Dean SpruceDemocratising or Demonising Drug Dependence?
By Steve Freeman, Solution Focused Practitioner
We know that mental health care still resonates with echoes of the moral judgement applied by Victorian philanthropists. Heart disease, fractures, and other physical ailments were seen as being mechanical failures with more or less effective remedies. Deteriorating mental health was seen as God’s judgement and, even when physical interventions were attempted, the cause was seen as moral failure on the part of the individual. Hence the dichotomy that exists between services, professions, sites of access, funding and public perception. Stigma is almost as evident now as it was 20 years ago. Despite, or because of, many statutory and third sector initiatives and celebrity endorsements you’re still more likely to be stigmatised because of your symptoms of psychological distress than anything requiring a bandage and an x-ray.
What could be worse? Could it be worse? Yes it could. You could be drug dependent. That’s where stigma resides more than just about any other area of health and social care and public opinion.
Take a minute to think about this scenario. Your sibling, child, best friend announces that they’re in a relationship with someone wonderful. They met at the vegetable counter in the supermarket. They share an interest in healthier eating. Their partner because of their diabetes. What is your minds eye view of a diabetic in their 20’s?
Now imagine the same scenario with “drug dependent” instead of diabetes. What’s your minds eye view now? Be honest. Are you just as happy to have them round for tea?
It doesn’t mean you’re a bad person. You’re just well trained by the overwhelming stigma surrounding drug dependence. It’s hard to overcome.
But what does drug dependent mean? For many it suggests use of illicit drugs and illicit use of legal ones. It is synonymous with criminal activity, poor personal hygiene and less than appealing interpersonal skills. The stereotypical ‘druggie’, ‘addict’ or ‘user’ in many people’s imagination. It’s an image supported by press, drama and everyday social conversation.
Is this accurate? More importantly is it democratic? If you’re reading this you probably have some well developed ideas on social inequality, social justice and supporting the disenfranchised in society. Despite this we (yes I’m part of the problem too!) take a very undemocratic view of drug dependence.
Figures from Public Health England updated in November 2019 estimate that in mid 2017 between a half and three quarters of a million people were alcohol dependent. This compares to between 260 and 270 thousand people estimated to be opiate dependent. A BMJ article from 2015 suggests that 20% of people accessing primary care services are alcohol dependent. These figures are extremely unlikely to have reduced. The demographic may have shifted and yet the numbers continue to rise. A note of caution here. These are estimates because reporting is notoriously inaccurate and not fit for purpose.
Why not shift our attention to the majority rather than a stigmatised minority? Why not democratise the attention we pay to those who we refer to as ‘addicts’ and ‘users’?
Alcohol use in the UK is not only endemic. It is also a social requirement in many situations. A lifelong relationship. Met someone at the pub. Engagement party. Wedding. Housewarming. Lost my job. Leaving do. Got a new job. Payday. Out with mates. Wet the baby’s head. Endless birthdays, sporting and social events and anniversaries, funerals; the list is seemingly endless and unavoidable. No one has to drink alcohol at these events and many don’t. And yet the pressure to conform is there. “Driving? You’re allowed two pints.” We haven’t been allowed two pints of beer before driving in living memory and yet this myth persists. If the phrase “social drinking” has crossed your mind…….Stop! There is no such thing.
The role of alcohol in violent and abusive relationships has to ne noted. Alcohol is the most evident drug in sexual abuse within and beyond families. Alcohol and violent crime is far greater than other drug related crime. Driving under the influence of alcohol is still far more comment than “drug driving.” Abusive relationships of any type will often see alcohol used as an anaesthetic to cope with physical and psychological trauma.
At a point in time when stress and anxiety are significant issues and when our immune systems are critically important it is worth recognising that alcohol does harm in all these areas.
From low level use to severe dependence there are several levels of use. As with sexual health the reality is that “safe” is none at all. Cautious and careful use is “safer” not safe. UK Government guidelines are easy to remember. 2 to 3 and 2 to 3. That is 2-3 units maximum in 24 hours and 2 to 3 alcohol free days. The same limits have applied to men and women since January 2018. This is the alternative view of “social drinking.” Exceeding, and even staying within, these suggested limits has an impact of health; physical, psychological and social harm go hand in hand with alcohol use. The more alcohol the more harm.
What about dependence? Simply put if alcohol use has a negative impact on physical, psychological and social health then there’s an alcohol problem. If someone feels unable to change their relationship with alcohol then there’s a level of dependence. It isn’t simply a matter of experiencing physical withdrawal symptoms. Don’t forget that a hangover is a form of alcohol withdrawal.
There are a wide range of assessment tools to identify problematic use of alcohol. The simplest and remarkably accurate is CAGE. Four simple questions based on your experience of the last 6 weeks.
· Have you ever needed to or been advised to Cut down on your alcohol use?
· Have you ever become Annoyed or upset when asked about you alcohol use?
· Have you ever felt Guilty about your alcohol use?
· Have you ever needed something to steady your nerves or reduce a hangover after a drinking session? An Eyeopener.
Answering Yes to 2 or more of these questions for these questions shows a significant probability of an alcohol problem and a need to seek help, a more detailed assessment and more information on alcohol.
There’s much more to discuss about alcohol use and alcohol related harm in terms of all aspects of life. Too much to discuss here. Hopefully this will be enough to start discussions with customers and others in your life. You can’t now say that you didn’t know!
Hopefully we can move to a more democratic view of drug dependence by reflecting on the relative impact of illicit and legal drugs. Perhaps even take a more balanced view of customers behaviour when we reflect on the dependence that we see in ourselves, colleagues and families. Perhaps recognise the inequity of society and health professionals demonising “drug use” whilst enjoying and being flippant about one of the most harmful drugs known to humankind.
Useful links.
Alcohol dependence data
https://www.gov.uk/government/publications/alcohol-dependence-prevalence-in-england
Alcohol prevalence 2015
Assessment and management of alcohol use disorders https://www.bmj.com/content/350/bmj.h715
Alcohol units
https://www.nhs.uk/live-well/alcohol-support/calculating-alcohol-units/
https://www.drinkaware.co.uk/alcohol-facts/alcoholic-drinks-units/latest-uk-alcohol-unit-guidance/
CAGE assessment tool.
Opiate and other illicit drug dependence data https://www.gov.uk/government/publications/opiate-and-crack-cocaine-use-prevalence-estimates-for-local-populations