Pubdate: Sat, 07 Jan 2012
Source: Lancet, The (UK)
Copyright: 2012 The Lancet Ltd
Contact:  http://www.thelancet.com/journals/lancet
Details: http://www.mapinc.org/media/231
Author: Virginia Berridge

THE RISE, FALL, AND REVIVAL OF RECOVERY IN DRUG POLICY

The British Government's recent drug strategy, Reducing Demand, 
Restricting Supply, Building Recovery: Supporting People to Live a 
Drug-Free Life (2010), focuses on recovery from addiction. The 
strategy claims that it has recovery at its heart. Long-term extended 
treatment using methadone or other substitute prescribing, without a 
definite endpoint, is now out of favour. Many addicts say that they 
want to come off drugs and so the Government aims to facilitate that 
desire. This so-called new abstentionism has been a controversial 
change in the drug field. Some commentators have feared that the 
focus on abstinence will end the era of harm reduction in drug 
policy. One prominent debate in the UK last year, "The Future of Harm 
Reduction and Drug Prevention in the UK", pitched Neil McKeganey, a 
sociologist and prominent advocate of abstinence, against Stanton 
Peele, a psychologist and analyst of the "meaning of addiction", thus 
epitomising the divergent positions.

Recovery is by no means a new idea in the treatment of addiction, 
although the language used to categorise it has varied much over the 
years. Why has recovery gained and lost support, and why has it been 
spoken about in different ways? The history of treatment for people 
who use illicit drugs, and the language that is used to describe 
them, tells us about a wider context, about the operation of 
interests within politics and within the discipline of addiction.

Recovery is a term redolent of 19th-century temperance, with the 
pledge as creed and reformed drunkards as the saved. In the late 19th 
century, the concept was framed through a different, medical lens. 
The idea of treatment for a condition called "inebriety", which 
encompassed both alcohol and drugs, began to form the basis of a new 
form of specialist practice. Up until then, "treating" people who 
drank alcohol or took drugs had not been much discussed; such people 
were not seen as diseased or in need of a doctor's attention. The 
British professional society, established in 1884, was originally the 
Society for the Study and Cure of Inebriety (nowadays it is the 
Society for the Study of Addiction). Initially, optimism about 
recovery was to the fore. But just a few years after its foundation, 
"cure" of the presumed disease disappeared from the strap line, as 
some of that early optimism waned.

Cure did not go away, however, and became bound up in institutional 
solutions during the late 19th and early 20th century. Doctors wanted 
to establish a state-funded system of treatment aimed primarily at 
the alcoholic caught up in the revolving door of the criminal justice 
system. Addicts sent to prison would instead be referred to 
"inebriate asylums" rather like so-called lunatic asylums, where they 
would undergo long-term treatment aimed at ultimate abstinence. The 
treatment described at that time was most often a combination of 
food, work, and religion, the rebuilding of "moral" qualities seen as 
lacking in the addict, and removing him or her from polluting 
environments. There were experiments, too, with new drug 
treatments-cannabis perhaps, coca, or chloral. There were debates 
about whether abrupt, gradual, or long-term withdrawal was most 
appropriate. Abstinence, as for temperance, was the ultimate aim. The 
proposed system never fully took root and had died away in most 
European countries and in the USA by World War 1. Recovery was not to 
come through institutional confinement.

Just after that war, during the 1920s, recovery underwent an 
important redefinition. This reconfiguration of policy lasted for 
some 40 years, into the 1960s. Treatment again assumed prominence in 
drug policy discussions. The exception was alcohol, which went its 
own way as temperance waned as a policy issue. The postwar peace 
settlement in 1918 established an international system of drug 
control, still in operation today, and national systems for the 
regulation of "dangerous" drugs.

Britain and the USA took different paths in drug treatment. In the 
USA, there was no option but abstinence-or the black market. The 
prohibition of prescription to addicts dated back to the 1914 
Harrison Narcotics Act. Doctors were prosecuted thereafter if they 
prescribed. In the UK it was different. The continuance of heroin and 
other opiate-based prescribing there in the 1920s owed much to the 
power of the British medical profession and the particular focus on 
mainly middle-class addicts. Attempts by the Home Office, newly in 
charge of drug policy, to impose a state-authorised policy of abrupt 
withdrawal, foundered in the face of medical opposition. The language 
at the time pitted the British Home Office's preference for "stamping 
out addiction", which was inspired by US policy, against the medical 
emphasis on minimum doses of drugs for addicts who could not 
otherwise lead "useful and fairly normal" lives. By the late 1920s, a 
medical modus vivendi with the Home Office had been established on 
that basis-sometimes known as the British system-which set the tone 
of policy and treatment for the next 40 years. But abrupt withdrawal 
was still the norm for addicts who came from low socioeconomic 
groups, who self-medicated, or who ended up in prison. Who controlled 
the drug and what sort of person took it was important in defining 
whether the endpoint was abstinence or continued prescription.

Contextual issues like these also affected the change towards 
methadone prescribing during the 1960s and 1970s. In the USA, a 
switch from abstinence as the only legal option to methadone as a 
substitute prescription took
place under the influence of doctors Vincent Dole and Marie Nyswander 
in New York, but also through the broader dynamic of the changes in 
the USA drug-treatment system in the wake of the Vietnam war and the 
return of addicted conscripts. Methadone had the status of a 
"medical" drug, whereas heroin in the US did not.

In Britain, the change that took place was from prescribing heroin on 
a long-term basis to prescribing methadone in the short term with the 
aim of achieving abstinence. The specialist drug dependence units 
established in the late 1960s had silted up with long-term heroin 
users. Evidence produced at the time provided a rationale for a focus 
on addicts' ultimate recovery, an approach promoted by clinic staff 
who longed for a therapeutic function. Abstinence was tied to what 
was called rehabilitation, a social "disability" model transferred 
across from similar developments in the alcohol field, and used most 
significantly by the UK's Advisory Council on the Misuse of Drugs in 
their report Treatment and Rehabilitation of 1982.

The focus on abstinence had its critics in the drug field and 
elsewhere. During the 1980s, the expanding drug voluntary sector in 
the UK was wedded to reducing harm from drugs, but this remained a 
largely unspoken objective in the context of the public "war on 
drugs". The advent of HIV/AIDS provided the opportunity for 
pre-existing ideas to be put into practice. The threat of the spread 
of HIV/AIDS into the general population through the conduit of drug 
users came to be seen as greater than the threat of the spread of 
drug misuse itself. The language changed again. What was called a 
"hierarchy of objectives" in drug treatment replaced the previous 
focus on short-term treatment leading to abstinence. That new 
hierarchy could include substitute prescribing. Both needle exchange 
and long-term maintenance with methadone became permissible, 
redefined as essential prevention strategies to tackle HIV/AIDS.

Even in those days, British Conservative politicians were unconvinced 
about treatment. But research commissioned for the Treatment 
Effectiveness Review initiated by the then Minister of Health Brian 
Mawhinney in the mid-1990s was subsequently interpreted as showing 
that "treatment works". In particular it seemed to work in ensuring 
that addicts stayed out of prison, an idea which harked back to the 
late 19th century. So maintenance and methadone revived as part of 
the incoming Labour Government's criminal justice agenda. The 
influence of the "user movement" ensured that prescribing continued 
as a central strategy.

In the USA, different issues prevailed and needle exchange as a harm 
reduction tactic (rather than methadone) proved to be particularly 
controversial. For example, in some African-American communities 
community leaders questioned the provision of needle exchanges and 
raised objections. Treatment has been legitimised in a different way. 
In the USA the "brain disease" model, which has now assumed purchase 
on both sides of the Atlantic, had its origin in the assertion from 
the US National Institute on Drug Abuse that addiction was a "chronic 
relapsing brain disorder", and so would be amenable to drug 
treatment-a portfolio of developing pharmaceutical interventions.

Now the post-AIDS consensus in the UK around harm reduction is 
questioned and recovery is the definition of the moment. Some 
commentary has identified a political strategy. Conservative 
politicians, notably Iain Duncan Smith, had questioned continuing 
drug prescription and advocated abstinence well before the Coalition 
Government came to power. Mental health had adopted the term and the 
language of "recovery" seems to have percolated through to the drugs 
field. The influence of the significant American focus on abstinence 
can also be detected. Professional interests are involved. Some 
workers in the drug field had grown tired of the focus on what one 
called "methadone, wine and welfare" and, as in the 1970s, longed for 
change. The purpose of treatment and the meaning-and history-of 
"recovery" is being negotiated. The UK Drug Policy Commission has 
defined recovery as a process, which may involve support from 
medication. Economics, payment by results, is also on the new agenda. 
How "recovery" differs from "cure", "rehabilitation", or a "hierarchy 
of objectives" will depend on the changing context within which the 
new language operates, and the political and professional interests 
who negotiate to establish its meaning in policy and in practice.
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