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What are drug users looking for when they contact drug services: Abstinence or harm reduction?

  • Centre for Substance Use Research Ltd.

Abstract and Figures

Within the UK and in many other countries two of the most significant issues with regard to the development of health and social care services for drug users has been the growth of the consumer perspective and the philosophy of harm reduction. In this paper we look at drug users' aspirations from treatment and consider whether drug users are looking to treatment to reduce their risk behaviour or to become abstinent from their drug use. The paper is based on interviews using a core schedule with 1007 drug users starting a new episode of drug treatment in Scotland. Participants were recruited from a total of 33 drug treatment agencies located in rural, urban and inner-city areas across Scotland. Our research has identified widespread support for abstinence as a goal of treatment with 56.6% of drug users questioned identifying 'abstinence' as the only change they hoped to achieve on the basis of attending the drug treatment agency. By contrast relatively small proportions of drug users questioned identified harm reduction changes in terms of their aspiration from treatment, 7.1% cited 'reduced drug use', and 7.4% cited 'stabilization' only. Less than 1% of respondents identified 'safer drug use' or 'another goal', whilst just over 4% reported having 'no goals'. The prioritization of abstinence over harm reduction in drug users treatment aspirations was consistent across treatment setting (prison, residential and community) gender, treatment type (with the exception of those receiving methadone) and severity of dependence. On the basis of these results there would appear to be a need for harm reduction services to be assiduous in explaining to clients the reason for their focus and for ensuring that drug users have access to an array of services encompassing those that stress a harm reduction focus and those that are more oriented towards abstinence.
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What Are Drug Users Looking For When They Contact
Drug Services: abstinence or harm reduction?
*, ZOE
Centre for Drug Misuse Research, University of Glasgow, UK;
Judge Institute of Management, University of Cambridge, Trumpington Street,
Cambridge, UK;
Department of Social Policy and Social Work, University of York, UK;
Robertson Centre for Biostatistics, University of Glasgow, UK
ABSTRACT Within the UK and in many other countries two of the most significant
issues with regard to the development of health and social care services for drug users has
been the growth of the consumer perspective and the philosophy of harm reduction. In this
paper we look at drug users’ aspirations from treatment and consider whether drug users
are looking to treatment to reduce their risk behaviour or to become abstinent from their
drug use. The paper is based on interviews using a core schedule with 1007 drug users
starting a new episode of drug treatment in Scotland. Participants were recruited from
a total of 33 drug treatment agencies located in rural, urban and inner-city areas
across Scotland. Our research has identified widespread support for abstinence as a goal
of treatment with 56.6% of drug users questioned identifying ‘abstinence’ as the only
change they hoped to achieve on the basis of attending the drug treatment agency. By
contrast relatively small proportions of drug users questioned identified harm reduction
changes in terms of their aspiration from treatment, 7.1% cited ‘reduced drug use’, and
7.4% cited ‘stabilization’ only. Less than 1% of respondents identified ‘safer drug use’
or ‘another goal’, whilst just over 4% reported having ‘no goals’. The prioritization of
abstinence over harm reduction in drug users treatment aspirations was consistent across
treatment setting (prison, residential and community) gender, treatment type (with the
exception of those receiving methadone) and severity of dependence. On the basis of these
results there would appear to be a need for harm reduction services to be assiduous in
explaining to clients the reason for their focus and for ensuring that drug users have access
to an array of services encompassing those that stress a harm reduction focus and those
that are more oriented towards abstinence.
Over the last fifteen years, two important developments have in different
ways influenced the provision of treatment and care to drug users within
the UK. The first of these is an increasing focus on the consumer perspective in
health and social care services (Forbes & Sashidharan, 1997; Lindow, 1999;
Drugs: education, prevention and policy ISSN 0968–7637 print/ISSN 1465–3370 online #2004 Taylor & Francis Ltd
DOI: 10.1080/09687630410001723229
Drugs: education, prevention and policy,
Vol. 11, No. 5, 423–435, October, 2004
* Correspondence to: Neil McKeganey, Centre for Drug Misuse Research, University of Glasgow, UK.
Tel: 0141 3303616. Fax: 0141 3302820. E-mail:
Kemshall & Littlechild, 2000). The second is the increase in, and diversity of, harm
reduction initiatives that have evolved as pragmatic approaches to the problem of
drug addiction (Berridge, 1991; Stimson, 1995; Gossop, 1998).
In terms of the consumer perspective, it has become commonplace to obtain
the views of service users in assessing virtually every aspect of service provision
from development to delivery. Historically, though, this perspective has had
rather less impact on the world of drug misuse treatment than other areas of
health and social care (Neale, 1998). By and large, professionals and resource
availability determine the planning and provision of drug treatment and this
seems to hold true across the various available treatment options. Thus, decisions
about whether individuals are offered methadone maintenance rather than
methadone reduction, dihyrocodeine rather than diazepam, or a place in a
residential rehabilitation unit rather than a residential detoxification service are
seldom made by drug users themselves. Similarly, the particular mix of residen-
tial and community-based services within any given local area is invariably a
function of provider perspectives and funding priorities, not the views of local
people affected by addiction (Kennedy et al., 2001).
The above does not, of course, mean that the views of drug users have been
entirely ignored by service planners and providers. Indeed, the Scottish Executive
has recently promoted the development of drug-user groups throughout
Scotland in the expectation that service providers would consult their clients.
In addition, the Scottish Drugs Forum has an active user and carer involvement
team, which had been developing a distinctive model of practice across the
country over the last four years. Despite this, it is still the case that hardly any
drug action teams within Scotland or elsewhere in the UK, have allocated places
specifically to members of drug-user groups (Kennedy et al., 2001).
If the consumerist perspective has had only limited impact on the world of
drug-use treatment and care within the UK, the situation is very much the
opposite in respect of the harm-reduction perspective. In recent years, this
approach has had an unparalleled impact on the world of drug-abuse treatment
and care (Marlatt, 2002). Although there is no clear single definition of harm
reduction within the drugs field, the International Harm Reduction Association
has characterized it as a set of:
...policies and programs which attempt primarily to reduce the adverse
health, social and economic consequences of mood altering substances
to individuals, drug users, their families and their communities.
(IHRA, 2002)
The harm-reduction perspective is thus very different from the abstinence
approach, which encourages drug users to cease all use of illicit substances.
A harm-reduction model of service delivery recognizes that abstinence can be
an unrealistic goal for many. Accordingly, it is considered entirely appropriate
to provide addicted individuals with the means to reduce the harm associated
with their continued substance use. Within the UK, much of the impetus
underpinning the development of harm-reduction approaches in the care and
treatment of drug users was the statement by the Advisory Council for the Misuse
of Drugs that the:
threat to individual and public health posed by HIV and AIDS was much
greater than the threat posed by drug misuse. (ACMD, 1988)
424 N. McKeganey et al.
In light of the perceived public health threat of AIDS and HIV, the UK Govern-
ment extended the use of harm-reduction measures, such as substitute drug
prescribing, and authorized the development of needle and syringe exchange
programmes. Whilst some people saw the provision of sterile injecting equipment
as condoning an illegal activity, there was widespread agreement that this was at
least one way in which drug users, as well as society in general, could be
protected from a deadly new infection (Berridge, 1991; Gossop, 1998). Over
time, harm reduction has acquired the status of a distinctive social movement
with its own international organization and annual conference lobbying in favour
of a wide range of pragmatic drug policies including the depenalization or
legalization of illegal drug use, pill testing, and the development of safe injecting
In this article, we combine this focus on consumerism and harm reduction
by asking whether drug users contacting treatment services are looking for
help in reducing the harms associated with their continued drug use or for
assistance in achieving abstinence. The data on which the paper is based have
been collected in the course of an ongoing prospective study of drug users
contacting drug-treatment services in Scotland. It will be helpful to provide some
background information on this study before looking in detail at individuals’
treatment aspirations.
Between 1 October 2001 and 30 June 2002, 1007 individuals beginning a new
episode of drug treatment were interviewed as part of the Drug Outcome
Research in Scotland (DORIS) study. DORIS is a prospective cohort research
project that is designed to provide a wide-ranging evaluation of the main
treatment services currently available to drug users in Scotland. The study has
full ethical approval from the Scottish Multi Centre Research Ethics Committee
and involves an intake interview (to collect baseline information on participants’
circumstances) and interviews thereafter on an eight-monthly cycle to assess
individuals’ progress over time.
Drug users were recruited onto the study from 33 agencies located in rural,
urban and inner-city areas across Scotland. Prior to joining the cohort, potential
participants were given an information sheet about the research; fully apprised
of the study requirements—including the need for subsequent interviews;
reassured of the confidentiality of their responses; and asked to sign a consent
form. After completing their first interview, each drug user was paid £10 for their
inconvenience [1] and told when they would next be contacted.
Respondents were interviewed using a structured questionnaire administered
by one of a team of trained interviewers from the Centre for Drug Misuse
Research at Glasgow University. This structured questionnaire collected informa-
tion on issues including current and recent drug use (legal, illegal and pre-
scribed), previous use of drug-treatment services, employment status, housing
circumstances, relationships with peers and family members, health, involvement
in criminal activities, and contact with the criminal justice system. Interviews
generally took between one and two hours to complete and 88% of the new
treatment clients approached agreed to participate in the research. The figure of
1007 drug users included in this study represents approximately one in twelve
What Are Drug Users Looking For? 425
of all drug users contacting drug-treatment services in Scotland for a new episode
of treatment over a twelve-month period.
Of the 1007 drug users interviewed, 695 (69%) were male and 312 (31%) were
female. Their median age was 27 years (range 16–53) and 1000 (99%) were white.
Women were generally younger than men, the median age of females being
24 years compared to 28 years for males. At the time of their first interview,
respondents were starting to receive a range of treatments. These were substitute
drugs excluding methadone [2] (29%); methadone (27%); non-clinical assistance
[3] (20%); residential detoxification (12%); and residential rehabilitation (12%).
In total, 560 individuals (56%) were recruited from a community setting (specialist
drug service, GP practice or pharmacy) and 447 individuals (44%) were recruited
from a prison. Although this paper is principally based upon data from the first
sweep of DORIS interviews the paper also contains information on the propor-
tion of drug users who were able to attain a period of abstinence eight months
and sixteen months following their recruitment into the study. These data on
abstinence are drawn from the second and third sweeps of the DORIS study.
Statistical Analysis
Analyses were carried out on the drug users’ achievement hopes from the drug
agency they were attending. Comparisons were made between the responses
for treatment type (residential, non-clinical, etc.); treatment setting (community
and prison); gender and finally severity of dependence scale (SDS) score for their
main drug. As part of the DORIS questionnaire, the SDS was completed in respect
of each individual’s main drug (Gossop et al., 1995). The SDS involves five
questions (each scored from 0 to 3) that collectively quantify the degree of
psychological dependence experienced by users. These five questions are: ‘Did
you ever think that your [main drug] use was out of control?’; ‘Did the prospect
of not taking any [main drug] make you anxious or worried?’; ‘Did you worry
about your [main drug] use?’; ‘Did you wish you could stop using [main drug]?’;
and ‘How difficult would you find it to stop, or go without [main drug]?’. Total
SDS scores range from 0 to 15, with higher scores indicating more problematic
drug use. For the categorical variables analyses were carried out using chi-square
test of association. For the SDS score an analysis of variance test (ANOVA) was
carried out.
The data in Figure 1 are based on responses to the question: ‘What changes
in your drug use do you hope to achieve by coming to this agency?’ Drug users
were then asked to tick all responses that applied to them from a list of options
that included: ‘abstinence/drug free’; ‘reduced drug use’; ‘stabilization’; ‘safer
drug use’; ‘no goals’; and ‘other goals’. Nine individuals indicated ‘other goals’
and in eight cases it was possible to categorize the response into one of the options
‘abstinence/drug free’, ‘reduced drug use’, ‘stabilization’ or ‘safer drug use’.
In response to this question more than half of the drug users (56.6%) cited
‘abstinence’ as the only change they hoped to achieve from attending the
drug agency, while nearly a quarter (24.0%) ticked more than one goal. Relatively
small proportions of respondents cited ‘stabilization’ (7.4%) or ‘reduced drug
use’ (7.1%) as the only change they wished to bring about while even fewer
selected ‘safer drug use’ (0.7%). In addition, 4.1% had ‘no goals’.
426 N. McKeganey et al.
Figure 1 clearly shows that abstinence was the mostly commonly reported
outcome desired from contact with a drug-treatment service. Nevertheless, the
finding that nearly a quarter of drug users cited more than one goal seemed
to merit closer investigation. Accordingly, the responses of individuals citing
multiple goals were reviewed and reclassified with the responses evident in
Table 1.
Table 1 shows that multiple responses subdivided into two main categories:
‘abstinence plus one or more harm-reduction goals’ (n¼185) and ‘combinations
of harm-reduction goals’ (n¼41). The most frequent combination of outcomes
was ‘abstinence and stabilization’ (n¼82). In addition, a small number of indi-
viduals (n¼16) reported other groupings such as ‘abstinence, harm reduction
and other’ or ‘harm-reduction goal(s) and other’. Table 1 thus reveals that
respondents often desired a range of outcomes in tandem and frequently these
involved abstinence in combination with one or more harm-reduction aims.
For subsequent analyses, it seemed most useful to focus on the three main
groups of respondents: (1) those seeking abstinence only (n¼570); (2) those
desiring harm-reduction goal(s) only (n¼197) [4]; and (3) those wanting both
abstinence and harm-reduction goal(s) (n¼199). Respondents citing no goals
(n¼41) were excluded from these analyses, as were responses which could not be
included in one of the three groupings, such as wishing to be abstinent from
a particular drug or those specifying particular treatment types. In addition,
respondents who failed to answer the question were excluded from the analysis.
Therefore 966 cases were included in the subsequent analyses.
Aspirations by Treatment Type
In the introduction to this paper, we noted that drug treatment providers
have in recent years focused increasingly on harm reduction. Nonetheless, it
7.4 7.1
Abstinence only
Stabilization only
Reduced use only
Safer use only
Another goal
More thanone goal
Figure 1. Treatment goals.
What Are Drug Users Looking For? 427
would not be accurate to state that all kinds of service provision have embraced
this philosophy to the same extent. For example, residential detoxification and
rehabilitation services obviously adhere to a more abstinence-orientated approach
than substitute prescribing services. It therefore seemed valuable to consider the
drug users’ aspirations according to the different kinds of treatment that they
were about to receive and the results of this analysis are depicted in Figure 2.
Although abstinence was clearly the predominant aspiration across each of
the treatment categories, particularly high proportions of drug users in residen-
tial services were seeking to be completely drug free. Indeed, over 80% of
residential rehabilitation clients and 73.4% of residential detoxification clients
reported abstinence to be their only goal. Amongst those receiving non-clinical
treatments and other substitute drugs, the percentages of individuals desiring
Table 1. Breakdown of respondents citing more than one goal
Goal n
(1) Abstinence plus harm-reduction goal(s)
Abstinence and stabilization 82
Abstinence, stabilization and reduced use 33
Abstinence and all 3 harm-reduction goals 32
Abstinence and reduced use 23
Abstinence and safer use 8
Abstinence, stabilization and safer use 5
Abstinence, reduced use and safer use 2
Total 185
(2) Harm-reduction goal(s) only
Stabilization and reduced use 23
All 3 harm-reduction goals 10
Stabilization and safer use 4
Reduced use and safer use 4
Total 41
(3) Includes ‘other’—14 with both abstinence and harm-reduction goal(s),
and 2 with harm-reduction goal(s)
Res rehab
Res detox
Other subsitute drug
Abstinence only
HR only
Abstinence & HR
Figure 2. Aspirations by treatment type.
428 N. McKeganey et al.
abstinence were also very high (nearly 60% in both cases). Meanwhile, 42.5% of
respondents receiving methadone stated that they hoped to achieve abstinence
Figure 2 also reveals that the most common treatment goal after abstinence
only was abstinence in conjunction with a harm-reduction goal or goals. This was
the case across all treatment types except other substitute drugs where harm
reduction was preferred. These differences in aspirations across treatment
types were highly statistically significant with a p-value of <0.0001.
Aspirations by Treatment Setting
As highlighted previously, nearly half of the DORIS sample was recruited from
the Scottish Prison Service. Treatment options offered in this setting differ
appreciably from those offered within the community. Specifically, there is a
greater inclination to non-clinical interventions, non-methadone drugs tend to be
preferred over methadone, and there is an absence of ‘residential treatment
provision’ (as defined by ‘a structured programme of therapeutic activities within
a supportive residential environment’). In addition, drug users’ motivations for
participating in treatment within a prison are likely to differ from motivations
within the community. In this regard, previous research has shown that prison
and criminal-justice referred drug-treatment clients tend to be less motivated than
other drug users (Farabee et al., 1993; Kline, 1997; Brochu et al., 1999). Accordingly,
one might speculate that the prisoners would be less likely to aspire to being
completely drug free.
Figure 3 compares respondents’ aspirations for treatment across the prison
and community drug-treatment settings and shows that 59.1% of drug users
interviewed in prison reported ‘abstinence’ only as their desired goal, with 33.3%
citing harm-reduction goal(s) and 7.6% reporting both abstinence and harm-
reduction goals. Amongst those interviewed in community-based agencies, 59.0%
cited ‘abstinence’ only, 10.9% reported harm-reduction goal(s), and 30.1%
indicated combined goals. Counter intuitively, then, prison drug users were
no less inclined towards abstinence or harm reduction goals, but seem much less
likely to specific both types of goal. Nonetheless, they still expressed a very clear
desire to be totally drug free. These differences in aspirations across treatment
setting were highly statistically significant with a p-value of <0.0001.
Prison Community-based
Abstinence only
HR only
Abstinence & HR
Figure 3. Aspirations by treatment setting.
What Are Drug Users Looking For? 429
Aspirations by Gender
Although there has been no previous research investigating gender differences
in desired treatment outcomes, a number of studies have revealed significant
differences in the drug careers and treatment trajectories of men and women
(e.g. Callaghan & Cunnigham, 2002; Green et al., 2002; Neale, 2004). In particular,
there is widespread evidence that women encounter more barriers in accessing
drug services and these include negative stereotyping; social stigma; ignorance
about the range of treatment options available; concerns about childcare; trans-
portation problems; and anxieties about the confrontational models used within
some treatment programmes (Copeland, 1997; Fraser, 1997; Marsh et al., 2000).
It seemed likely, therefore, that those women who have actually begun the
treatment process would be very determined to succeed and thus especially keen
to achieve abstinence.
Figure 4 presents responses for the DORIS drug users’ treatment goals by
gender. As anticipated, women were more likely to report aspirations for
abstinence. However, this should not detract from the finding that once again
being drug free was the overwhelming desire of both male (57.1%) and female
(63.4%) drug users. At the same time, very similar proportions of men and
women desired harm reduction goal(s) (21.6% and 17.6% respectively) and
combined abstinence and harm-reduction goal(s) (21.3% and 19.0%) respectively.
These differences in aspirations across gender were not statistically significant
with a p-value of 0.17.
Aspirations by Severity of Drug Dependence
Levels of drug dependence have been found to predict initiation of treatment
(Weisner et al., 2001) in some cases but not in others (Hser et al., 1997). Despite
this, there is some logic to the argument that individuals experiencing the most
problematic forms of drug use are more likely to identify a need for complex
multifaceted forms of treatment. In contrast, those with the least problematic use
may be more likely to desire less radical and less interventionist forms of
assistance because they do not yet feel ready for change. In the next analysis,
we considered treatment aspirations by levels of dependence.
The 966 DORIS study participants included in the analysis had a mean
total SDS score of 10.65 (SD ¼3.85), thus indicating overall high levels of drug
dependence compared with other studies (Gossop et al., 1995). The breakdown
of mean scores of the three respondent groups is depicted in Figure 5.
21.6 21.3
17.6 19
Abstinence only
HR only
Abstinence & HR
Figure 4. Aspirations by gender.
430 N. McKeganey et al.
As anticipated, those who said they had harm-reduction goals had the lowest
mean SDS score (M¼9.64; SD ¼3.98). Meanwhile, those who stated abstinence as
their only goal had a slightly higher mean score (M¼10.62; SD ¼3.93) and those
identifying harm-reduction and abstinence goals reported the highest levels of
dependency (M¼11.72; SD ¼3.17). These differences in SDS score between the
aspirations groups were highly statistically significant with a p-value of <0.0001.
Achieving Abstinence
Much of this paper has been about drug users’ aspirations for abstinence. We
have shown that the majority of drug users recruited into the DORIS research
cited abstinence as the sole change that they wished to bring about on the basis of
contacting the drug agency where they were interviewed. Because DORIS is
a prospective study, with drug users being interviewed on an eight-monthly
cycle, we have the opportunity of looking at what proportion of drug users were
able to sustain a period of abstinence over successive sweeps of the DORIS
interviews. In Figure 6 we have summarized the proportion of respondents who
were abstinent of all drugs and those whose drug use was confined to cannabis at
the time of their successive DORIS interviews. We have also looked at the
proportions of DORIS respondents who had a period of abstinence of at least
two weeks’ duration between the DORIS interview sweeps. In the case of the
second DORIS interviews, undertaken eight months after the first interview,
we were able to interview 85% of the original 1007 cohort (859 respondents).
In the case of the third interview (undertaken sixteen months after the first
DORIS interview) we were able to interview 78% of the original 1007 cohort.
Between the first and second DORIS interviews 11% of respondents had a
period of abstinence of at least two weeks’ duration, where their drug use was
confined to cannabis, and 30% had been completely abstinent over a similar
period. However, at the actual point of the DORIS 2 interviews only 6% of drug
users were abstinent apart from cannabis use. At the point of the DORIS 3
interviews 12% of drug users were abstinent from all drugs. These data show
that a significant minority of drug users are able to achieve at least a period
of abstinence within a relatively short period of having started drug-abuse
treatment. It is evident, however, that sustaining abstinence is by no means a
simple task.
Abstinence only
HR only
Abstinence & HR
Mean SDS score
Figure 5. Aspirations by severity of dependence scale score for main drug.
What Are Drug Users Looking For? 431
In this paper, we have looked at drug users’ aspirations for change on first contact
with a drug agency for a new episode of treatment. We have seen that when
individuals contacting drug-treatment services were presented with a range of
possible aims (from abstinence to harm reduction), almost 60% of individuals
said that abstinence was the only goal that they were seeking to achieve. This
finding was consistent across all treatments except methadone; all treatment
settings, except community settings (where 70% of methadone prescribing took
place); as well as gender. Whilst there were differences in level of dependence
between the groups, those respondents with the highest levels were the most
likely to cite abstinence as the desired goal of treatment.
In contrast, very few drug users cited harm-reduction outcomes (reduced use,
stabilization or safer use) as the only change that they desired. This is a surprising
finding since harm reduction and its associated goals have had an unparalleled
influence on the world of drug-user treatment and care in the UK over the last
ten years or so. On this basis one would have thought that the goals of harm
reduction (reduced risk behaviour, stabilization, safer injection etc.) would have
been more salient in terms of drug users’ aspirations for treatment.
The data presented within this paper should not be interpreted simplistically
as suggesting that one type of approach to service provision (abstinence) should
be provided in preference to another (harm reduction). A number of other
relevant factors need to be considered. Firstly, the views of drug users are only
one of many relevant factors that should be considered when developing
and delivering drug-treatment services. Harm-reduction approaches are a valu-
able public-health measure in protecting drug users, their families and the wider
community from a range of harms. It is therefore arguable that even if no
individuals cited harm-reduction as an aim, it would still be appropriate for
services to provide a harm-reduction input. Secondly, few people make an
immediate and once-only transition from drug use to abstinence, which means
that harm-reduction measures are still relevant to them as long as they are using.
Abstinent except for
Completely abstinent
Between DORIS 1 & 2
Between DORIS 2 & 3
Figure 6. Abstinence periods between DORIS 1 and 2, and between DORIS 2
and 3 (% drug users).
432 N. McKeganey et al.
Thirdly, abstinence may not be a realistic goal for some drug users even though
they may aspire to it. Thus, one might want to question whether persistent
failed attempts at abstinence will ultimately be more damaging and demoralizing
for drug-agency clients than success on at least one significant measure of harm
reduction. We cannot answer this question with these data. What we can say,
however, is that in principle the two things (harm reduction and abstinence) are
not mutually exclusive and that if we conceive of recovery as a process, then
harm reduction may form an essential element of transitional support, allowing
that peoples’ capacities for and commitment to change may vary over time, such
that in due course abstinence may come to be perceived by drug-treatment
agency staff as an achievable for many if not most drug users (McIntosh &
McKeganey, 2002).
Finally, there may be some issues around the meaning of abstinence itself
that might influence the findings. It is possible that drug users may have been
providing what they thought would be the most socially acceptable response
to the question about desired changes in drug use rather than the response
which most accurately reflected their actual expectations for change, thus over-
prioritizing abstinence. In addition, drug users’ definitions of abstinence were
not sought. In this regard, further examination of whether respondents really
interpreted abstinence as meaning ‘no illicit drugs at all’ rather than only
‘abstinence from their main problem drugs’ seems to be required. It may also
have been the case that in responding to the question about treatment goals, drug
users were more inclined to cite what they saw as their long-term and ultimate
objective, rather than any intermediate aims, within which harm reduction might
have featured more prominently.
These uncertainties aside, a key message appears to be arising from the data,
that is, that many drug users simply do not perceive harm reduction as treatment
goals that they are seeking to bring about at the point of contacting agencies.
Within the context of the growing value placed upon obtaining the views of
consumers and service users, it is obviously important that service providers
consider and address the changes that drug users themselves are hoping to
achieve in coming forward for treatment and this would suggest much
greater emphasis being given to abstinence than has been the case in the recent
past within drug-treatment agencies. Certainly the finding that as may as 30% of
drug users within the DORIS study had a period of complete abstinence of
at least two weeks duration between their first and second interview suggests that
abstinence as such is not an unrealistic goal for a significant minority of drug
users even if they are likely to face difficulties in sustaining their non-drug use.
Over recent years, policy and practice within the drug-misuse field has tended
to prioritize harm reduction over abstinence. The reasons for this are likely to be
complex but may in part consist of a perception amongst workers in drug-
treatment and care services that abstinence is a long-term goal that is difficult, if
not impossible, to achieve and that their efforts will be more profitably directed at
reducing some of the dangers associated with individuals’ continued drug
use. What emerges very clearly from our data is the fact that, on the whole,
drug users contacting drug-treatment services in Scotland tend to be looking
for abstinence rather than harm reduction as the change they are seeking to
What Are Drug Users Looking For? 433
bring about. In the light of this finding there is a need to ensure that services that
have a harm-reduction focus are prepared to enable drug users to move over time
from a concern with reducing the dangers of their continued to drug use towards
a position where their drug use ceases. Equally, given that so few respondents
articulated harm reduction as the change that they were seeking to bring about
on the basis of having contacted drug-treatment services, it is clearly important
that drug-agency staff (many of whom will be adopting a harm-reduction
perspective in their work with clients) invest time in explaining to their clients
the value of harm reduction as part of a broader strategy of ceasing all drug use.
Finally on the basis of these results it is important to ensure that drug users
have access to an array of services both those which have a harm-reduction
focus and those that are more explicitly oriented towards abstinence.
The Drug Outcomes Research in Scotland study (DORIS) is funded by the
Robertson Trust and supported by the Scottish Executive. The views expressed
in this paper are those of the authors and should not be attributed to either of
these bodies. We are grateful to all of the individuals who have agreed to be
interviewed in this study and who remain participants in this research. We are
also grateful to all of the interviewers and to Carole Bain and Vicky Hamilton
for their work on the DORIS project.
[1] Drug users interviewed within prisons were excluded from payments for
legal reasons.
[2] Mostly,dihydrocodeine and diazepam.
[3] Counselling or group work.
[4] This comprised individuals desiring stabilization (n¼75), reduced drug
use (n¼71), safer drug use (n¼7) and any combination of one or more
harm-reduction goals (n¼44).
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... In a number of linked articles over the past two decades, sociologists have drawn attention to the uses of social scientific research methods as methodologically relevant for engaging the challenges of researching recovery in the contemporary context ( McIntosh & McKeganey, 2000 ;McKeganey et al., 2004 ;Nettleton, Neale, & Pickering, 20102012Neale et al., 2014Neale et al., , 2015Neale et al., , 2016. Drawing attention to the politics of qualitative, quantitative and interpretive methods as methodologically relevant for intervening in debates on the concept, meaning, practice and policy of recovery, these empirical studies highlight the uses of social research methods and role of the sociologist as involving the production and disruption of expert knowledge practices. ...
... The methodological and epistemological implications of sociological studies of recovery for drugs research and policy are foregrounded in a series of interlinked empirical projects and research articles ( McKeganey et al., 2004 ;Neale et al., 2014Neale et al., , 2015Neale et al., , 2016. These studies sought to initiate debate about the effects of established research methods and concepts for evaluating drug outcomes in relation to drug treatment and drug services. ...
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This article investigates the methodological potential of interdisciplinary research to generate collective rather than interpretive or reflective knowledge practices for the study of recovery from addiction to drugs and alcohol. The question that informs this investigation of knowledge practices is how researchers participate in knowledge production and the possibility of building alternative interdisciplinary methods that connect experts to treatment services and service-users in new ways. In the first part, we trace and evaluate methodological debates on research methods in academic, professional and treatment service settings. In so doing we consider the role sociologists have played in engaging qualitative, quantitative and deconstructive methods for researching recovery from addiction, and the strengths and limitations of empirical and critical research methodologies in responding to drug policy on recovery. In the second part of the article, describing a research collaboration with the sociologists Nicole Vitellone and Lena Theodoropoulou, the visual artist and filmmaker Melanie Manchot, and research participants' from creative recovery services in Liverpool, we outline the possibilities offered by the concept of recovery as a minor practice to reconfigure the role of experts, methods, and participants in new collaborative lines of inquiry. Turning to observations of a set of cinema-based pilot workshops from 2019 and 2020 with people in recovery, we describe the effects and consequences of an interdisciplinary methodology for enabling a different way of thinking about recovery as a minor practice. In rethinking and reimagining recovery as a minor practice, the article provides a distinctive interdisciplinary approach for recovery-oriented practice and policy.
... Less research has examined the goals of individuals with drug use disorders (DUDs), but the few studies that assessed substance use goals among individuals seeking DUD treatment suggest about 1 in 5 endorse nonabstinence goals (Lozano et al., 2015;McKeganey, Morris, Neale, & Robertson, 2004). This proportion may be higher (about 29%) among those who seek treatment for cannabis use (Lozano et al., 2006). ...
... This proportion may be higher (about 29%) among those who seek treatment for cannabis use (Lozano et al., 2006). In addition to individuals with only nonabstinence goals, 20% of those seeking treatment for DUD simultaneously endorse a combination of abstinence and nonabstinence goals if given the option to select all that apply from a list of goal options (e.g., abstinence, stabilization, and safer use; McKeganey et al., 2004). Studies have not compared rates of nonabstinence goals between individuals with AUD vs. DUD; however, among individuals seeking AUD treatment, comorbid DUD is not significantly associated with likelihood of either goal choice (Lozano et al., 2015). ...
Only a small minority of people with substance use disorders (SUDs) receive treatment. A focus on abstinence is pervasive in SUD treatment, defining success in both research and practice, and punitive measures are often imposed on those who do not abstain. Most adults with SUD do not seek treatment because they do not wish to stop using substances, though many also recognize a need for help. This narrative review considers the need for increased research attention on nonabstinence psychosocial treatment of SUD – especially drug use disorders – as a potential way to engage and retain more people in treatment, to engage people in treatment earlier, and to improve treatment effectiveness. We describe the development of nonabstinence approaches within the historical context of SUD treatment in the United States, review theoretical and empirical rationales for nonabstinence SUD treatment, and review existing models of nonabstinence psychosocial treatment for SUD among adults to identify gaps in the literature and directions for future research. Despite significant empirical support for nonabstinence alcohol interventions, there is a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders. Future research must test the effectiveness of nonabstinence treatments for drug use and address barriers to implementation.
... Closed-door institutions such as prisons or forensic hospitals appeared to be preoccupied with confinement, keeping their institutions drug-free and offering drugfree treatment. But we know from the literature that some drug consumers who do not accept total abstinence from drugs are, however, willing to reduce consumption or to reduce risks or harms related to drug use (McKeganey et al., 2004). While some intervention programs, notably in the UK and Denmark, have adopted harm and risk reduction approaches, zero-tolerance policies and penalization of drug possession means that existing intervention programs in most of the EPPIC countries rarely offer harm and risk reduction approaches. ...
... Probably the most helpful thing about the support is the, is just the education of what's actually going on, because there's no point telling me not to do it if I don't know why … educated me in what it's actually doing, and I think I'm a knowledgeable enough person to make my own decisions based on what I've been given, so that's really helped me … it has all helped me to like minimise my drug use and has stopped me taking all these things. (UK_29_M_ALT_17) These quotes highlight a point raised by interviewees that an approach based on 'stop taking drugs' is likely to be resisted by young people and could even be counter-productive (McKeganey et al., 2004). ...
The aim of this paper is to assess to what extent prohibitive drug policies hamper the management of drug problems from the perspective of young people who have experience with the criminal justice systems (CJS). Qualitative, in-depth interviews were carried out in six European countries (Austria, Denmark, Germany, Italy, Poland, and the UK) following a common interview guide to obtain comparative data on the life trajectories of drug experienced youth. Altogether 198 interviews with people aged 14–25 years were collected and analysed by national teams following a common coding book. Unintended consequences of drug policies for the individual and society were identified. Individual consequences included health consequences and traumatic experiences with law enforcement. Social consequences included those affecting social relations such as stigmatisation and those impacting on institutions, for example, focusing on drug use and neglecting other problems. This paper confirmed earlier research indicating unintended consequences of prohibitive drug policies but also added to the literature its cross-national perspective and use of young people narratives as a source of analyses. There are, however, policy measures available that may reduce the volume and range of unintended effects. Their implementation is crucial to reduce the array of unintended consequences of prohibitive drug policies.
... due to non-conformity to the demands of the system, inability "play by the rules" [31], or side-effects of the medication, such as constipation, headaches or sedation [32]. For some, lasting abstinence [33,34] and abstinence from all opioids, including opioid agonist medication, is the treatment goal [35]. ...
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Background The opioid antagonist extended-release naltrexone (XR-NTX) in the treatment of opioid use disorder (OUD) is effective in terms of safety, abstinence from opioid use and retention in treatment. However, it is unclear how patients experience and adjust to losing the possibility of achieving an opioid effect. This qualitative study is the first to explore how people with opioid dependence experience XR-NTX treatment, focusing on the process of treatment over time. Methods Using a purposive sampling strategy, semi-structured interviews were undertaken with 19 persons with opioid use disorder (15 men, four women, 22–55 years of age) participating in a clinical trial of XR-NTX in Norway. The interviewees had received at least three XR-NTX injections. Qualitative content analysis with an inductive approach was used. Findings Participants described that XR-NTX treatment had many advantages. However they still faced multiple challenges, some of which they were not prepared for. Having to find a new foothold and adapt to no longer gaining an effect from opioids due to the antagonist medication was challenging. This was especially true for those struggling emotionally and transitioning into the harmful use of non-opioid substances. Additional support was considered crucial. Even so, the treatment led to an opportunity to participate in society and reclaim identity. Participants had strong goals for the future and described that XR-NTX enabled a more meaningful life. Expectations of a better life could however turn into broken hopes. Although participants were largely optimistic about the future, thinking about the end of treatment could cause apprehension. Conclusions XR-NTX treatment offers freedom from opioids and can facilitate the recovery process for people with OUD. However, our findings also highlight several challenges associated with XR-NTX treatment, emphasizing the importance of monitoring emotional difficulties and increase of non-opioid substances during treatment. As opioid abstinence in itself does not necessarily equal recovery, our findings underscore the importance of seeing XR-NTX as part of a comprehensive, individualized treatment approach. Trial registration : # NCT03647774, first Registered: Aug 28, 2018.
... Thus, amidst rising controversies about the degree of effectiveness of recovery-based treatment programs, several research studies using both qualitative and quantitative approaches, addressed the questions "what drug users really want from drug treatment" and "whether harm reduction is a useful strategy when drug users want abstinence (McKeganey, Morris, Neal et al., 2004;Neale, Nettleton, & Pickering, 2013)? These studies found that most people reaching out for harm reduction services hope to achieve a lifelong abstinence instead of reduced but continuing consumption, and therefore suggest to allow harm reduction services to incorporate lifelong strategies to ensure complete abstinence (McKeganey et al., 2004). ...
What is recovery? Is recovery a process of individual transformation, an endpoint, or a part of drug use? How do people ‘do’ recovery and how can research trace this? How do different drug policies and national drug discourses understand and enforce recovery? This work explores these questions and offers personal accounts of recovery that shed light on differences, contexts, relations, and meanings. It aims to expand research into individual, communal, and political roles of recovery and take the use of the concept beyond the discourse of free will, reintegration, and formal treatment. It is also the aim of this book to address the questions on what makes recovery a contested concept, how can we better approach it, and whether there is a need to talk about recovery at all, especially in semiotic, socio-material and relational forms. As the book progresses, we encounter a list of definitions that different health organizations, treatment professionals, and researchers have given to recovery. Merging bio-medical, social-psychological, and environmental dimensions, recovery in itself is a delicate concept to study. Much depends on the researcher’s ideas of where to ‘locate’ recovery, how and when to begin to study it, and how long to follow participants to establish whether recovery was successful, is still in progress, or became a closed chapter in someone’s life. It becomes an especially thorny issue if one tries to fix the process of recovery in such temporal dimensions. Therefore, in this thesis, the reader is presented with accounts that do not reveal neat and causal stories of recovery, but with ones that spur the chaos, unruliness, and contingency of day to day practices, of everyday life. It is the aim of this thesis to tell a number of stories of recovery and offer multiple definitions of the concept, as well as ways to see more clearly the erratic, arbitrary, ambiguous, but ‘real’ experiences. Empowered by Science and Technology Studies (STS) theory and groundbreaking works of many critical drug scholars on re-thinking new ways on how to approach concepts of addiction, consumption, drugs, and recovery, the thesis gradually builds from material aspects and semiotic and socio-material relations, to cultural and structural dimensions informing the immediate recovery experiences.
... Such aftercare can help to determine the threshold-level when substitutes help early recovery or hinder sustained and stable recovery. Finally, it is equally important to recognize that persons seeking recovery from addictive behaviors have different treatment aspirations and goals (Neale et al., 2011) and that while abstinence may be desired, for some it may not be possible (McKeganey et al., 2004). Therefore, substitute addictions potentially present a harm reduction mechanism toward ultimately achieving abstinence (Pentz et al., 1997), or in the long-term, recovery without abstinence. ...
Background: Substitute addictions, addictive behaviors that sequentially replace each other’s functions, have implications for recovery trajectories but remain poorly understood. We sought to scope the extent, range, and characteristics of research on substitute addictions in persons with substance use disorders. Method: Using Arksey and O’Malley’s framework for scoping reviews, a systematic search was conducted to identify publications that referenced substitute addictions up to April 2018. Study characteristics were extracted and summarized to provide an overview of the extant literature. Results: The 63 included studies show that substitute addictions are terminologically and conceptually ambiguous. Much of the available literature is concentrated in developed contexts – and in particular the United States of America. While presentations varied, at least two sub-types of substitute addictions appeared: long-term replacement and temporary replacement. Existing theories suggest a multifactorial etiology. Conclusions: The findings suggest a strong need for: increased awareness of substitute addictions and its potential consequences for recovery; interventions that structure prevention and pre-, during-, and post-treatment interactions as well as future research to explore its nature and dynamics drawing on multiple methods.
... Alcoholism truly was a chronically relapsing progressive disease for those members at the extreme end of the spectrum, where failure to abstain meant ending up in jail, in an institution, or dead (Leach, 1975). While this view might seem absolutist, the goal of abstinence is a reasonable one for people with a long history of chronic alcohol dependence resulting in or exacerbating physical and psychological problems (Berglund et al., 2019;Cohen et al., 2007;Cunningham, 1999;DeMartini et al., 2014;Fleury et al., 2016;Grant et al., 2015;Haug et al., 2017;Heather et al., 2010;Heilig, 2018;Hodgins et al., 1997;Hoffmann, 2020b;Hoffmann & Kopak, 2015;Humphreys et al., 1995;Ilgen et al., 2008;Kelly, Bergman, et al., 2017;Koenig et al., 2020;Marlow et al., 2019;McKeganey et al., 2004;Owen & Marlatt, 2001;Rosenberg, 1993 Alcoholics Anonymous uses a stark portrayal of alcoholism's early symptoms, along with a stress on the inevitable progression of these symptoms, as a strategy to preempt or disrupt this anticipated progression. This portrayal also offers participants the opportunity to take control of their behavior. ...
Background: The Twelve Steps of Alcoholics Anonymous (AA) has proven to be an effective aid in recovery for many people with alcohol use disorder. While constructive criticisms of AA can be beneficial to the organization, other criticisms have merely served as rhetorical devices intent on discrediting the 12-step approach. Objectives: This paper examines six prominent critiques of AA, paying special attention to the premises, tone, and factual basis of the statements. Interpretations grounded in AA literature are offered to address claims or critiques around prominent themes, which are organized into two main classes: purported causes of alcoholism and factors maintaining alcoholism. Results: Findings reveal tenuous statements in the AA literature that appear contradictory and thereby invite a misreading. These statements, some of which misrepresent the tenets of AA and its founders, underscore certain vocal criticisms that are not entirely unfounded. While many pages of the AA literature are imbued with timeless wisdom, even the most apologetic interpretations—distilled into benefit-of-the-doubt renderings—largely falter in defending the nature of the language that originated in the early 1900s at odds with 21st century understandings of alcohol use disorder. Conclusions/Importance: The AA literature essentially presents a valid target for critics, fueling resistance to this free community-based resource that may prevent people who could benefit from AA from seeking the help of the 12-steps.
Recovery is often understood and sometimes even interchangeably used, as part of formal treatment. As recent developments in policy and research continue challenging normative ideas around drugs and people who use drugs, the concept of recovery finds a growing ubiquity in theory and practice. More so, the emergence of new policies on recovery-based treatment and systems of care contribute to promoting the importance of professional intervention and financial investment in recovery programs.
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Background Extended-release naltrexone (XR-NTX), an opioid antagonist, has demonstrated equal treatment outcomes, in terms of safety, opioid use, and retention, to the recommended OMT medication buprenorphine. However, premature discontinuation of XR-NTX treatment is still common and poorly understood. Research on patient experiences of XR-NTX treatment is limited. We sought to explore participants' experiences with discontinuation of treatment with XR-NTX, particularly motivation for XR-NTX, experiences of initiation and treatment, and rationale for leaving treatment. Methods We conducted qualitative, semi-structured interviews with participants from a clinical trial of XR-NTX. The study participants (N = 13) included seven women and six men with opioid dependence, who had received a minimum of one and maximum of four injections of XR-NTX. The study team analyzed transcribed interviews, employing thematic analysis with a critical realist approach. Findings The research team identified three themes, and we present them as a chronological narrative: theme 1: Entering treatment – I thought I knew what I was going into; theme 2: Life with XR-NTX – I had something in me that I didn't want; and theme 3: Leaving treatment – I want to go somewhere in life. Patients' unfulfilled expectations of how XR-NTX would lead to a better life were central to decisions about discontinuation, including unexpected physical, emotional, or mental reactions as well as a lack of expected effects, notably some described an opioid effect from buprenorphine. A few participants ended treatment because they had reached their treatment goal, but most expressed disappointment about not achieving this goal. Some also expressed renewed acceptance of OMT. The participants' motivation for abstinence from illegal substances generally remained. Conclusion Our findings emphasize that a dynamic understanding of discontinuation of treatment is necessary to achieve a long-term approach to recovery: the field should understand discontinuation as a feature of typical treatment trajectories, and discontinuation can be followed by re-initiation of treatment.
Innovation in addiction recovery in Scotland includes the transfer of effective models from other countries, such as San Patrignano, Italy and Basta, Sweden. Independence from Drugs and Alcohol Scotland (IFDAS) was founded to develop a new model for Scotland, based on social enterprise. Drawing on the San Patrignano programme theory, this prospective study investigates IFDAS stakeholders’ perspectives on which mechanisms should be transferred, and which require adaptation of the delivery mode, for the Scottish context. Data collection included interviews with ten stakeholders with expertise including: drugs policy, social enterprise, alcohol and drug partnership practice and therapeutic community methods. Drawing on realist principles, data were analysed using inductive and deductive approaches and synthesised using frameworks. San Patrignano mechanisms identified for transfer include: the need for motivation, recovery peer mentors, visionary leadership and social enterprise. Adaptations from Basta include: extending abstinence to alcohol and creating a smaller, semi-permeable, residential community. Further adaptations to mechanism delivery include a ‘step-wise’ model of housing and work. Scottish contextual factors shaping adaptations include: the culture of alcohol misuse, social care standards, housing regulations and socio-cultural acceptability. This study contributes to the evidence on international transfer and adaptation of complex interventions and documents stakeholders’ theory-informed decision making in the development of a new Scottish recovery model.
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There has been no recent large-scale systematic UK investigation of differences between male and female drug users seeking treatment. Equally, there has been no debate within the social work field regarding how best to address any gender-specific needs of drug-using clients. This is despite the fact that social workers frequently work with both drug-dependent individuals and members of their families. This paper examines differences between men and women beginning a new episode of drug treatment in Scotland and considers some of the implications of the findings for social work practice. Data were collected from structured interviews conducted with 1,033 individuals (715 males and 318 females) in a range of treatment settings. Chi-square statistics were computed to investigate sex differences on key categorical variables relating to: (i) patterns of drug use; (ii) education, employment and income; (iii) offending behaviour; (iv) housing circumstances; (v) health status; and (vi) personal relationships. Analyses identified many differences between the men and women interviewed, but also many common difficulties faced by respondents of both sexes. Additionally, the extensive range of problems and stressful life circumstances encountered suggested that the lives of individuals seeking drug treatment were extremely heterogeneous. It is concluded that social workers can employ a range of practical interventions and theoretical approaches when working with both male and female drug-using clients.
In recent years, users of social work, like those of psychiatry, have been increasingly drawn into the organization and delivery of social work and mental health services. This has been largely welcomed as a desirable development by planners, academics and practitioners in the field. In this article, we reappraise the broad issues raised by user involvement and consider the implications of this trend. Despite the attractiveness of the user perspective in the policy and delivery of social work and psychiatric services, we point to the dangers of incorporation and moderation of an oppositional position, from which, we argue, users can best challenge existing practices and connect with wider political struggles.
The Severity of Dependence Scale (SDS) was devised to provide a short, easily administered scale which can be used to measure the degree of dependence experienced by users of different types of drugs. The SDS contains five items, all of which are explicitly concerned with psychological components of dependence. These items are specifically concerned with impaired control over drug taking and with preoccupation and anxieties about drug use. The SDS was given to five samples of drug users in London and Sydney. The samples comprised users of heroin and users of cocaine in London, and users of amphetamines and methadone maintenance patients in Sydney. The SDS satisfies a number of criteria which indicate its suitability as a measure of dependence. All SDS items load significantly with a single factor, and the total SDS score was extremely highly correlated with the single factor score. The SDS score is related to behavioural patterns of drug taking that are, in themselves, indicators of dependence, such as dose, frequency of use, duration of use, daily use and degree of contact with other drug users; it also shows criterion validity in that drug users who have sought treatment at specialist and non-specialist agencies for drug problems have higher SDS scores than non-treatment samples. The psychometric properties of the scale were good in all five samples, despite being applied to primary users of different classes of drug, wing different recruitment procedures in different cities in different countries.
This study compared the psychosocial profiles of 136 criminal justice-referred substance abuse outpatients with 40 noncriminal justice-referred outpatients at the same facility. Profiles were based on the Texas Christian University Self-Rating Form, consisting of 11 scales: Self-Esteem, Depression, Anxiety, Decision Making, Childhood Problems, Hostility, Risk Taking, Socialization, Assessment of Drug Use Problems, Desire for Help, and Readiness for Treatment. Except for the last three scales, which correspond to Prochaska and DiClemente's stages of change, the profiles of both groups were virtually identical. The criminal justice-referred participants, however, scored significantly lower in their Assessment of Drug Problems, Desire for Help, and Readiness for Treatment. The need for enhancing such clients' motivation early in treatment id discussed.
The purpose of this article is to explore the ways in which clinic practices create obstacles for women who seek drug treatment. On the basis of interviews and participant observation at a methadone clinic, this article uncovers issues that women negotiate with their status as methadone clients. Being a woman and being a methadone client, from a feminist perspective, interact in our society to provide various meanings for women. Accounts from female clients make visible the neglect that persists in treatment settings. Their experiences illustrate the dilemmas women face when entering a male-dominated organization. These stories comprise the everyday workings of the methadone clinic and are part of the production of subsequent clinic culture, which is embedded in the larger social world that is gendered.
Replies to the comments by D. Cadogan (see record 1999-11644-010) and K. Resnicow and E. Drucker (see record 1999-11644-011) on the present author's article (see record 1998-11971-003) which examined 3 strategies for dealing with the harmful consequences of drug use and risky behaviors. The author clarifies some misunderstandings and highlights recent developments in the psychology of harm reduction. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Aims. To assess the impact of a substance abuse treatment program for women with children designed to increase access to treatment through transportation, outreach and child-care services. Also, to assess the impact of using access services on the use of other services and on treatment effectiveness. Design. A quasi-experimental non-equivalent control group design was used with path analysis to examine the impact of participation in an enhanced services program that provided transportation, outreach and child-care services on the use of other social services and on the use of alcohol and illicit drugs. Setting. Treatment clients were interviewed in- person at enhanced treatment programs and regular substance abuse programs. Participants. Study participants included a randomly selected sample of women with children who were clients of the Illinois Department of Children and Family Services. Participants were enrolled in enhanced or regular substance abuse treatment programs. Measurements. Study participants completed in-person interviews about their characteristics, services use and past and current substance use. Findings. Participation in the enhanced program was negatively related to substance use. Further, use of access services was related to use of social services which in turn, was negatively related to substance use. Conclusion. The study indicates that services that enhance access to treatment and respond to the range of social service needs of women are important for effective substance abuse treatment for women with children.
This paper assesses policy development, service changes and trends in HIV infection and risk behavior among injecting drug users (IDUs) in the United Kingdom. In 1986, the U.K. was faced with the possible rapid spread of HIV infection among IDUs. The combination of an outbreak of HIV infection with prevalence levels of 50% or more in Edinburgh, the recent diffusion of drug injecting, and high levels of syringe-sharing risk behaviour, suggested that HIV infection might spread rapidly through IDU populations. HIV prevention activities commenced in 1986 and developed in 1987. The first report on AIDS and Drugs Misuse by the Advisory Council on the Misuse of Drugs in 1988 was a major catalyst for change. It supported and legitimized emergent views on new ways of working with drug users. Between 1988 and 1993 innovative public health projects increased the ability to target vulnerable populations through syringe distribution, expansion of methadone treatment and outreach to hard-to-reach populations. There were major changes in service philosophy and practices, as ideas of harm minimization, accessibility, flexibility and multiple and intermediate goals were developed. There is evidence that these public health projects encouraged extensive changes in the health behaviour of IDUs. There have been major reductions in syringe-sharing risk behaviour and sharing syringes is no longer the norm. Evaluation of specific interventions (e.g. syringe-exchange) shows their importance in encouraging reductions in risk behaviour. Levels of HIV infection in IDUs remain low by international standards. Outside of London rates of about 1% have been reported; London has a low and declining prevalence of infection to around 7% in 1993; previous high levels in Edinburgh (55%) have since declined to 20%. Britain has to date avoided the rapid increase in HIV infection among injectors that has occurred in many parts of the world. The same period saw the continuation of high prevalence levels in New York and many European cities, and the explosive spread of HIV in many countries in south-east Asia. This paper acknowledges the difficulties is proving links between social interventions and epidemic prevention. It argues that there is prima facie evidence for the success of public health prevention, that the collection of intervention approaches in the U.K. had a significant impact on IDUs behaviour, and that this has helped prevent an epidemic of HIV infection among IDUs. The U.K. experience adds to the growing evidence of the significance of early interventions in encouraging behaviour change and in limiting the spread of HIV infection.