drugs, addiction, abstinence and harm reduction

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Exploring the benefits and approach of harm reduction compared to an abstinence approach

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  • 1. Harm Reduction or AbstinenceJulian Buchananjulianbuchanan@gmail.com

2. Harm Reduction: Conflictswith CJSContradictions that hinder the effort to reduce harm through the criminaljustice system. The first is the fact that criminal justice systemsthemselves produce harms. arrests, fines, community penalties,imprisonment and parole all infringe on individual freedoms andpleasures.Countries do not use prison as a direct, rational measure to reducecrime. Rather, they choose through a complex process of ideological,moral, political and juridical negotiation the level of pain that they arewilling to inflict on their citizens (Christie 1982). If we choose the level ofharm that we inflict, we can also choose to reduce it. (p.380)Stevens A., Stover, H. & Brentari, C. (2010) Criminal justiceApproaches to Harm Reduction in Europe, pp379-402 in EMCDDA,Harm reduction: evidence, impacts and challenges EMCDDA,Lisbon, April 2010On Blackboard 3. Issues with Treatment in the CJS The second contradiction in pursuing harm reduction in the criminaljustice system is that between the pursuit of abstinence and theacknowledgement of continuing drug use. Countries are obliged,through the UN drug conventions, to prohibit and to penalise thepossession of certain substances. The criminal justice system is the process that puts these obligationsinto practice. It is very difficult for the same system toacknowledge that the people under its control continue to defythe law. (p.380)Stevens A., Stover, H. & Brentari, C. 2010 Criminal justice Approaches to Harm Reduction in Europe, pp379-402 inEMCDDA, Harm reduction: evidence, impacts and challenges EMCDDA, Lisbon, April 2010 4. Coercive Benefits Both drug courts and coerced abstinence interventions deploy frequentmonitoring and chemical tests with the threat of graduated penal sanctions todeter re-initiating drug use and to reduce the probability of more serious offendingand subsequent criminal sanctions. Other enforcement measures may also have promise. Stricter controls onprecursor chemicals appear to have at least short-term effects onmethamphetamine consumption (Cunningham & Liu 2003). Work-place testing isargued by some to have led to reductions in adult drug use, by threatening jobloss (Frenchet al. 2004). Evaluations of school testing programs provide hints thatthese, too, might reduce adolescent substance use.(p.351) [my emphasis]Addiction: 101 341-347 (March 2006)How much can treatment reduce national drug Problems? Peter Reuter & Harold Pollack School of Public Policy,University of Maryland and the RAND Corporation, CA, USA and School of Social Service Administration, University ofChicago, IL, USA 5. AbstinenceModel Addicts typically lie, hide, manipulate and hurt themselvesand others they need confronting Addicts need to hit rock bottom to see sense People need to become clean we can drug test them Drug Free is the only way to be Any level of use is unacceptable they have a lifelongdisease and should never use again People are either addicts or ex-addicts 6. ABSTINENCEEradicate drugsCriminalisationStigmatisationSeparationHomogenous viewCureDeny & deterAll use problematic 7. Counselling principles lost inenforcing abstinence Listen Respect the person unconditional positive regard Go at the clients pace Be non judgmental Empathy/care Understand No hidden agenda Client led and ownedBased upon Ghodse, H. (2002) Drugs and Addictive Behaviour: A Guide toTreatment (3rd edn). Cambridge: Cambridge University Press 8. Abstinence Approach:RUSSIAhttp://uculr.com/2012/04/05/solving-the-russian-hiv-crisis-with-harm-reduction-strategies%EF%BB%BF-2/http://newsbeastlabs.thedailybeast.com/projects/death-by-indifference/ 9. Harm Reduction -Risk Reduction1. Pragmatic2. Humane3. Realistic4. Engages 10. But doesnt.Harm Reduction condone druguse, encourages risk takingand removes the harshrealities of dangerousbehaviour which people whodo drugs should suffer? 11. Do seat belts encourage speedingand dangerous drivingShould they be allowed? 12. My experience of pushing abstinence asa Probation Officer1. Court Reports2. Supervision - The evidence and dangers of drugs3. Push the chance to become drug free4. Detox - Cold Turkey5. Rehab6. Return relapse Guilt Broken relationships7. Rethink! 13. My journey from abstinenceto risk reduction mid 1980san abstentionist viewpoint - the expectation togive up is pressed from the outset of contact, theclient succumbs to that pressure of expectationand attempts abstinence through either coldturkey, detoxification programme or rehabilitationunit.Unfortunately the degree of success achieved isminimal with by far the majority failing andreturning to the drug scene, increasing officerfamily and self frustration and feelings offailure. We have come to believe that a differentphilosophy should be adopted whichincorporates both apparently irreconcilableviews [abstinence vs maintenance] onto a scaleor ladder of achievable targets. This philosophybegins with the pragmatic statement that: 14. From abstinence to risk reductionIf it is, at a particular moment in time, impossible to cure adrug addict, one can at least try to create an environmentfor harm reduction.The implications of such a statement are that first one mustidentify those drug abusers who are dependent anddifferentiate from those who are experimental or recreationalusers.One must also seek to ascertain what clients themselves wishto do, for whilst we might see their drug abuse as problematic,they may see it as the answer to a problem or may not wish tochange their abuse for a variety of reasons. If one begins withthe stance of Risk Reduction, many more doors are open toengage with the client and discover ways of helping them. (pp.123-124)Buchanan, J. & Wyke, G. (1987) Drug Abuse, Probation Practice and the Specialist Worker, ProbationJournal Vol. 34 No. 4 pp. 123-126 15. HARM REDUCTIONLive with drugsDecriminalisationNormalisationIntegrationHeterogenous viewMinimise harmFreedom & responsibilitySome use problematic 16. Engaging &helping peopleAbstinence water levelHarm reduction water levelPeoplewith drugproblems 17. ABSTINENCEEradicate drugsCriminalisationStigmatisationSeparationHomogenous viewCureDeny & deterAll use problematicHARM REDUCTIONLive with drugsDecriminalisationNormalisationIntegrationHeterogenous viewMinimise harmFreedom & responsibilitySome use problematicBased uponGoldberg, T. 1999,Demystifyingdrugs: Apsychosocialperspective,Macmillan Press,London 18. Needle Park Zurich http://dotsub.com/view/7119acc7-8ea0-4041-ba5d-ec5169bf08ae 19. 66%swisssupportedroll out 20. Learning from Switzerlandhttp://www.youtube.com/watch?v=Cco4BT-KDK8 21. Swiss HATThe Swiss heroin prescription program was targeted at hard-core drug userswith very well established heroin habits. These people were heavilyengaged in both drug dealing and other forms of crime. It substantially reduced the consumption among the heaviestusers, and this reduction in demand affected the viability ofthe market. It reduced levels of other criminal activity associated with themarket. By removing local addicts and dealers, Swiss casual usersfound it difficult to make contact with sellers.The Impact of Heroin Prescription on Heroin Markets in Switzerland by Martin Kiillias andMarcelo F . Aebi Crime Prevention Studies, volume 11, pp. 83-99 (2000)http://www.popcenter.org/library/crimeprevention/volume_11/ 22. Swiss programme 23. Heroin Assisted Treatment systematic reviewhttp://www.emcdda.europa.eu/publications/insights/heroin-assisted-treatment 24. http://www.youtube.com/watch?feature=player_embedded&v=3KxldfcQlQE#t=80Watch to 4:06 25. Importance of harm reduction given the frequent contact between drug users andcriminal justice systems, and ongoing epidemics ofblood-borne viruses linked to problem drug use, thereis an urgent need for harm reduction services to bescaled-up EMCDDA 2010 (p.394) Harm reduction: evidence, impacts and challengesChapter 14 by Alex Stevens, Heino Stver and Cinzia Brentari Criminal justice approaches to harmreduction in Europe seehttp://www.academia.edu/2835065/Criminal_justice_approaches_to_harm_reduction_in_Europe 26. A review of the evidence-base for harm reductionapproaches to drug use by Neil Hunt In essence, harm reduction refers to policies andprogrammes that aim to reduce the harms associatedwith the use of drugs. A defining feature is their focus on the prevention of drug-relatedharm rather than the prevention of drug use perse. One widely-cited conception of harm reductiondistinguishes harm at different levels individual,community and societal - and of different types - health,social and economic (Newcombe 1992). These distinctions give a good indication of the breadth offocus and concern within harm reduction.Document URL: http://www.forward-thinking-on-drugs.org/review2-print.html 27. Harm Reduction Approach:MALAYSIAhttp://www.aljazeera.com/video/asia-pacific/2011/11/201111308512277302.html 28. Harm Reductioncomplemented byMotivational Interviewingand the Cycle of Changean effective approach forany habit or learntbehaviour 29. Harm Reductionutilising Millar & RollnicksMotivational Interviewingand Prochaska & Di ClementesCycle of Change 30. Cycle of Change Prochaska, Di Clemente & Norcross (1992)Contemplation RELAPSE32MaintenancePreContemplationTerminationAction Preparation 31. Motivational Interviewing directive and client controlled .(Rollnick and Miller1995) Aims to elicit behaviour change by helping clients toexplore and resolve ambivalence (Peterson and McBride, 2002). Is only a prelude to treatment; it creates openness tochange, which paves the way for further importanttherapeutic work (Goodman, 2007)33 32. Goldberg, T. 1999,Demystifying drugs: Apsychosocial perspective,Macmillan Press, London 33. Harm Reduction Case Study Katie is young single parent mother aged 22 ye

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