Transcript `harm reduction` and `recovery` in the treatment of drug dependence

Friends or foes?
The roles of harm reduction and abstinent
recovery in the treatment of drug dependence
Alex Stevens
University of Kent
#nadra2016
@AlexStevensKent
Social construction of policy target groups
Valence
Positive
High
Power
Low
Adapted from Ingram, Schneider and DeLeon (2007): Social construction and policy design
Negative
Social construction of policy target groups
Valence
Positive
Negative
High
Advantaged
Contenders
Low
Dependents
Deviants
Power
Adapted from Ingram, Schneider and DeLeon (2007): Social construction and policy design
Social construction of policy target groups
Valence
Positive
High
Advantaged
Negative
Contenders
E.g. Scientists
Power
Low
Dependents
Adapted from Ingram, Schneider and DeLeon (2007): Social construction and policy design
Deviants
Social construction of policy target groups
Valence
Positive
High
Negative
Advantaged
E.g. Scientists
Contenders
E.g. Pharmaceutical
companies
Power
Low
Dependents
Adapted from Ingram, Schneider and DeLeon (2007): Social construction and policy design
Deviants
Social construction of policy target groups
Valence
Positive
High
Negative
Advantaged
E.g. Scientists
Contenders
E.g.Pharmaceutical
companies
Power
E.g. Petty criminals
Low
Dependents
Adapted from Ingram, Schneider and DeLeon (2007): Social construction and policy design
Deviants
Social construction of policy target groups
Valence
Positive
High
Advantaged
Negative
Contenders
E.g. Scientists
E.g. Pharmaceutical
companies
E.g. Sick patients
E.g. Petty criminals
Power
Low
Dependents
Adapted from Ingram & Schneider (2007): Social construction and policy design
Deviants
Social construction of harm reduction
• “‘Harm Reduction’ refers to policies, programmes 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 International (italics added)
Harm reduction in practice
• Widely applied
– Providing information on safer use
– Opiate substitution treatment (OST)
• Methadone, buprenorphine
– Needle and syringe exchange programmes
• Rapidly spreading
– Naloxone to reverse opiate overdose.
• Less common
– Medically supervised drug consumption rooms
– Heroin-assisted treatment
– Drug checking at festivals and nightclubs
Evidence on harm reduction
• Effects of harm reduction practices:
– Increased engagement and retention of problematic drug users in health
services.
– Reductions in HIV and other infections.
– Reduction in criminal offending.
– Reductions in drug-related deaths.
• Found by systematic reviews, including:
– Amato et al (2005); Ritter & Cameron (2006); Killias et al (2009); Mattick et al
(2009); Gowing et al (2011); Hedrich et al (2012); MacArthur et al (2012); Larney
et al (2014); Strang et al (2015); Marotta & McCullagh (2016).
– Harm reduction “cost-effective in the short term and cost-saving in the long
term” (Wilson et al 2015)
Some examples…
• Introduction of OST in Barcelona associated with an increase of 21
years in the life expectancy of heroin users (Brugal et al 2005).
• Annual (ICD-10) drug-related deaths fell in Portugal from 76 in 2001
to 9 in 2005 (Hughes & Stevens 2010)
• Threefold increase in OST in Sweden, 2000-2006, associated with a
reduction in opiate deaths of 20-30% (Romelsjö et al 2010)
• Risk of death for English heroin users in treatment is double if they
are not in OST (White et al 2016)
Drug-related death by country
Drug-related deaths (per 100,000 population)
7
6
5
Sweden
Norway
4
Denmark
United Kingdom
3
Finland
Netherlands
2
Portugal
1
0
2005
2006
Source: EMCDDA
2007
2008
2009
2010
2011
2012
2013
2014
Unintended consequences of HR
• Diversion of OST drugs to other users (and, occasionally,
children).
– Deaths from OST drugs
– Initiation of opiate using careers (e.g. in prison)
•
•
•
•
Medicalisation of the complex problem of dependence
Imposing extra discipline on the bodies of some drug users.
Demotivating some drug users to change.
Not meeting drug users’ own desires to end drug use.
For example…
• “Some here are so high on methadone that they sit sleeping in the
living room, or fall asleep with their face in the porridge or in the
cornflakes.”
– Quote from interview by Sandberg (2015).
• “I’d never get on maintenance again. It’s like being in prison. I can’t
stand that. They got you scared all the time. They threaten you: “Do
this” and “Do that”. And they fuck with you all the time. You know,
fuckin’ following the rules. And then when they get a little hair up
their ass about something, they gonna cut you down.”
– Quote from field notes by Bourgois (2000)
The case for abstinent reovery
• Sustained abstinence self-evidently reduces drug harms.
• Most people who enter drug treatment want to end their drug
use.
– 57% of 1,007 Scottish drug users entering treated wanted to achieve
'abstinence', compared to only 1% wanting 'safer drug use'
(McKeganey et al 2004).
• Public opinion is more supportive of abstinent treatment.
– Survey of general public in Scotland: 61% see no value in methadone
maintenance, compared to 48% for residential rehabilitation
(Matheson et al 2014)
Does OST prolong drug use?
Findings from a study of 749 patients with history of injecting, Edinburgh, 1980-2007
Probability of survival (i.e. avoiding death)
Probability of continuing injecting
Source: Kimber et al (2010) Survival and Cessation in Injecting Drug Users: Prospective Observational Study of Outcomes and Effect of Opiate Substitution
Treatment, BMJ
A potential mechanism?
• Methadone associated with lower cognitive performance (Mintzer
& Stitzer 2002)
• But note complexity and confounding:
– People who are in OST for longer may have more serious underlying
health problems and use multiple other substances (including heavy
alcohol use)
– So they are more likely to inject for longer and have worse cognitive
function, even if methadone does not have this effect (see, eg., Best 2009)
• More recent research: any effects on cognitive function may not be
clinically significant (Rass et al 2014)
Also note ambivalence among users
• “What you just said to me is ‘do I want to stop taking drugs?’,
or something like that... Now, yes I do, but it’s an impossible
thing to say...because if you say ‘cocaine’, I love cocaine, it’s a
good fun drug, and if you can control it, it’s great. Now if you
say ‘forever’, that’s a very, very impossible thing for me to say.
Yes I would like not to take crack and heroin ‘forever’, but it’s a
very hard thing to say.” (Male, 43 years, starting Subutex)
– Quote from interviewee of Neale, Nettleton and Pickering (2011)
Evidence, morality and policy
• Scientific evidence will have less influence where:
– Social constructions of target groups are deeply embedded in
dominant discourses, and…
– The evidence is complicated, incomplete and ambivalent.
• Especially when the policy topic:
– Is inherently moral.
– Reflects durable divisions in moral foundations
The moral bases of drug policy
Harm reduction
Individual
freedom
Abstinence
Conformity
(authority/
loyalty)
Disagreement on loyalty & authority as moral values
Source: Nilsson et al (2015) The Moral Foundations taxonomy: Structural validity and relation to
political ideology in Sweden Personality and Individual Differences
‘Public health’ as a bridge?
Harm reduction
Abstinence
Public health
Individual
freedom
Conformity
(authority/
loyalty)
‘Public health’ as a bridge?
Harm reduction
Abstinence
Public health
Safety
Individual
freedom
Social control
Conformity
(authority/
loyalty)
Agreement on harm/care as moral value
A shared moral basis for drug policy
Harm reduction
Individual
freedom
Abstinence
Conformity
(authority/
loyalty)
Care for human life and dignity (harm/care)
Can harm reduction integrate recovery?
• In the UK, “recovery-oriented” treatment incorporates:
–
–
–
–
–
Opiate substitution for those who need it.
One-to-one psychosocial therapy and counselling.
Links to peer support groups (eg. 12 step, SMART Recover)
Welfare, housing and employment support.
Naloxone provision and training
• But:
– Proportion of opiate users completing treatment “successfully” fluctuates
around 30% (PHE 2015)
– Wide variation in treatment outcomes between areas (Marsden et al 2012)
– Reports of pressure to leave or reduce OST too soon.
Can recovery integrate harm reduction?
• WHOS (We Help OurSelves) in New South Wales
• Incorporated harm reduction into all 6 of their therapeutic
communities
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–
–
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Needle exchange in the residential setting (anonymous)
Clients can enter programme on OST
Methadone prescription on site
Integration of OST and abstinent clients in some therapy groups
• Results observed so far:
– Improved retention and completion
– Improved self-reported health gains (Stubley & Popple 2016)
– But no controlled studies.
WORKSHOP/
GARDENING
RTOD
Admissions
OSTAR
OSTAR2
DAINTREE/JACARANDA MENS
TRANSITION
RECREATION HALL
GUNYAH
Community
Cafe
WHOS HQ
NEW BEGINNINGS
PEPPERCORN EXIT
HOUSE
TREETOPS WOMENS
TRANSITION
A progressive alliance of harm reduction and
recovery?
• On the basis of a shared concern for human life and dignity...
• … agree that both harm reduction and abstinent recovery services
be provided to people with drug problems.
• Necessary conditions:
– Harm reductionists accept that abstinence is a valid goal of drug
treatment.
– Recovery advocates accept that harm reduction is not a barrier to
achieving sustained abstinence.
– Governments provide funding for the full range of drug treatment services.
– Governments support the educational, social and welfare services that
help people to move through harm reduction to recovery and “wellness”.
Can “liberals” accept conservatives desire for conformity (abstinence)?
Can “conservatives” reconcile tensions between their own moral values?
Drug users worthy of harm reduction and recovery
Valence
Positive
Negative
High
Equal citizenship
Power
Drug users equally
worthy of care
and dignity
Low
References (1)
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Gowing, Linda, Michael F. Farrell, Reinhard Bornemann, Lynn E. Sullivan, and Robert Ali. 2011. Oral Substitution Treatment of Injecting Opioid Users for Prevention of HIV
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