The social handling of drug problems

Robin Room Centre for Alcohol Policy Research, Turning Point, Fitzroy, Australia;

Melbourne School of Population & Global Health, University of Melbourne; and Centre for Social Research on Alcohol & Drugs, Stockholm University

robinr@turningpoint.org.au

Presented at a conference on drug addiction and treatment, SFI - Danish National Centre for Social Research.

Copenhagen, Denmark, 28 August 2014

Psychoactive substances matter in everyday life • Valued physical goods

– Subject to commodification, globalization – Possession/use often a symbol of power/domination

• Use as social behaviour – Social meanings attached to use – Use often demarcates inclusion/exclusion in group

• Use as intimate behaviour – substance ingested – Risk of contamination/poison, as well as

nutrition/pleasure/solace – prescriptions & taboos

• Affect thinking and feeling, expected to affect behaviour – To the extent of “possession” – submerging the true self? – Or, revealing the true self? ”In vino veritas”

...and yet have down sides. Drugs may be seen as causing ...

Problems for the user – Physical health problems (overdose, esophageal cancer) – Mental illness due to the drug use (alcoholic psychosis,

dementia), ”addiction” Problems for others as well as the user – Accidents, injuries – Violence, aggression – Property crime, disturbance of peace – Sloth, non-productivity – work role default – Needy, neglected children -- family role default

The social gaze seeing problems and drawing connections varies by time and place

• Cigarette smoking was sufficiently banalised in the 1950s that nicotine was not thought of as psychoactive

• Some US scientists at Repeal of Prohibition made a serious argument that beer was not intoxicating

– Pauly PJ (1994) Is liquor intoxicating? scientists, Prohibition, and the normalization of drinking, Amer J Public Health 84:305-313.

• Drug use defined as a medical problem of addiction in 1940s Denmark, as “youth euphomania” in the 1960s, then eventually as “misuse”

– Houberg, E. (in press) Concepts and institutions in Danish drug treatment. Nordic Studies on Alcohol and Drugs.

• New psychoactive substances, one after another, have been defined as the solution to addiction problems from earlier substances

Cultures vary in what is defined as a problem • Variation in what is addiction/dependence

• Jellinek’s “species” of alcoholism: gamma for Anglo-Saxon, delta for French, epsilon for Finnish

(Room et al., “Cross-cultural applicability research…”, Addiction 91:199-230, 1996)

• and the definition varies over time: • in the U.S.: tobacco as an addiction in 1905, not in 1950,

again in 1995 (Courtwright, “Mr. ATOD’s wild ride”, Social History of Alcohol & Drugs 20:105-140, 2005)

• Terms and meanings vary: – abuse/misuse/harmful use

• Abuse as a diagnosis in the U.S., not in the U.K.

(Room, “Alcohol & drug disorders in the ICD: a shifting kaleidoscope”, Drug & Alcohol Review 17:305-317, 1998)

– intoxication vs. 5+ drinks, teenagers in S & N Europe (Hibell et al., The ESPAD Report 2003. Stockholm: CAN, 2004)…

Cultures vary in the threshold of application Two thresholds? The relation of alcohol dependence rates to volume of consumption: the Americas and India (above the diagonals) vs. the rest

(Rehm J & Eschmann S, Global monitoring of average volume of alcohol consumption, Soz. Präventivmed. 47:48-58, 2002)

Alcohol consumption per capita and AAA-mortality in 14 European countries; Data for 1987-1995.

A puzzle: weak negative relationship

Per capita alcohol consumption (litres)

1816141210864

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n)

4

3

2

1

0

-1

uk

se

espt

no

nl

it

ie

gr

defr

fi

dk

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The puzzle resolved: Variation in professional application of diagnoses

variation in the cultural framing (Ramstedt R, p. 52 in Leifman et al., Alcohol in Postwar Europe, ECAS II, 2002)

Per capita alcohol consumption (litres)

1816141210864

AAA-

mor

talit

y (L

n)4

3

2

1

0

-1

Southern

Central

Northern

espt

it

gr

fr

uknl

ie

de

dk

beat

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fi

Why so much flux? A social terrain in No Man’s Land

• “In drunkenness of all degrees of every variety, the Church sees only the sin; the World the vice; the State the crime. On the other hand the medical profession uncovers a state of disease.”

– Norman Kerr, Inebriety or Narcomania (1888)

• In the modern welfare state, social handling of the terrain is divided between health, mental health, criminal justice, social welfare.

Components of conceptualizations of alcohol/drug problems

• What’s the defining problem? • Under which social rubric does it fall?

• Vice/sin; Crime; Physical Sickness; Mental Illness; Disability; Destitution

• Which social handling institutions should deal with it?

• Which professions should deal with it? • What is the action model to counter the problem?

Which institutions and professions to handle the problem?

(A correspondence, but not complete)

• Health institutions • Mental institutions • Criminal justice

system • Church, faith insts. • Welfare institutions

• Mutual help groups

• Doctors, nurses • Psychiatrists, psychologists • Lawyers, judges, probation

workers • Priests, deacons • Social workers • “experience workers”

Action models: “a disease like ... bronchitis; diabetes; smallpox; schizophrenia;...”

• Allopathic medical – Eliminate use – Modify use/problems

• Surgical • Cognitive behavioural

– Eliminate use – Modify use/problems

• Psychotherapeutic • Rehabilitative,

reintegrative • Protective • Public health/epidemic

• Medicines – Aversive; removal of craving – Maintenance; relief of symptoms

• Lobotomy; eugenic sterilization

• Reasoning; persuasion; counseling; deterrence

• Resolve underlying psychopathology • Skills training, socialization,

provide resources

• Provide sheltered environment • Insulate, isolate

Often there are competing action models within a profession’s terrain: e.g., medicine

• In medicine, so long as a disorder is not “solved” (a remedy, a vaccine, an operation) and clinical intervention is at best modestly successful, doctors often resort to argument by analogy from successes elsewhere, with action models to match, e.g. – Like an allergy (AA and Silkworth) so abstain – Like a contagious disease (epidemic model in 1970s US and UK) so

quarantine those infected, in prison or therapeutic community – Chronic relapsing brain disease (NIDA and other official US ideology)

methadone & other palliation while waiting for the “lesion” breakthrough

-- Room R [Drinking and disease: comment on ‘The alcohologist's addiction’.] Quart. J. Stud. Alcohol 33:1049-1059, 1972.

Between rubrics, institutions and professions: some correspondence, but many loose ends.

Below are the parts that fit best.

Rubric Profession Institutions Physical illness Doctors Health insts.

Mental illness Psychiatrists Mental insts.

Crime Judges Criminal justice

Sin, vice Priests Church

Disability, destitution Social workers Welfare system

But neither the concrete problems nor the action models map cleanly onto these

(the arrows are not exhaustive)

Injuries Physical illness

Doctors Health insts. Medicines

Loss of control

Mental illness Psychiatrists Mental insts. Cog. beh.

Violence Crime Judges Criminal justice

Psychoth.

Sloth Sin, vice Priests Church Skills trng.

Intoxication

Disability, destitution

Social workers

Welfare system Shelter

Room, R., Hall, W. “Frameworks for understanding drug use and societal responses”. In: Ritter, A. et al., eds. Drug Use in Australian Society, pp. 51-66. South Melbourne, Vic.: Oxford University Press, 2013.

Variations across cultures in governing images and leading institutions for alcohol problems

• Medical – Liver clinics and doctors as the leading response in Italy

• Psychiatric – Psychiatrists and mental hospitals as the leading response in

Poland and Austria

• Welfare – The welfare system as the leading treatment provider in Finland

and Sweden (successor to the Temperance Boards)

• Criminal justice – Soviet Union (plus narcologists [medical specialists] and their

institutions)

• 12-step “Minnesota Model” – U.S. treatment services, staffed by experience-based counselors

Variations in a society across eras: 1. The U.S.A.

• “Moral passage” between eras in the U.S. – Repentant drinker (early, moral-persuasion temperance) – Enemy drinker (prohibitionist period, late 19th – early 20th C) – Sick drinker (post-1940s alcoholism movement)

• Gusfield JR. Moral passage: The symbolic process in public designations of deviance. Social Problems 15: 175–188, 1967.

• Alcohol problems/“new public health” approach – Focus on market control, the drinking context,

reducing harms, not changing the drinker • Room R. Alcohol control and public health. Annual Review of Public Health 5:293-317, 1984.

Variations in a society across eras: 2. Bruun’s periodization for alcohol in Finland

(summarized from Bruun K, ”Finland: The non-medical approach” 1971 with some rewording)

Dates Dominant model

Rubric Institutions Professions Action model

<1918 Deterrent Crime Prisons, hospitals

Lawyers, doctors

Punish

1919-1931

Prohibition law

Crime/sin Prisons, hospitals

Above + temperance

workers

Inner awakening

1932-1952

Alcoholic law

Bad habit Above + specialized institutions

Above + soc. welfare

bureaucracy

Compulsory treatment

1953-1970

Act ... [on] treatment of misusers ...

Symptom Above + outpatient

Above + soc. workers, nurses

Above + voluntary treatment

Variations in a society across eras: 3. Sutton’s periodizing of Swedish alcohol concepts

(adapted from: Sutton C. Swedish Alcohol Discourse: Constructions of a Social Problem, p. 148. PhD Sociology. Uppsala, 1998.)

• 1900-1955: poor behaviour and low morals – Solutions: monopoly, registration, rationing

• 1955-1960s: Alcoholism, Medicine 1: biochemical or environmental causes of alcoholism as illness – Cure: psychotherapy, long-term care

• 1960s-70s: alcoholism as symptom: Social structure poor integration alcohol abuse – Provide social networks, shift to weaker beverages

• 1977-1995: Total consumption/public health, Medicine 2: drinking as collective health & other harm – Prevention at different levels of risk

• late 1990s: EU integration: primacy of market & competition should limit state control – Prevention at different levels of risk + limits on regulation on behalf of free market

Variations in a society across eras and substances: Denmark

“a strange hybrid” in 2005: alcohol under Ministry of Interior Affairs, drugs under Ministry of Social Affairs (Pedersen, M.-U., A Danish perspective on the treatment of substance users in Norway, Nordic Stud Alcohol & Drugs 22:174-8, 2005)

• Before 1960s, drug treatment in psychiatric system • Moved in 1960s to 20 youth centres – social

interventions • 1980s-1996: inpatient treatment centres, alcohol and

drugs together • 1996+: specialty drug treatment, under county, then

municipality 2007+ (2012 National Report to the EMCDDA: Denmark. Sundhedstyrelsen)

• So drug (and alcohol) problems are: – Intractable, ”wicked problems” – the problems

can be reduced but not eliminated; – in-between problems – they fall between major

social institutions and professions; • overlapping jurisdictions, without being central to any

– subject to professional and policy fashions (including action by analogy)

• Bruun (1971) on the Finnish history: “The consistent frustrations concerning the relative

lack of success in fighting alcoholism made [Finland] move compulsively from one model to another”

Those identified as having alcohol and drug problems and treated for them

are often highly marginalised • Comparing those in treatment for alcohol

problems in Stockholm with the general Stockholm population: – 5 times as likely to qualify as alcohol dependent; – 6 times as likely to be in an unstable living situation; – 18 times as likely to have been in treatment in the

previous 12 months; – 26 times as likely to be on retired sick leave as to be

working

The connections are not just through poverty but also through marginalisation

• The causal arrows between drug use/heavy drinking and marginalisation are likely to go in both directions

• Poor people are less well protected than richer people against problems arising from heavy drug/alcohol use

• But being marginalised and stigmatised adds to the burdens on the heavy drinker/drug user.

The double burden for those who come to treatment: poorer and stigmatised

• More adverse consequences of use for the poor (less insulation from harm) – though their incidence and volume of use may not be less

• But there is an extra dimension in the adverse consequences for alcohol and drugs: – Alcohol and drug use and problems are heavily moralized

stigma and marginalization important in adverse outcomes

• Coming to treatment may itself be stigmatizing • Drug/alcohol use as leading to marginalisation/social

abandonment both through direct effects and through stigmatization

Stigma ... “... means disqualification from social acceptance,

derogation, marginalization and ostracism encountered by ... persons who abuse alcohol or other drugs as the result of negative social attitudes, feeling, perceptions, representations and acts of discrimination”

-- Wisconsin State Alcohol, Drug Abuse, Developmental Disabilities and Mental Health Act

• No necessary relation with poverty/social inequality – “deserving” vs. “undeserving” poor

• No necessary relation with drug or alcohol use – use often associated with high-prestige and positively-valued

actívites and statuses – e.g. champagne, ecstasy, cocaine

Social movements to remove stigma

• “alcoholism movement”: replace the “old moral model” with the disease model

• assumptive frame: disease rubric less stigmatized than crime/sin rubrics

• But rubrics are not mutually exclusive – adopting one does not mean abandoning the other – a disease can still be heavily moralized

• The label may change, but not the handling or the social definition – in Swedish compulsory treatment in the 1950s

“inmate” “care recipient” without other change (Edman, 2009)

Whether “dependence”, “addiction”, “alcoholism”, “misuse”, “abuse” or “drunk”,

the labels carry a heavy stigma

• A cultural universal? – 14-country WHO study of cross-cultural

applicability of disability concepts and classifications …

Condition(& Ordering in Total

Sample)

Country

Canada China Egypt Greece India Japan Luxembourg Netherlands Nigeria Romania Spain Tunisia Turkey UK

Wheelchair bound (1) 2 3 1 5 2 5 2 2 1 3 2 1 1 2

Blind (2) 1 5 2 2 4 9 1 1 3 1 1 2 3 1

Inability to read (3) 6 6 3 3 1 2 5 3 2 5 4 5 2 6

Borderline Intelligence (4) 3 4 4 7 5 7 3 4 5 7 5 7 6 4

Obese (5) 9 1 5 1 3 1 4 7 4 4 6 3 14 11

Depression (6) 5 2 10 4 6 15 6 6 9 2 3 12 5 3

Dementia (7) 4 8 7 6 9 10 9 8 7 8 7 4 9 5

Facial disfigurement (8) 7 7 8 8 8 3 7 10 6 6 8 9 8 7

Cannot hold down a job (9) 10 11 12 10 10 4 8 9 11 10 11 11 7 10

Homeless (10) 16 9 6 9 7 12 13 15 8 16 10 8 12 8

Chronic mental disorder (11) 12 13 11 12 14 17 10 8 15 9 9 10 10 12

Leprosy (12) 11 16 9 15 13 11 11 11 18 13 14 6 13 9

Dirty & unkempt (13) 15 14 13 11 12 8 12 12 12 12 13 13 11 14

Does not take care of theirchildren (14)

18 10 16 14 11 6 16 14 10 11 15 17 4 17

Alcoholism (15) 8 12 15 13 15 14 15 16 13 14 12 14 17 15

Criminal record for burglary(16)

13 17 17 16 16 13 17 17 17 18 16 15 15 16

HIV positive (17) 14 18 14 18 17 16 14 13 14 15 18 16 16 13

Drug addiction (18) 17 15 18 17 18 18 18 18 16 17 17 18 18 18

N 15 15 16 15 47 18 16 13 15 15 18 15 15 12Note: Ranking of 1 indicates least stigma, ranking of 18 indicates most stigma.

Condition(& Ordering in Total

Sample)

Does not take care of theirchildren (14)

Criminal record for burglary(16)

Note: Ranking of 1 indicates least stigma, ranking of 18 indicates most stigma.

Degree of social disapproval/stigma of different disabilities, including “alcoholism” and “drugs addiction”: rank order in each country (expert rankings)

(Room et al., Cross-cultural views on stigma, valuation, parity and societal attitudes towards disability, in Üstün et al., eds., Disability and Culture: Universalism and Diversity, pp. 247-291. Hofgrebe & Huber, 2001)

Those classified as addicts or heavy users are devalued

• Public opinion on setting health priorities (Britain, U.S., Australia): less priority for -- – tobacco smokers – “high” alcohol users – illegal drug users (Olsen et al., 2003)

• In “disadvantaged” categories of people in deprived districts in Portugal: – alcoholics and ”hard drug users” had bad health, but – relatively unlikely to have used health services, and – often had “bad” or “very bad” opinion of services (Santana, 2002) …

Utilization of and attitudes to the health system among categories of the disadvantaged living in

poor districts in Portugal (Santana, 2002)

Alcohol addicts

Hard drug users

Home-less

Ex-prisoners

Single mothers

Poor elderly

Health < good

100 96 100 90 87 99

Used health services

15 35 12 20 35 58

Bad opinion of health services

42 31 50 29 28 26

Sources of substance-related stigmatization

• Intimate processes of social control and censure in the family and among friends – Often effective – But may result in extrusion &/or pushing into

treatment • Decisions by social agents and agencies

– Attending often to the most problematic cases – Decision often amplify the marginalizationa nd stigma

(if “tough love” does not “succeed”) • Policy decisions by local or national governments

– criminalization – regulatory actions; e.g., eviction of family from public

housing if a member mixed up in dealing drugs – public information campaigns, etc., can also stigmatize

Objects of substance-related stigmatization: what is problematic?

1. Occurrence of problems ascribed to use: illness, violence, casualties, failure in work & family roles – e.g. Violence and alcohol dependence:

• Vignette of a man drinking more than used to, can’t cut down – becomes agitated, has become unreliable: ”how likely to do something violent?” -- 71% of US adults say at least ”somewhat likely”, more than for schizophrenia or depression, though less than for cocaine addiction (Link et al., 1999)

– Those with problems often stigmatized by other heavy users:

• “Getting caught” is the problem; the ideal of the “competent drinker”, controlling the risks

Three other areas of stigmatization arising from the link with problems:

2. Intoxication per se

– Other than in “time out”, for alcohol? – Unpredictable, disinhibiting, causing bad behaviour – Defended only in literary and artistic cultural space – Reprehensible or at least questionable in most other

public discourse – “wrong to appear in public”: the 14-country study

again:

Country

Condition

Total

% Canada

China

Egypt

Greece

India

Japan

Luxem- bourg

Nether- lands

Nigeria

Romania

Spain

Tunisia

Turkey

UK

A woman in her 8th month of pregnancy

2

0

0

0

0

4

0

0

0

7

0

0

0

7

0

Someone who is blind

3

7

0

0

0

6

0

0

0

7

13

0

0

0

0

A person in a wheelchair

2

0

0

0

13

7

0

0

0

0

0

0

0

0

0

An obese person

12

20

7

13

7

6

19

31

8

13

0

17

0

20

8

A person who is intellectually “slow”

7

7

0

0

0

4

23

0

0

13

0

0

14

33

8

Someone with a face disfigured from burns

6

0

33

6

0

0

0

12

0

20

0

0

13

7

0

Someone with a chronic mental disorder who “acts out”

15

0

33

0

20

17

12

19

17

13

27

22

0

0

17

Someone who is dirty and unkempt

25

20

27

69

20

17

0

44

8

47

40

17

43

0

33

Someone who is visibly drunk

46

13

27

88

27

46

6

81

8

80

73

50

79

14

50

Someone who is visibly under the influence of drugs

58

20

57

100

40

67

M

56

17

64

67

56

79

M

M

N

245

15

15

16

15

47

18

16

13

15

15

18

15

15

12

“People would think it was wrong” for a person to appear in public, “visibly drunk”, “visibly under the influence of drugs”, % of expert

informants in each country (Room et al., 2001)

Objects of substance-related stigmatization: what is problematic? 3. Addiction/dependence

– “diseases of the will” -- loss of control • “One of the most vivid and isolating distinctions which can be made in a

culture which attributes morality, success, and respectability to the power of a disciplined will” (Lemert, 1957)

– The dilemma of drugs for the consumer society • Expectation and encouragement of consumption • Consumption drives the economy • Habit-forming consumables as the best drivers of all

– vs. Expectation of sobriety and clear-mindedness • Driving a car, working, watching small children ...

– Addiction as the reconciliation: the problem redefined as the individual’s loss of control

• “the peculiarly resonant relations that seem to obtain between the problematics of addiction and those of the consumer phase of international capitalism” (Sedgewick, 1992)

Addiction/dependence and stigma • Alcoholism concept originally promoted to reduce

the stigma on the alcoholic/inebriate – Within AA: ”sickness” concept as reducing the intolerable load of guilt for

new recruits – Alcoholism movement: alcoholic distinguished from the “common drunk”

(Marty Mann)

• But it carries its own stigma – 7 presidents of tobacco companies swearing to U.S. Congress in 1994

that they do not believe cigarettes are addictive (stance abandomed in 1998)

– Acknowledges failure of self-management and -control

Objects of substance-related stigmatization: what is problematic? 4. Use per se

– Justified in terms of risk of harm, addiction • Preamble to the 1961 Single Narcotics Convention,

prohibiting nonmedical use of drugs: – “recognizing the addition to narcotic drugs constitutes a

serious evil for the individual and is fraught with social and economic danger to mankind...”

– Selective stigmatization • Not for alcohol in mainstream of industrial societies

– But among Moslems, Mormons, ... • Increasingly for tobacco • For illicit drugs, at least officially

– Normalisation in youth cultures??

Studying stigma: two different traditions

– Oriented around illness/mental illness/disability: • Stigma taken for granted as a social evil • Studying effects of stigma, methods of neutralizing

– Oriented around crime: • Stigma taken for granted as an instrument of social

control – as formal punishment or as an adjunct or alternative

• Often viewed positively, e.g. re corporate crime • “Stigma saturation”: recognition of perverse effects

(sociologists: “secondary deviance”, creation of subculture of the excluded)

Alcohol and drugs in studies of stigma

• Not many studies, most analysis in the clinical tradition – Stigma as barrier to treatment – Managing stigma post-treatment – Documenting and decrying public attitudes

• Some parts of field (e.g., drinking-driving) easily fit in the stigma-as-social-control tradition

• As a matter of cultural politics, difficult to extend either frame to cover the whole alcohol and drug field

The ambiguous role of treatment entry • “doing something about my problem” • the vouching function of treatment

– “s/he’s better now”

BUT • a signal of difference, of incompetence • when incentives fail, difference is reinforced Can a “hidden addict” be better off left hidden? • How and when does marginalization &

stigmatization happen in the path to treatment? • How to construct treatment services & systems, so: – it is no stigma to enter? – increasing stigma is not a possible outcome?

Paths forward on stigma and alcohol/drugs • Destigmatizing addiction-specific services: a challenge

– Often issues in internal attitudes & functioning – Still doesn’t solve issues in the outside society – Some changes over time, but still an uphill climb

• Relation between social inequality, marginalization & stigma in alcohol/drug context needs more study

• Should stigma be considered in a balanced frame – are there preventive effects and when? – what and how big are the negative/perverse effects? – nonstigmatizing alternatives for social control?

• Give priority to studying what happens when there are changes in social inequality, marginalization, stigma

Studying social handling • Patterns in the general population

– Who uses? Who gets into what kind of trouble? How do those around respond? When & how is the decision to seek help made?

• Clinical populations, at the point of entry – How did they come, what do they expect, what are their

characteristics, use patterns and problems?

• What happens in the treatment or other handling? – How do the service providers define their role? What do they

expect from the clients? What is the path of the clients after entry? What outcomes?

• How are policies on social handling set? – Who makes the policies? What professional and

commercial interests are involved? Is there a client voice?