the case that heavy users simply consume ever-increasing quantities. After a period of escalating consumption, a person tends to find a dose level which he then maintains (Gossop, 2007; West, 2006). For example, a regular smoker will stick to approximately the same number of cigarettes a day or a dependent drinker the same amount of alcohol. Both psychological and physiological factors may be at play here. With regard to physiological factors, a ceiling on the capacity of the individual’s nervous system and liver, and balancing changes in the neurotransmitters, lead to a particular baseline of use.

Psychological dependence. Here the person experiences a feeling of needing to take the substance irrespective of whether physical dependence is present. Many people exhibit mild psychological dependence, an example being wanting a few drinks to cope with social occasions. At the other extreme, psychological dependence can be experienced as a preoccupation with substance taking, involving overpowering feelings of being unable to cope without using and overwhelming cravings.

The jazz great Charlie Parker (undated), who had serious difficulties with heroin, neatly encapsulated these different facets of dependence: ‘They can get it out of your blood but they can’t get it out of your mind.’

It is the combination of psychological and physical dependence which we tend to call ‘addiction’. Problems with defining addiction led the World Health Organization (WHO, 2013a) to replace it with the concept of the dependence syndrome:

A cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value. A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take psychoactive drugs (which may or may not have been medically prescribed), alcohol, or tobacco. There may be evidence that return to substance use after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with nondependent individuals.

The WHO (2013a) then suggests that a diagnoses of the syndrome can be made if a person displays three or more of the following characteristics at the same point in the previous 12 months: a desire to use; problems of control; withdrawals; tolerance; disregard for alternative activities; continuing to use despite problems.

This certainly captures a pattern of substance use distinguished by fixation with drug taking and an apparent inability to exercise restraint. However, it does not solve all the difficulties of definition. West (2006, p. 174) notes that addiction is a ‘social construct’ with ‘fuzzy boundaries’ and so, too, is the WHO conc...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of Illustrative Material
• Introduction
• Acknowledgements
• List of Abbreviations
• PART I Context and Theory
• PART II Interventions in Practice
• PART III Specific Populations
• Appendix: Validated Questionnaires
• References
• Index