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Dublin: 10°C Thursday 24 September 2020

Opinion: Addiction is often boiled down to sound bites – but the truth is complex

We need to reflect on how addiction affects an individual, their experience of seeking help, and what the throes of addiction are like.

Tony Duffin CEO of the Ana Liffey Drug Project

ADDICTION HAS AGAIN been in the public spotlight recently. A number of media outlets have focused on public drug use in Dublin city centre. There has also been large gatherings of concerned residents in Roscrea, who are demanding action be taken in relation to the issues that the town is facing in relation to drugs and drug use.

Coverage of addiction related issues often appear during the summer months. This is unsurprising – issues like public drug use and unsafe disposal of drug paraphernalia are particularly relevant during periods when our cities and towns are filled with tourists. Similarly, there is a human interest element to stories of drug use; such stories are emotive, and can make for simple sound bites. However, it’s important to have a balanced view. What’s generally lacking in the discourse is some reflection on how addiction impacts on the individual; what their experience is when trying to get help; and what works when trying to help the many people in the throes of addiction.

Consider the position of John (not his real name), an Ana Liffey service user outside Dublin. After using heroin in his youth, John managed to stop using and worked in the construction industry for 20 years. In his early 40s and after a relationship breakup, he started using drugs again. Eventually he started using heroin, which he has been doing for the last 15 years. He started injecting about three years ago. It has taken its toll on him both physically and psychologically. He accepts that people need to take responsibility for their behaviours and that people are at different levels of accepting this responsibility. He is thankful for having support from some services available. However, he also feels that people need more support from services than punishment and he feels that ‘when people are down, they seem to be kicked’, which doesn’t help them get back up.

Or consider James (not his real name) who is 34 and an Ana Liffey service user in Dublin. James first started smoking hash when he was 11 and by the age of 14 he had started to use heroin. James admits to having shoplifted to feed his habit – he has numerous convictions for this. However, James’ criminality ended up being a barrier to him entering treatment. Naturally, James was very well known to the Gardaí over the years, and he would be so nervous that the Gardaí would come in to a service looking for him that he would not access services at all.

John’s view, and James’s experience, are representative of many people who use drugs. Some people will empathise with their experiences, others will not, and this is typical of the debate around how we deal with drugs as a whole – it is easy for it to become polarised, black and white.

Drug use is an emotive topic

People hold strong opinions with regard to how we, as a society, should deal with drugs. There are those who see addiction as a failure to take personal responsibility, others who see it as symptomatic of a societal failing instead. There are those who advocate for non-criminal responses to some drug offences, like simple possession, and those that advocate for much harsher criminal sanctions.

This polarisation is understandable – drug use is an emotive topic. It can also be helpful. As Dean Tjosvold notes, conflict involves incompatible behaviours rather than competitive goals. Broadly, all the stakeholders – be they people who use drugs, politicians, taxpayers, businesses or addiction service providers – want the same thing. For example, everybody is agreed that there is a problem with public drug use in Dublin. Everybody is agreed that we don’t want people injecting drugs in public spaces. Everybody is agreed that we should work to minimise the harm that drug use causes individuals, families and communities. Everybody is agreed that we should minimise the financial cost drug use has on our health and criminal justice systems.

The point is that if we step back and look at the broader picture, we can see that, in general, everyone is agreed on what outcomes we should work towards. Where people differ is on how we should get there. I have argued elsewhere that what we need to do to decide how to get there is to look at the objective evidence for what works, rather than simply going with our gut.

So, what is the evidence? At a broad level, the evidence is that drug policy should have a health focus as opposed to a criminal justice focus. So, insofar as we wish to commit additional resources to addressing drug use, the taxpayer will likely get better value out of investment in the health sector than the criminal justice sector. This is not to say that law enforcement has no role to play in dealing with drug use – clearly it does – merely that calls for increased punitive approaches in response to the current issues the country faces need to be evaluated in light of the evidence concerning that approach, which is comparatively negative.

Politics versus policy

Recently many commentators suggested that people need to take ‘personal responsibility’ for their drug use. This is a noble enough (and commonly espoused) sentiment, but misses a key point. Addiction is complex and multifaceted. Many people who use drugs, particularly those who are visible on the streets or engage in public drug use have comorbid mental health issues, are homeless and are isolated from their families and other supports.

If someone is to change their drug taking behaviour, the perceived alternative has to be better than the status quo. If the alternative doesn’t include timely treatment and stable housing, it’s not hard to see how for this group the drug taking can persist. In any event, there will always be those who are either unwilling or unable to take personal responsibility for their drug use at any given time. While, ultimately, those calling for people to take personal responsibility are right – no one has ever changed any behaviour without first taking responsibility for it – we need to create the conditions in which people are able to make positive change. In this regard, it is better to provide people with support to change their behaviours, rather than condemning them for failing to change them.

Saying that people should take responsibility for their drug use – this is politics, but not policy. Saying it won’t make it so. Without describing realistic conditions that should be put in place, saying people should take responsibility is just an opinion, not a call to action.

However, it can be turned into a call. Recently, both Dublin’s Lord Mayor Cllr Christy Burke and Fr Peter McVerry noted that a key problem with addiction services is that there is a lack of rehabilitation and residential spaces. They are right – there is a pressing need to provide more residential treatment and rehabilitation beds in Ireland. However, we also need to look at the entry criteria for residential treatment; the vast majority of residential treatment beds in Ireland have criteria which exclude those who could benefit most from the service.

For example, I’m not aware of any residential services in Ireland which are free, provide access based on presenting need, will deal with active poly-drug users and are directly accessible by an individual without having to go through a gatekeeper service. Although there are arguments against such provision to people who use drugs with chaotic lifestyles (notably that residential care is expensive and should be targeted at those that are likely to maintain a drug/alcohol free lifestyle), they operate successfully in the UK and there is also support for their introduction here.

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As the 2007 Report of the HSE Working Group on Residential Treatment & Rehabilitation (Substance Abuse) noted:

There is widespread acceptance that matching clients to treatment is a good idea even though the evidence base does not provide complete backing for the concept. The evidence is, however, supportive of the effectiveness and efficiency of reserving the more intensive services for patients with the more severe problems.

The working group also noted that experience (national and international) points to a number of criteria which can be used to determine if a particular individual will require and/or is likely to obtain particular benefit from inpatient provision. The list includes factors such as co-morbidity/dual diagnosis, chaotic poly-drug use and those unlikely to cope with outpatient withdrawal due to isolation, homelessness, or lack of family support.

In short, the system we currently have excludes from residential services those who are likely to most need them. If we’re serious about providing solutions, we need to provide meaningful options for people.

Similarly, everyone agrees that public drug use in Dublin City Centre is a problem. However, the reality is that the current system doesn’t provide many options to people who inject drugs in public. The evidence for the provision of medically supervised injecting centres is strong; they should be trialled and evaluated, with a view to seeing if the results we see elsewhere like a reduction in public drug use and a reduction in unsafe disposal can be replicated in Dublin.

To conclude, a few core points can be noted. First, while there is conflict in opinion, there is no such conflict in goals. Broadly, all stakeholders want the same thing. Second, as far as taxpayer investment in interventions is concerned, health provides a better return than criminal justice. Third, if we want people to take responsibility for their drug use, our services need to be better geared towards supporting them to do just that. Of course, all of this is going to require sufficient funding being made available to ensure that there are enough services to address the current level of addiction within Irish society.

Tony Duffin is the Director of the Ana Liffey Drug Project, a national addiction service working to reduce the harm caused by drug use in Ireland. Ana Liffey provided direct services to over 3,500 clients in 2012, many of whom are among the most marginalised from mainstream service provision. To find out more about the Ana Liffey’s services visit www.aldp.ie/services, Facebook or Twitter @AnaLiffey

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About the author:

Tony Duffin  / CEO of the Ana Liffey Drug Project

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