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. - --- MAP posted-by: Jo-D