|5. From treatment to rehabilitation — aspects of the evolution of British policy on the care of drug-takers|
|Books - A Land Fit for Heroin|
|Written by Suzanne Mcgregor|
Drug use is a common social activity, the motivations, methods and consequences of which are shaped by a variety of historical, cultural and political forces. Similarly, official responses to drug taking are influenced by those same forces, whether or not they are socially visible. It is beyond the scope of this chapter to analyse in detail how these social forces have operated over time or their level of impact on the development of treatment and rehabilitation policies. We simply describe current treatment and rehabilitation policies and ask if they represent a rational response appropriate to the realities of the 1980s and to the new wave of concern with heroin misuse in Britain.
Drug policies in the 1980s: achieving priority status
Concern about drug misuse has grown steadily in the 1980s. In the space of one or two years, policies regarding drug misuse have been elevated to priority status and the drug issue is recognised as a major social problem. In June 1984, the DHSS circulated forceful 'guidance' to health authorities declaring that 'Ministers now regard the improvement of services for drug misusers as of the highest priority', of equal importance with service development for the elderly, the mentally handicapped and mentally ill. The Government now considers that 'the development of services for drug misusers must remain a high priority for the foreseeable future' (DHSS, 1985).
An investigation by the Home Affairs Select Committee (1986) in 1985-6 led to its first report Misuse of Hard Drugs. This Committee visited Amsterdam and The Hague; New York; Washington, DC, and Miami — as well as the Channel Islands. Perhaps as a result of what they heard on these travels, the Home Affairs Committee phrased its report in relatively alarming language: 'Drug dealers . . . threaten us all, including our children, with a nightmare of drug addiction which has become a reality for America' (Home Affairs Select Committee, 1986, p. vi). They declared that 'immediate and effective action has to be taken if Britain is not to risk inheriting the American drug problem in less than five years' and 'everything possible [should] be done to try to avoid what has occurred in the USA' (Home Affairs Select Committee, 1986, p. viii). Earlier the Chajrman, Sir Edward Gardner, had referred to the drugs problem as an epidemic, a plague, the 'most serious peace-time threat to national well-being'. Reference to the 'Americanisation' of the problem refers not only to its size but to an intractability where drug taking becomes a way of life for the under-class in `no-go' ghettoes, where crime, from the Mafia to street thefts, permèates everyday life and public affairs to an extent not yet known in Britain. Some observers fear they see this on the horizon. Statements such as have seen the future and it is frightening' are reflections not just on drug misuse in British society, but on our social structure and on everyday life in decaying urban areas.
How serious is the drugs problem in Britain?
The crisis of drug misuse has two dimensions. There is a crisis, we would argue, if crisis is defined as a condition which cannot be remedied without fundamental structural change. This crisis is the result of the coincidence of two features:
1. the nature and size of the problem — that is, the increase in drug taking and the increase in the problems associated with drug misuse;
2. the failure of the existing treatment system and the inadequacy of the current response.
The rate of increase is serious and a cause for concern, if not quite the 'grave illness and terrifying social evil' described by Bernard Braine in the Daily Telegraph (14 April 1984). A review of the character of the situation in the 1980s compared with previous decades highlights:
• the centrality of illicitly imported heroin;
The increase in supply reflects a vast increase in world-wide production which shows little sign of abating (see Chapter 2, this volume).
Increased availability and use obviously increases the numbers likely to experience problems. Even if the present 'epidemic' were to wane 'naturally' as the 'vulnerable group' became saturated or as a clamp-down on supply proved effective, we can expect increases in the number of 'problem drug takers' for a number of years ahead. An upsurge produces a ratchet effect so that demand for treatment and care does not fall back to the previous lower level. This group will continue to make demands on services for some considerable time.
An indication of the national pattern is provided by a recent study by Glanz and Taylor (1986) on the increasingly important role of GPs in the treatment of opiate misuse. This is evidenced by rising proportions of all first-time notifications resulting from the statutory duty of medical practitioners to notify the Home Office of addicts who come to their notice. These rose from 29 per cent of all notifications in 1975, to 49 per cent in 1980 and to 55 per cent in 1984. From this survey of 845 GPs carried out between May and August 1985, an estimate of 44 000 new cases of opiate drug misusers consulting GPs in 1985-86 has been produced.
This is the tip of the iceberg. What proportion of all opiate drug misusers consult a GP in any one year? Is it likely to be all of them, a half or a quarter? One in five GPs comes into contact with an opiate-drug misuser during any one month. This indicates the important role already being played by GPs and their crucial position in any future development of services. In Guidelines of Good Clinical Practice (Medical Working Group on Drug Dependence, 1984), the circular distributed to all GPs by the government, the principle was stressed that 'it is the responsibility of all doctors to provide care for both general health needs of drug misusers and drug-related problems, as they would for patients with other relapsing conditions'. Additionally, the idea that drug users are a heterogeneous group was stressed as a principle of treatment. Linked with this principle is what emerges from many studies: the crucial distinction between drug taking and drug misuse, that is, a difference between experimenting with drugs (occasional, intermittent, recreational drug taking) and getting into trouble, developing problems, becoming dependent or addicted (through regular use of heroin for example). In discussing explanations for these patterns and in formulating policies, it is of the utmost importance to keep cle-ar this distinction. There is no one solution, and policies for the one are inappropriate for the other.
Treating heroin addicts: the development of the 'British system'
Much of what we discuss in this chapter regarding changes in services providing some form of care for drug users acknowledges the influence of what has been called the 'British system' of prescribing heroin to 'addicts'. The term 'British system' is, perhaps, rather misleading, since it suggests that consistent planning has accompanied the development of policies and practice and has led some commentators to oversimplify and eulogise the British approach (Trebach, 1982). Compared with the history of drug policies in the United States, in which enforcement has played the primary role in attempts to contain heroin use, the British approach appears relatively liberal and medicalised. But it should be remembered that it is only in respect of dependent users of heroin (and other opiates, and to a lesser extent, cocaine) that maintenance-prescribing has been a feature of the British response. Against occasional (non-dependent) users of opiates and against users of other drugs, the British system has resorted to law enforcement just as the United States has.
The British system of maintenance prescribing is, then, part of the British control system rather than its core. As the Advisory Council on Misuse of Drugs observed:
The controls over drugs of addiction introduced in the United Kingdom in 1920 preserved the right of doctors to prescribe for the purpose of medical treatment, thereby enabling them, if they thought it right, to prescribe controlled drugs to addicts. This principle was, however, soon questioned and subjected to detailed review by a Departmental Committee (the Rolleston Committee) [which] laid down guidelines as to when it would be appropriate to prescribe morphine or heroin to addicts:
a. when undergoing treatment for the cure of addiction by the gradual withdrawal method;
b. when, after every effort had been made to overcome addiction, the drug could not be withdrawn completely, either because withdrawal produced symptoms which could not be treated satisfactorily under the ordinary conditions of private practice (i.e. other than in a hospital); or because the patient, while capable of leading a useful and fairly normal life so long as he took a certain non-progressive quantity, usually small, of the drug of addiction, ceased to do so when the regular allowance is withdrawn.
These guidelines, which were accepted by the government of the day and the medical profession, thus provided the foundation of what has since become known internationally as the 'British System', i.e. the management of an addict by the prescription of maintenance doses, often over a fairly lengthy period (ACMD, 1982, pp. 7-8).
Subsequently, the right to prescribe opiates (though not the right to care for drug users in other ways) was restricted to doctors working in a setting in which a comprehensive range of services appropriate for addicts could be provided. Modification of the British system resulted in the establishment of NHS Drug Dependency Units — 'drug clinics', as they are more popularly known.
The restriction of prescribing to the clinics can be traced to several concerns around changing patterns of availability and use of opiates in the mid-1960s. These included changes in the user population with the emergence of younger, working-class male users (Jamieson et al. , 1984, p. 4) alongside older users — generally those who had become dependent in the course of medical treatment with opiates or who had had some kind of professional access to such drugs and developed a problem after recreational or experimental use. The new, younger users were seen as a disturbing challenge — not adults and not `respectable'. It was in response to their emergence that the 1965 report of the reconvened Brain Committee called for the provision of 'suitable' unitsjor the treatment of drug addiction, stating that:
each centre should have facilities for medical treatment, including laboratory investigation and provision for research. A centre might form part of a psychiatric hospital or of the psychiatric wing of a general hospital (Interdepartmental Committee, 1965, paragraph 22).
The provision of such facilities, combined with stricter controls over the supply and availability of opiate drugs, was intended to contain the spread of addiction. The clinics were to be under the direction of consultant psychiatrists, backed up by nursing staff. 'The new system gave each consultant control over her or his clinic's policy, and allowed the clinic psychiatrists as a group to maintain a united front against the involvement of ordinary GPs in the treatment of dependent persons. For a while, the clinics generally adopted a fairly liberal prescribing policy, attracting a large proportion of existing users — who had hitherto obtained their heroin from doctors no longer authorised to prescribe it. However, during the 1970s the clinics moved away from prescribing injectable heroin or methadone, substituting the relatively unexciting orally taken methadone, almost invariably on a schedule of reducing dosage. Partly for this reason, a smaller . proportion of heroin users today obtain their supplies in a legitimate way, from doctors, than was the case twenty years ago.
The clinics remain an important feature of the statutory health and welfare response in Britain, having been supplemented by a variety of non-statutory services such as rehabilitation houses and street agencies. The following paragraphs describe the emergence of these services.
The emergence of rehabilitation as an adjunct to treatment
Reassessment, debate and deliberation have consistently surrounded the development of treatment and rehabilitation policies for drug misusers. Prior to the 1980s, policies in this area implied a dichotomy between treatment and rehabilitation, as noted by the Advisory Council on the Misuse of Drugs (ACMD, 1982). For example, treatment was restricted to the medical setting of the clinic, while rehabilitation (a non-statutory agency response) was regarded as a more active process, encouraging self-determination and personal integration as well as the development of social skills and interpersonal relationships. In practice this dichotomy created an unnecessary gap within the treatment and rehabilitation system.' As a result, two parallel approaches emerged: on the one hand, an individualised containment-cum-confrontational approach adopted by statutory agencies such as clinics; on the other a self-help community approach supported by non-statutory agencies (Jamieson, Glanz and MacGregor, 1984, p. 12).
The roots of this dichotomous way of thinking can be found in the Second Brain report (Interdepartmental Committee, 1965), two 1967 Ministry of Health Memoranda (Ministry of Health 1967a, 1967b) and the early work of the Advisory Committee on Drug Dependence (ACDD, 1968). The Second Brain report (Interdepartmental Committee, 1965) called for the establishment of special centres with facilities for medical treatment of drug addicts. This report also noted that details for the organisation of and provision for facilities for long-term rehabilitation' were 'outside their terms of reference'. Although a concern for rehabilitation was seen as necessary if relapse was to be prevented, the primary focus of concern was on treatment arrangements: the drug clinics. The subsequent publication in 1967 of two Ministry of Health memoranda, The Treatment and Supervision of Heroin Addiction (Ministry of Health, 1967a) and The Rehabilitation and After Care of Heroin Addiction (Ministry of Health, 1967b) outlined action taken or proposed on the recommendations of the Second Brain report. The former memorandum described treatment facilities which hospital authorities were asked to provide for persons addicted to heroin, while the latter provided the already promised guidance on joint planning by regional and local health authorities for establishing rehabilitation and after-care facilities for discharged patients. While close collaboration between hospital authorities, local health authorities, general practitioners and non-statutory agencies was emphasised in the second memorandum, both memoranda implied a distinction in principle, if not practice, between treatment and rehabilitation.
It was during this particular period in the formation of British drug policy that an official document mentioned non-statutory (voluntary) bodies in this field for the first time. This very casual mention occurs in the introduction to the second memorandum:
The form of possible arrangements has been discussed by the Department with psychiatrists experienced in the treatment of addiction, and with Medical Officers of Health and voluntary bodies having a special interest in this subject (Ministry of Health, 1967b).
At that time, rehabilitation was seen to involve two elements: the re-education of the individual to living without drugs and the development of social resources, including trade training and settlement in employment (social rehabilitation). It was believed that while the combined responses of treatment and rehabilitation would be complementary, only a small proportion of addicts would want long-term rehabilitation. Thus, treatment arrangements appeared again as the primary focus of concern.
The slow rise of rehabilitation
A more detailed view of rehabilitation, involving a variety of disciplines and services, was presented in the ACDD report on The Rehabilitation of Drug Addicts (1968). It was within this report, put forward by the ACDD's Rehabilitation Subcommittee, that rehabilitation, conceived as beginning with an addict's first contact with an out-patient clinic, was recognised as a special need rather than a mere adjunct to treatment as implied in previous documents. With the brief 'to consider the various ways in which rehabilitation of persons dependent on drugs can most effectively be arranged by statutory and non-statutory agencies' (ACDD, 1968, p. 1), the Subcommittee's key recommendations included: the establishment of hostels providing short-term accommodation for homeless addicts attending out-patient clinics; input from social workers at various service levels (in-patient, oue-patient, and after-care); planning for special hostels developed on experimental lines; the encouragement of voluntary bodies to pool their experiences and to discuss their plans and the need for local health authorities not only to set up hostels themselves or assist those run by voluntary agencies but also to provide support (both financial and advisory) in these developments. 'Good communication' on all levels was stressed and special mention was made of the positive contribution of the courts, prison service and probation in rehabilitation. The contributions of these agencies were subsequently addressed in more detail in the Report on Drug Dependents within the Prison System in England and Wales (ACMD, 1979), a report submitted by the Working Group on Treatment and Rehabilitation and endorsed by the full Council, then the ACMD, in 1979.
The concluding statement of the Rehabilitation of Drug Addicts report suggests the need for cooperation between treatment and rehabilitation services:
there should be a multi-disciplinary approach to the problems of prevention, treatment and control . . . there should be close cooperation between treatment and rehabilitation on the one hand and the police and courts on the other, and continuous care for the patient should be maintained by the same therapeutic team throughout (ACDD, 1968, p. 23).
This sentiment was resurrected in part by the ACMD (1982) when the need for a comprehensive approach, with treatment and rehabilitation linked as key elements within a long-term multi-disciplinary response, was stressed. On the other hand, the ACMD's 1982 report appears to reflect a shift in the official way of thinking. Indeed, by recognising the 'traditional' dichotomy between treatment and rehabilitation as 'counter-productive' and 'unrealistic', the ACMD appears to part company with its predecessors. For example, the need, put forward in 1982, for 'active involvement of a wider range of specialist and non-specialist agencies' (ACMD, 1982, p. 43) and the requirement for 'a programme of integrated treatments and a variety of agencies working with the client or patient over a period of several years' (ACMD, 1982, p. 35) challenges the 1968 view that 'addicts are to be cared for consistently by the same therapeutic team' (ACDD, 1968, p. 23). The subtle shift here is the movement towards a more comprehensive treatment and rehabilitation policy which attempts to ensure conditions for cooperation between statutory and non-statutory agencies. Both sectors of care are to be seen in equal partnership, supporting drug misusers.
Perhaps the shift towards a comprehensive response should be expected, given the pressures which service providers had experienced because of the changes in the nature and extent of the drug problem in Britain during the 1970s. Nevertheless an indication of a shift towards this way of thinking was recorded as early as 1967 when the view that 'getting the addict back into work and a settled way of life is an immensely more difficult problem than drug withdrawal' (Anonymous, 1967) was put forward in the British Medical Journal. Similar views (Expert Committee on Mental Health, 1967; Office of Health Economics, 1967) held at that time suggested the need for a full response involving a wide range of agencies.
Given all this, what was actually happening? What sorts of practices, policies and assumptions were being challenged by drug users and drug workers within both the statutory and non-statutory sectors of care?
The focus moves from heroin to multi-drug use, and back to heroin
While a major focus of policy concerned with drug addiction has been the Drug Dependence Unit (Smart, 1985), doubts about the efficiency and appropriateness of the clinic system arose within two or three years of its inception. Fuelled by pressure from the non-statutory sector and from a few key consultants and social workers, concern was expressed about the prescribing function of clinics, about drug misusers who were not being seen at the clinics (because they were not dependent on opiates) and about pressures on Accident and Emergency departments and street agencies (Ghodse, 1977, 1979 and et al. , 1981).
In both the clinics and the non-statutory street agencies, the rather gruesome fixing-rooms set up soon after the inception of the British system became displaced. While the strict enforcement of rules linked with the formalisation of treatment plans played a key part in this displacement, reduction in the amount prescribed and the switch from injectable to oral methadone were also crucial factors. Significantly, the notion of long-term maintenance was abandoned and it was assumed that patients would be willing to work towards abstinence. New programmes introduced in the field were based on psychological theories of social learning. Stimson and Oppenheimer (1982) see these changes in the 1970s as a response to the frustration felt primarily by staff at the clinics. Regardless of the reasons for these practical changes in and around the clinic system, key assumptions were challenged throughout the 1970s. Professional and lay opinion increasingly qu'estioned:
• the definition of 'the addict' in terms of the substance taken, rather than as someone for whom drug-taking overlaid and exacerbated other 'problems in living' and who might be better viewed as a 'multiple drug misuser' or 'problem drug taker' ;
• the dominance of the clinics and psychiatry in determining models of practice while techniques of therapy and rehabilitation, such as counselling and therapeutic communities, were playing an increasing role within both the statutory and non-statutory sector;
• the appropriateness of prescribing a dangerous drug especially on a long-term maintenance basis while the objective of health-care workers was a drug-free, healthy life;
• the limitations of a purely `physical' conception of problems while drug misusers faced considerable difficulties with housing, employment, child-care and treatment in prison;
• the assumption that services are best organised on the basis of a sharp distinction between the stereotype of the `junkie' or `addict' and other more `normal' patterns of drug use (for example, of alcohol, tranquillisers, etc.).
It is ironic that just as these challenges had been absorbed into the orthodoxy of the policy and practice of key decision-makers and had been set out in the ACMD report on Treatment and Rehabilitation (1982) a new wave of heroin addiction swept over the country and reinstated older notions of epidemic and danger, centred on one substance — heroin. While informed experts and practitioners in the small, closed circle of the `drugs field' had come to agree on notions of `problem drug taking' and the need for a 'multi-disciplinary approach', this professional consensus was swept aside as politicians and the public demanded that doctors should `do something' about this pernicious evil.
The clinic system under strain
The clinic system was under considerable strain well before the current concern and attention was devoted to the drugs problem. Problems soon arose with this `system' — which only in its earliest years looked much like its image, especially that held abroad of it as a maintenance-based, medical rather than social or criminalising system. For a start, only certain types of patients received treatment. Especially as doctors switched to oral methadone treatment programmes, large numbers of drug takers remained outside the clinics. What was happening to those who did not attend, or who attended for a short time but did not stay? Some were not treated at all. Some received treatment from GPs or from private doctors, evidenced in the vast increase in the_ number of notifications from GPs relative to clinics and prisons. Others found their way into the non-statutory sector. The non-statutory (or voluntary) sector developed rapidly to fill the gaps in the tight, restrictive state sector. In spite of the recognition of these problems by workers in the field, the authorities still felt able in 1978 to claim with some satisfaction that 'in comparison with several other countries facing similar problems, the UK appears at present to have a relatively stable situation as far as narcotic drug dependence is concerned' (Central Office of Information, 1978).
Yet by 1980 a Times leader could comment, 'the present machinery of drug-addiction clinics, registration of addicts, maintenance dosage and drug replacement is not for some reason competing adequately in the eyes of many customers with the market' and urged a re-examination of 'the effectiveness of our containment policy towards hard drugs' (13 August 1980).
A joint letter to The Times (23 January 1981) from a conference of representatives of the clinics and the non-statutory sector referred to the marked increase in the number of people seeking help for problems caused by drugs in the previous two years and pointed out that GPs were once again undertaking the care of opiate addicts. The letter noted the long wait involved in gaining admission to detoxification units and argued that the trend toward devorving the funding of services to local level must be reversed. Central government should accept the financial responsibility for provision of the core costs of specialist drugs services. As the letter argued:
The effect of local funding where competition with more attractive client groups is unavoidably direct is to exclude many drug addicts from specialist care. . . . Increasingly local funding has come to mean the withdrawal of support from resources and personnel.
The long list of forty-five recommendations in the ACMD report on Treatment and Rehabilitation (1982) form the basis of the current consensus on responses to the problem. They include reference to the principle that provision should not be substance-centred nor even diagnosis-centred but should focus on problems, and that policy responses should utilise not only the full range of specialist services but also other statutory services — social work, youth services, housing and employment; that regional and district multi-disciplinary drug teams or advisory committees should be set up; and that there should be more and improved training. The ACMD further commented: 'if there is to be an adequate response to the undoubted increase in problem drug taking then additional funding must be made available both at local level and from central government'.
The ACMD Report on Prevention followed two years later. It listed thirty-two recommendations which included a suggestion for limits on prescribing and a call for health education at a broad level. More training was called for. It concluded that the Home Secretary should assume specific responsibility for the coordination of policy on prevention of drug misuse at national level and reaffirmed the need for drug advisory committees at local level, which should include representatives from education and the community in addition to psychiatrists, community psychiatric nurses, and social workers. Since then the Social Services Committee has queried whether these committees, which do seem to have been established in most areas, might not degenerate into mere 'talking-shops' (Social Services Committee, 1985).
Current government strategy and the Central Funding Initiative (CFI)
Tackling Drug Misuse (Home Office, 1986) presents current government policy on drug misuse. First published in March 1985 and updated in March 1986 to take account of a whole range of further initiatives, this strategy document aims to attack the drug problem of five fronts, one of which is 'improving treatment and rehabilitation'. While the thinking of the ACMD informs much but not all of this presentation, part of Section 7, 'Treatment and Rehabilitation' (specifically paragraphs 7.4 and 7.10) indicates a shift towards non-medical community services which has widened the range of possibilities under discussion in the 1980s (see, for example, Strang, 1985).2
The Central Funding Initiative (CFI), a key element in the government's current strategy, may be seen as a way of remedying some old problems and rising to new challenges. Nevertheless, while the CFI was, in Norman Fowler's words, 'the government's initial response to the ACMD Report on Treatment and Rehabilitation' (DHSS, 1982) it has supported the increase in community-based services without establishing clear lines of vertical coordination from national to local level. The problem of lessening the gap between national and local levels and establishing the need for an alternative approach was voiced subsequently by the minority statement contained in the ACMD Report on Prevention (ACMD, 1984, pp. 79-83).
The total sum now expended through the CFI is estimated at £17.4m (Coomber, 1986). The Social Services Committee commented, however, that 'while good enough as far as it goes [the CFI] is totally inadequate as a governmental response to a rapidly growing problem' (Social Services Committee, 1985, para. 99). They recommended that the DHSS 'create a central fund for services for drug misusers to which Regions could apply; that it should use the accountability review process to chase up those Regions which do not show interest; and that it should exercise close control over the way in which these funds are spent' (Social Services Committee, 1985, para. 101). The Government's response to this, however, was to point to the pump-priming boost of the CFI and to reiterate that 'it is not the function of central government to determine local needs and make decisions about locarpriorities and the best way of meeting local needs. Health and local authorities are in the best position to make these judgements' (DHSS et al. , 1985).
It is still early days to see the impact of the CFI on the shape of services nationally or to evaluate whether or not this 'key element' has offered a viable solution to a growing problem. Regardless of the further injection of £5m per year from 1986 available to health authorities and additional to the CFI (DHSS, 1986), we are left with the fear echoed by the Standing Conference on Drug Abuse in their memorandum submitted to the Social Services Committee, that:
in three years' time, at worst there will be a significant reduction in services. At best, there will be such financial uncertainty that some voluntary organisations may not be able to continue and others will only survive at considerable cost to the staff, the service and most particularly, to people with drug problems (Standing Conference on Drug Abuse, 1985, para. 6.9).
Criticism of existing services
The Social Services Committee in its Fourth Report commented on the 'woefully inadequate' state of existing services for the treatment and rehabilitation of drug misusers. The final paragraph of this report encapsulates much of the informed current concern about services for drug misusers:
The misuse of drugs, and particularly misuse of heroin . . . is a serious and growing problem. It demands an immediate, determined response from government . . . Existing services are woefully inadequate to cope with the increasing pressure. Treatment facilities are few, underfunded, often inaccessible and always with long waiting-lists. Rehabilitation is provided, if at all, by voluntary organisations unable to plan ahead for lack of secure funding. Experienced staff are in very short gupply . . . Recent initiatives, national and local, are welcome but not enough . . . Most local and health authorities are apparently unwilling to give any degree of priority to services for drug misusers. The Government must put forward a clear long term strategy for the coordinated development and maintenance of services for drug misusers . . . New money will be needed . . . Training facilities for specialist staff of all disciplines must be increased greatly . . . Drug misuse can be tackled but only if expressions of concern are matched by action (Social Services Committee, 1985, para. 105).
To these statements could be added the following specific comments:
• opening hours at clinics and other services are often inflexible and do not suit everyone;
This indicates one of the costs of setting up special services for problem drug takers, insofar as practitioners in the general services (in health, education, social. work) tend to feel absolved from responsibility or they feel that the problem is necessarily too complicated for them to be able to deal with. The compartmentalisation of services leads to a lack of continuity and comprehensiveness of care and many fall through the gaps.
A pragmatic approach: a full response linked with the awareness of gender and race
If we start from where we are now, deal with the problem as we find it, with the resources we have available — that is adopt a pragmatic approach — we find that the available expertise is concentrated in the clinics and in the non-statutory or so-called voluntary sector. Throughout the 1970s there was and in some areas, remains, an antagonism between these two. But staff in a number of areas have broken down the barriers and developed coordinated action, as in the north-west, Tyneside, and Bloomsbury, based upon a philosophy shared among consultants, social workers, nurses and community workers.
This is one model for the development of services. It sees clinic staff as playing a key role, coordinating, training, acting as a catalyst but aiming to utilise a wider range of services — from GPs and community psychiatric nurses to health visitors and probation officers. Of course, an equal partnership with the non-statutory sector would be aimed at. Day centres and rehabilitation houses would all be linked in to provide a comprehensive network of services for drug misusers, which could see the client through from first contact to final 'settlement' in a home and a job on completion of rehabilitation. Such a vision of a network of services in each area would include a 24-hour, 7-day a week crisis intervention and detoxification unit, and advice and counselling, out-reach work, day centres, clinics and a variety of rehabilitation houses or residential accommodation with different regimes for different needs or inclinations.
Any new model should include a concern for the needs of special groups such as women and members of the black community who are under-represented quite strikingly in the current service provision for drug misusers. The 1985 DAWN survey (DAWN, 1985) of 254 London agencies highlighted the inadequacy of the current response with regard to the issues of gender and race. Briefly the six main findings were:
1. only 100 of the 254 projects surveyed made any particular effort to help women with drug/alcohol problems;
2. although all the 100 agencies surveyed were thought to be aware of the specific needs of women clients, eighty-three agencies responded that women clients had needs or problems different from men. Of the eighty-three agencies responding that women had special needs, eighteen agencies were unable to state any actual needs or problems specific to women;
3. only about one in four agencies recognised women's particular problems with child-care and housing, while less than one in five accepted that women face discrimination in treatment. (This latter finding did not square with the experiences of women themselves, reporting at DAWN open meetings);
4. only fifty-one agencies were able to specify what, if any, further facilities they felt were needed for women. Although the ACMD had expressed concern about the long-term prescription of minor tranquillisers to women, only one agency in the whole of the metropolis showed an awareness of the need for greater provision in this area;
5. despite the fact that London is a multi-racial city, many agencies responded as if cultures other than white European ones did not exist. Only one in twenty agencies saw more than 10 per cent black women or women of colour. None of the specialised drug/alcohol coordinating agencies offered any analysis of racism and of the problems faced by people from different cultures;
6. statutory facilities (Drug Dependence Units and Alcoholism Treatment Units) showed the least understanding of women's needs and were the most difficult group from whom to obtain responses.
Although DAWN made recommendations on the basis of these findings, there is still a lack of response in the addiction field to the needs of women with children; women users of tranquillisers; women of different cultures who experience problems with alcohol and/or drugs; and women problem drug takers and drinkers in prison or on parole.
The question of the effects of institutionalised racism or sexism on the overall provision of services is an important area of concern. A pragmatic approach would begin to reform existing sergices to make them more flexible in response to special need groups, as well as maintaining and developing forms of provision designed expressly and exclusively for specific groups (such as women-only services). Sensitivity to social groups, cultures and special needs could be a starting-point in providing better services for all drug takers. The exact shape and form of services — who would take the leading role and so on — however, can only develop organically over time in each locality, depending on the people active in that area and the level of local awareness.
In its Fourth Report, the Social Services Committee concluded that the situation is 'genuinely alarming', that 'overcoming drug dependency demands more of a social than a clinical approach' and that 'an immediate, sizeable and recurring injection of additional money by the Department (DHSS) is essential' (Social Services Committee, 1985, vii, ix, para. 100).
The crisis facing us at present provides an opportunity to develop a fresh approach to tackling the drug problem, an opportunity for debate to develop among the various authorities about their contribution. When the dust has settled, what will turn out to have been the outcome of this critical phase? A truly innovative new approach? Or just patching and mending? Or worse, neglect?
Should Local Authorities play a role? The Social Services Committee commented: 'few local authorities have much of a clue as to how to deal with this social problem, which has come to be seen as either medical or criminal and few feel obliged to take any initiative'. Yet it is clear that, because of the increase in the number of problem drug takers, the specialist services cannot cope alone. The clinics are overloaded and experience staff shortages. They are unable to meet the demand for immediate care, let alone take a central role in the development of services and involve themselves in training and education. GPs and probation officers are under pressure and need training and support. Their key problem is lack of confidence and lack of knowledge. Drug taking has to be demystified so that primary care workers and generic service workers feel willing and able to accept responsibility and to take on the care of drug takers, rather than being content to refer them to other services. However, they need also to be able to recognise when the situation is more complicated and it is appropriate to refer on to more specialised services. Here, too, more training and stpport services are required. Local Authority Social Services Departments are already involved in casework with clients with drug-related problems, and can work more closely with the voluntary agencies, GPs, clinics and probation officers to develop a coordinated response. Models such as those developed in Southwark, and Islington may be illuminating (see, for example, Working Party on Drug Abuse in Southwark, 1985).
One danger facing local initiatives is that drug misuse could become a political football between central government and local authorities and an opportunity to develop a fresh approach could be lost. The key issue is that of the financing of services for drug misusers. But together with this, it is still essential to consider the best use of money available (given that resource constraints are likely to be with us for some time) and the best use of the talents and skills available. From 1987 onwards, the three-year projects funded by the CFI come to the end of their term. Will these services attract sufficient local funding to survive — or will they go under because Local Authorities and Local Healtli Authorities will not or cannot pick up the bill? Will the late 1980s see an injection of central government funding into both Health and Local Authorities? Or will government choose to continue to directly fund (and hence more directly shape) at least some drug services?
The wider issue has to do with offering alternatives to drug taking and escapism for the beleaguered generation of the 1980s. Through the education service, training and employment, sport and leisure, cultural activities, and the youth services, efforts have to be directed to rebuilding broken communities. But the areas with the worst problems are those with the least revenue. Hard-pressed local authorities and Health Authorities find it difficult to put services for drug misusers ahead of those for, say, kidney transplants or old people. While youth have been damaged directly by the current recession, other groups, such as women and black people have also borne the brunt of the cut-backs. It is time, we paid more attention to the needs of each of these neglected groups.
1. For a fuller discussion of the effects of this dichotomy on the development of non-statutory agencies see Ettorre (1987).
2. British services are predominantly centred on a 'reformist' model of drug use and appropriate responses. The reformist model uses a rehabilitative approach, stipulating a change of life-style. The ultimate aim is a drug-free existence. The 'addict' is seen as an individual with a behavioural problem. For a discussion of three dominant philosophies (medical-model, reformist or libertarian) see Rosenbaum (1985). For a discussion of the centrality of the reformist model in Britain see MacGregor (1986).