Archive for the ‘Recovery’ Tag

What’s worse than being a woman with a drug problem?

Thursday, October 31st, 2013

Something which the Government failed to mention in its recent, polished figures is that female unemployment is at its highest for twenty five years. Women’s organisations are pointing out that austerity measures unfairly target women, by making cuts to child benefits at a time when childcare and household bills are rapidly increasing, whilst those that do have jobs still get paid less than men (in 2010, in the public sector – which one may imagine to be the least discriminatory employer – the pay gap between men and women was still an incredible 21%).

An interesting article in Drink and Drug News this month considers the impact of austerity on female drug users. I touched on the stigma faced by women who use substances in Baby wants a double vodka, but this article looks at the effects of the cuts to service provision, given the complexities that often come hand-in-hand with being a woman with a drug problem.

As Caroline Lucas MP points out, women’s substance misuse is often more complicated than men’s, regularly associated with parental and sexual stigmatisation and shame, childcare issues, domestic abuse and prostitution. Yet these specific needs were omitted entirely from the 2010 Drug Strategy, and the ‘bulk-buying” approach to commissioning has meant that gender nuances are now ignored.

The women’s drug service in our area has vanished during the cuts, and their work absorbed by generic drug workers who have less capacity for home visits and parenting work. Many of their clients, who have experienced issues such as sexual abuse, may now need to be seen by male workers, unless they have the confidence to make demands (confidence not being a trait often associated with this group – neither the balance of power when your script depends on it). And whereas having a family may be seen as increasing someone’s ‘recovery capital’, is this necessarily the same when, for women, this may include single parenthood and domestic abuse?

Attempts to maintain and develop best practice are further stretched as fewer staff mean workloads increase – and research into joint-working models has exposed that workers who attempt a multi-agency approach to supporting women often report having to hide this from their managers, as the extra work they do cannot be directly evidenced statistically and so is considered ‘out-of-remit’.

And then there’s what social worker Gretchen Precey has tagged ‘start again syndrome’ – the desire to see every woman’s pregnancy or birth as a fresh start. The dilemma working with this client group is balancing the constant need for motivation and positivity, the belief in the possibility of change, with prioritising the needs of helpless foetuses and babies. As workers, when we see chaos, we often understand vulnerability – and we desperately focus on the glint of positive in the shit pile of someone’s life. But to ignore a woman’s past experiences of motherhood is dangerous, warns Precey – and in a culture where professionals are blamed for any harm that comes to a child (as though, I always feel, they are the perpetrators), workers are left to balance hope against risk. It creates a moral clash. These are the cases that keep you awake at night.

Almost ten years ago, I was involved in a consultation on the Government’s white paper, Paying the Price, which looked at how best to manage prostitution. It seems sad that, years later, the comments I made then ring truer than ever. My point was – the links between child abuse and sex work are well-documented, and yet Social Care are increasingly under-funded and over-stretched. What was once a support service now exists almost exclusively for the purpose of risk management. And so, whether we consider female sex workers, female drug misusers, or women who struggle with motherhood, the common themes remain the same – and as long as we fail to address the root causes of these issues, we are producing the next generation exhibiting these behaviours. The chain continues.

And some of you will know how it feels to see the kids you tried to protect all those years ago arriving at your door with baby bumps, track marks and utter disgust at the world.

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Frank – it’s Cockney rhyming slang

Thursday, February 7th, 2013

It’s ten whole years since the Government launched their new weapon against the war on drugs – Frank. I’m guessing the name was intended to be a pun bulging with bathos.

At the time the campaign went public, there was a real need for something practical and useful for young people. Drug use was at an all-time high, and ecstacy had become cheaper than alcohol. Schools didn’t have a clue how to deal with drug use, with responses ranging from ignoring it to calling the Police, parents knew they were out of their depth, and the links for young people between vulnerability and drug use grew fiercely stronger.

The problem with Frank was – it was absolutely shit. Fancy branding and expensive adverts could not hide the fact that on the end of the phone was not Frank, knowledgable big brother with his hand on your shoulder and a quirky sense of humour, but instead Bernard, a middle-aged divorcee with charisma issues who works in a call centre and hasn’t yet quite mastered the software providing him with his stilted answers. It was like having a conversation about sex with a nun on an iPhone. I could have got better drugs advice off my grandma. Thinking about it, Frank could easily have been the most common name amongst its employees.

Ten years on, there are claims that this service is somehow linked to the reduction in drug use nationally. Then there is the opposition that the service has not stopped anyone taking drugs. These positions both seem to miss the central purpose of the service, as I understand it – Frank was never intended to stop people taking drugs. It was developed during the heyday of harm reduction, and was created to provide information so people made more informed decisions about their drug use.

These misconceptions are either accidental and come from the assumption that ‘drugs are bad, kids’, or are purposefully missing the point to support whichever political argument you might favour. However they may also be symptomatic of what Drink and Drug News have called ‘stigma created by an abstinence-focused recovery wave’. Which side-lines drug users. Which means people don’t get the information or support they need. Which leads to health and social problems. Which is why the harm reduction movement started. (Can anyone else see a pattern emerging..?)

I have to agree with the critics – that this is an attempt by the Government to plug a hole that should be filled by comprehensive drugs education in schools (possibly why it has escaped budget cuts so far). But as long as the drug stats are falling, despite this not being the raison d’ĂȘtre for the service, the politicians can sit back and say they are ‘addressing’ the drugs problem.

However, considering that they had nearly four million contacts with young people last year, Frank certainly seem to be doing something right.

To treat or not to treat, that is the question

Monday, December 3rd, 2012

A recent paradigm shift within the drugs field has further complicated an already difficult and lively debate around what constitutes drug treatment and who should qualify for it. This movement has, weirdly, sprung from a combination of both grass-roots support groups and the Coalition’s austerity measures.

In years gone by (and still in some regions today), Community Drug Teams were primarily made up of mental health nurses who, from what I could see, had got fed up with shift work on acute wards (having to work nights with full-blown nut jobs) and decided that community work was probably a cushy number (9-5 weekdays and 44p a mile). On the whole, these services met very nicely the needs of the nurses – and the prescribing psychiatrists – who admittedly had to endure sitting in grubby rooms in run-down buildings (god forbid drug users be seen in health centres and mix with the public), escorting their patients to the toilet for weekly supervised drug tests in return for a methadone prescription. Services were there to treat, almost exclusively, heroin users; a social group who, at the time, were massively excluded and disempowered, and who were very much at the services’ mercy. The power dynamic was engrained and aggressively maintained – CDT consultation rooms were reminiscent of Dickensian orphanages, and for those of us new to the field and not (at that point) full of cynicism, it was uncomfortable to witness. The approach was not holistic, nor did it address the psychological or social needs of the individual, and only those prepared to dip their caps, express their subordinate gratitude, reduce their drug use as instructed, attend regular appointments, and grovel for several weeks, if not months, ever made it past the waiting list for a prescription.

For those who did make it as far as an appointment with the prescriber, the only treatment available was low-dose, short-term methadone. The standard treatment plan was: enter treatment, stop using all drugs immediately, then reduce methadone dosage rapidly until opiate-free. Unsurprisingly, this method was rarely successful, as not only did it leave service users in a state of opiate withdrawal from treatment start until several weeks after treatment end, it also failed to take into account the person’s reasons for starting to take heroin in the first place – so as the opioids reduced, past trauma resurfaced, mental health problems were unmasked and exacerbated, and the reality of life hit right between the eyes. And should Mr Druguser share his concerns with Mrs Nurse, possibly disclosing self-prescribed codeine or Valium use to manage the symptoms produced by fast detoxification from methadone, he ran the risk of being labelled ‘not ready for treatment’ and being plonked back onto the waiting list. People could sit on these for up to a year in some areas, and the nurses seemed to miss the fact that heroin – well, it’s quite moreish. Needless to say, what became known as ‘The Revolving Door of Treatment’ only helped anyone whose motivation was extremely high, support networks were excellent, and mental health was completely stable. Everyone else spent their time trying to get onto a script, only to be either kicked off mid-treatment, or detoxed so fast that relapse onto heroin to manage withdrawal symptoms from methadone became almost unavoidable.

Then people started dying. Or at least, the public started to notice people dying. Bodies were being dumped in wheelie bins and skips because the Police automatically attended overdoses with ambulances. Families of the dead started to campaign, drug services came under fire, and at the same time, the links between Class A drug use and acquisitive crime were being formally logged, making these problems not just for those at the bottom of the social strata, but for the whole community.

And so came the 10-Year Drug Strategy, the new Labour Government’s attempt to tackle the problem. Money came flooding in to fund new services, and the focus of treatment shifted from purely medical to consider social and psychological aspects, meaning that there were opportunities for non-medical staff within the field (sometimes even within the mystical and superior world of prescribing). Services even started to employ ex-service users who had furthered themselves in education and experience. The power dynamic between service provider and service user started to dissolve, drug users were listened to – and, in many cases, preferred and pampered, with complementary therapies, immediate access to specialist education provision, and vulnerability tags when applying for housing.

The philosophy became – treat everybody. The research providing the evidence-base told us that a heroin user is less likely to die in treatment than when not in treatment; lessons from the 80s told us that legal and public denial of injecting practices led to steep increases in HIV and hepatitis C infection as a result of needle-sharing; the costs of treating health problems associated with long-term IV use and policing drug-fuelled acquisitive crime became clearer; and so thresholds for access to treatment were reduced. Harm Reduction was the phrase of the era, and this was extended to the harm caused to communities as well as to drug users themselves. Year by year, the money kept on coming and, to be honest, drug users and drug workers alike became a bit spoilt.

And so we move into a recession and a right-wing government. New presentations into opiate treatment are few and far between because heroin is so passĂ©, and those with the will have made use of the plethora of services and reintegrated into mainstream society. The group that are left are not happy – no more free gym passes or massages, no more sick pay for providing sick notes stating ‘substance misuse issues’, but instead an expectation to attend medicals and Jobcentre courses.

At the same time, the Recovery Movement becomes popular. Now the phrase, ‘Recovery’, does not sit comfortably with me. It is a phrase that comes from the mental health domain and conjures in my mind images of the sick – all very 12-Step Model, where substance use is not a choice but a disease for which there is no cure, where the victim must struggle through and put faith in a ‘higher power’ to help them manage this terrible affliction. Dodgy. I personally find it disempowering, patronising and lacking in the notion of personal responsibility – it’s not a disease, it’s a lifestyle choice, you haven’t got cancer for christ’s sake – but I appreciate that it is a phrase that was chosen and adopted by a group of service users, and so who am I to criticise. If it works and people relate to it, that’s fine by me.

The Recovery Model also promotes working towards abstinence. Now abstinence became somewhat of a taboo phrase during the Harm Reduction Years, as the focus was on engagement and retainment in treatment, to reduce the damage drug use did to individuals’ health and the overall damage done to communities (admittedly for financial reasons, not the sympathetic reasons Tony might have had us believe). And so what the Coalition has done, somewhat cleverly it has to be said, it to take a service user-led movement which focuses on moving people away from substance use by moving them towards ‘recovery’, and twisted this into “You know that expensive drug treatment you’ve all been getting for years? Well, much like your benefits, you’re not going to be getting it for much longer. Get your head round it. Oh and – it’s for your own good you know”. Handy – and cheap.

Now I’m not one for enabling drug users to remain unquestioningly stationary – and anyone who has read my other posts will know that I am also sick to death of the ‘dependency culture’ that has developed in this country. But taking a group of people who have been socially vilified then pitied, who have been consistently encouraged to get in treatment, stay in treatment, and routinely drink the green nectar as their contribution to society for the last ten years – and then giving them six months to fully detox from methadone and get a job – that is just too much to ask and too great a challenge to the belief system of someone who thinks that going to the chemist every day is a vocation.

Some services, fearing decommissioning, have done exactly that – employed a ‘six months and you’re out’ policy. Others have decided that if someone drops out of treatment, that ‘probably means’ they don’t need treatment any more and so must be classed statistically as a ‘successful discharge’. This lack of any real health-focused philosophy within drug services is driven by the Government’s new system of Payment By Results – and the results they want are drug users out of treatment and into work (hence the targets around successful discharges). As well as the questionable morality of removing what has been sold for many years as a medical intervention (without a change in the research-base about its effectiveness, may I add), it chooses to turn a blind eye to the lack of skill, experience or motivation of most of the people left within this (pretty hopeless) group. Most importantly, it fails to acknowledge the level of psychological dependence on the medication that has enabled the opiate-dependent to function as normal human beings, given that methadone and buprenorphine (Subutex) both have long half-lives where heroin’s is very short, and so users take their medication once a day and then can go about their business (probably watching Jeremy Kyle, training their Staffies to fight, and seeing who picks up benzodiazepines at the chemist today if I’m honest – but many also work, parent successfully, and lead more stable lives than I). The fear of opiate withdrawals is significantly worse and longer-lasting than the physical withdrawals themselves, and politicians encouraging, promoting and feeding that dependency for TEN YEARS, then withdrawing it, is, in my mind, nothing short of abusive.

And where will it take us, I wonder, when in a few months’ time this group are poorer, more desperate and without the crutch that for so long has reduced their risk of dying? Is that a revolving door I see…?

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