and the society's paradigmatic views on drugs.

Transcription

1 1 English 3308 Victoria Papa February 23, 2012 Unit 2: Research Paper ASA Harm Reduction: When does it work? As prohibition and the War on Drugs in the United States have proven to be ineffective at controlling the availability of drugs and drug use, it is clear that punitive models which define substances or their users as problematic are costly and devastating to society. However, there recently Unclear as is, possible reveision-- but their work has not placed much emphasis upon the kinds of situations which harm reduction strategies are most e ective. As a parallel construction this is illogical. It wouldn t make sense to say when society approaches drug use which reflect a humanistic view. You could say when society holistically approaches drug use and creates policies which... or when society s approaches to drug use and its policties reflect... Nice job stating thesis here. has been a shift from the legal sanction debate on drugs to public health principles thus paving the way to the harm reduction approach (Cheung 2000, Marlatt and Witkiewitz 2010). Many scholars have already been writing about harm reduction strategies in addition to their benefits, but there has not been much emphasis on in what situations harm reduction strategies are the most effective. While the harm reduction model provides an alternative strategy for societies to handle drug users while minimizing the negative consequences on the individual and society, harm reduction strategies are only successful when society approaches drug use and creates policies which reflect a humanistic view. A comparison between the United States and other countries demonstrates that although harm reduction programs can be implemented in various political climates, their effectiveness depends on the legal status of drugs and the society's paradigmatic views on drugs. In their book, The Social Construction of Reality, Peter L. Berger and Thomas Luckmann focus on how persons and groups interacting in a society form, over time, concepts or mental representations No need for commas before and after over time

2 of each other s actions, and that these concepts eventually become habituated, institutionalized, and 2 internalized (1966). Berger and Luckmann argue that we cannot ever know an objective reality, but instead relate to our socially created or constructed realities (1966). Based on their theory, drug use and Good insight. abuse are social phenomena subject to the definition and reaction of a society. The way we define and understand drug use, misuse, and addiction affects the way we regulate drugs and drug users. Three major shifts in the United States demonstrate that drug use has been perceived differently over time based on social context. For example, in the 17 th and 18 th centuries alcohol was highly regarded and universally consumed; however, with the spread of religious ideology and the dominant Christian influence in the early 1800s, many people began to define alcohol consumption as a sin. Temperance organizations initiated the movement because of the belief that alcohol consumption led to corruption, prostitution, spousal abuse, and other criminal activities (Levine 1984:109). In the early twentieth century, the United States faced the 18 th Amendment which prohibited the production, sale, and transport of intoxicating liquors. Alcohol Prohibition lasted for over a decade during which the criminal justice system became the agent of social control (Levine 1984:109). A paradigmatic shift Interesting. from alcohol use as a sin to a crime then paved the way to the medicalization of alcoholism: after prohibition was repealed, alcohol consumption was redefined as a disease, an addiction, and a sickness, supported by the development of Alcoholics Anonymous and the spread of its ideas (Levine 1984:109). The legacy of prohibition, rooted in temperance movements of past, lives on as prohibition has extended to many illicit drugs including as marijuana, cocaine, ecstasy, and heroin, and continues to shape our socially constructed definitions and understandings of drug use and users. In the past several decades, belief in an ever-growing drug problem has continued to fuel the prohibitionist reaction to drug use and users in the United States. The prohibitionist view assumes that illicit drug use is a morally corrupt behavior of an individual and that the drug itself is inherently bad

3 3 (Cheung 2000, MacMaster 2004). This has led to the development of a strong criminal justice model, the War on Drugs, and an attempt to reduce both supply and demand of drugs. The major criticisms of the prohibitionist model include moral arbitrariness in dividing drugs into licit and illicit categories, infringement of the civil rights of citizens, indirect sustenance of a black market, and the inability to curb availability and consumption of illicit drugs (Cheung 2000). With the harm reduction model, on the other hand, drug use is seen as a public issue and focuses on the well-being of individuals as well as social and economic functioning. At the conceptual level, harm reduction maintains a value-neutral, humanistic view of drug use and users, neither insists on nor objects to abstinence, and acknowledges the active role of the user in harm reduction programs (Cheung 2000, MacMaster 2004:356). It is a perspective and a set of practical strategies to reduce negative consequences from drug use or mitigate effects of abuse (Marlatt and Witkiewitz 2010:593). Many scholars and professionals have discussed needle exchange programs as a It would be helpful here to have a brief description of what this entails as even a disciplinary focused audience might not know of such programs. way to reduce the spread of blood-borne diseases (including HIV and hepatitis) among injection drug users (Marlatt and Witkiewitz 2010:595). Several countries also operate safe injection facilities where drug users can inject their own drugs using clean equipment with the supervision of medically trained personnel (Greenwald 2009:15, Csete and Grob 2011:83). At least 28 studies have been published that indicate safe injection facilities are associated with significant reductions in needle sharing and reuse, overdoses, and injecting/discarding needles in public places (Marlatt and Witkiewitz 2010:596). Another harm reduction program is opioid substitution. Opioid dependency from heroin, oxycodone, morphine, etc. is associated with severe psychological, neurobiological, health, and societal consequences. Substitution therapy (e.g. methadone maintenance) has been widely employed around the world to provide administration of a less harmful drug under medical supervision to reduce the harms associated with opioid dependency. Several reviews have concluded that opioid substitution

4 4 therapy is effective in reducing HIV risk behaviors, criminal activity, and opioid-related death (Marlatt and Witkiewitz 2010:596). Other harm reduction strategies include education and prevention programs and address pointof-need issues such as housing assistance, trauma centers, and a variety of therapy approaches based on individual assessment. Overdose-prevention programs recommend the administration of naloxone in persons experiencing drug overdose. Naloxone is inexpensive, has no abuse potential, can be prescribed by a doctor, and is often accompanied by an educational component that instructs how and when to administer naloxone. Other programs include school-based and work-based substance useprevention programs and web-based interventions. Preventing the initiation of substance use is the most cost-effective and efficient method for reducing the harm related to substance use (Marlatt and Witkiewitz 2010: ). By implementing harm reduction services and programs, some countries' policies have changed. concerning what? For example, Portugal decriminalized all drugs on July 1, 2001 as a way to more effectively manage treatment barriers and resource drain imposed by the criminalization regime (Greenwald 2009:6). By decriminalizing drugs, Portugal redirected its focus to primary prevention; extending and improving the quality and response capacity of the health care networks for drug addicts to ensure treatment access for those who seek it; and emphasizing a public health rather than punitive approach (Greenwald 2009:7). Prior to the decriminalization act, substitution treatments and other harm reduction services were available, but the most substantial barrier to offering treatment to the addict population was the addicts fear of arrest (Greenwald 2009:9). Criminalization and punitive approaches to the drug issue Good only perpetuate the harms associated with drug use; harm reduction strategies allow people to access the services they need without constantly living in a state of fear of punishment or stigma.

5 5 Portugal also has expanded drug treatment options to include after-care and social reintegration, monitoring drug treatment, and substitution treatment. Since drugs were decriminalized, the number of people in Portugal receiving substitution treatment increased from 6,040 to 25,808 in 2008 (EMCDDA 2012). Allowing drug users to access harm reduction services rather than serve prison As stated, the words allowing and requires in this clause are imprecise. A clearer revision might be: Rather than punishing drug users with prison sentences, harm reduction services advocate a humanistic approach by allowing drug users the ability to access treatment OR perhaps more precisely,...harm reduction services advocate a humanistic approach by granting drug users the agency to access treatment. Good. To bring this back to your theoretical framework, which is standard in academic writing, you might say something like this: In turn, as Berger and Luckmann s theory of the social construction of reality suggests, these concepts... sentences shows that harm reduction requires a humanistic approach: drug users are viewed as people who have the right to access treatment rather than as criminals, deviants, or second-class citizens. Though harm reduction services were available in Portugal since the 1970s, the decriminalization of drugs and a more human-rights oriented approach allowed harm reduction programs to service more people without drug use increasing (EMCDDA 2012). By providing health and social services for drug users, and thus treating users as equal members of society, other persons begin to develop new concepts or mental representations of drug use and users. These concepts eventually become institutionalized, affect policies, and reflect a new theoretical paradigm on drug use which becomes the new social reality of a society. Germany's drug policy is also considered rather progressive and has a harm reduction focus. In 1994, the Federal Constitutional Court ruled that drug addiction and possession of small amounts of drugs were not a crime, and in 2000, the German narcotic law was changed to allow for supervised drug-injection rooms. According to Lorenzo Bollinger, German drug policy has evolved in a series of stages that follow three distinct policy paradigms: (1) criminalization; (2) medicalization; and (3) acceptance (2004). Over time, there seems to have been a slow transition throughout these paradigms implying that elements of all three approaches have been integrated into various policies and strategies. Nice. How these transitions have occurred, however, is through newly constructed social realities: interactions, the exchange of and access to new information, and the institutionalization of new ideas

6 allows a society to evolve and enter new stages of policy paradigms. Under the current acceptance 6 paradigm, regulation of substance abuse is limited to drug prevention and education, consumer protection, and health measures (Bollinger 2004). Based on Germany's progression through the policy paradigms, the United States needs to adopt a new social reality, a new understanding of drugs and drug users before it can see reflective policies. As many states have began to adopt medical marijuana laws, it is argued that the United States is currently transitioning, slowly, from a criminalization to a medicalization paradigm, so long as trends continue in the current direction of change. Like much of Europe, Switzerland in the mid-1970s had a drug law that criminalized individual Smoother transition needed drug possession and use with the goal of a drug-free society (Csete and Grob 2012:92). As a result, all public programs who serviced illicit drug users were required to be abstinence-based, and although heroin was widely used, medically assisted treatment options were largely unavailable (Csete and Grob 2012:83). In spite of a strict drug law and rigorous drug policing, drug use grew and was a visible social concern in some Swiss cities in the 1980s. In 1985, the Zurich city council, under pressure from residents tired of open drug use, decided to try to contain and tolerate drug use in one of the city s important recreational parks, Platzspitz. Because there was an exchange in new knowledge and discussion about change among local residents, new understandings of the drug phenomena began to arise. In 1988, a ground-breaking intervention called ZIPP-AIDS (Zurich Intervention Pilot Project AIDS) brought badly needed HIV and hepatitis prevention services to people in the Platzspitz (Csete and Grob 2012:83). Pioneering services began to appear in other cities thanks to visionary health professionals and advocates. The medical initiatives in Platzspitz and other cities coincided with a growing national debate on drug policy and helped to inform new thinking on approaches to drug use. Knowledge of the program spread to other areas and began to create a new reality in much of Switzerland. Harm reduction services began appearing and the federal government began to be open to

7 a much stronger orientation to public health measures as a central element of drug policy than in the 7 past. The Swiss even created a heroin-assisted therapy program for those with long-standing opiate dependence who were not helped by methadone programs (Csete and Grob 2012:83). Though Switzerland s approach to drug use has veered excessively towards medical solutions, they perhaps have too little attention to the social service needs and rights of drug users beyond access of medical care (Csete and Grob 2012:85). It seems that the Swiss are currently in the second policy paradigm of medicalization and have yet to achieve acceptance. The Swiss experience remains nonetheless exemplary for the many countries in the world still trying to rely on policing to address the complexities and who have yet to transition out of the criminalization model. of drug use Despite the many positive consequences that can result from harm reduction programs, the political climate and punitive model in the United States prevents harm reduction programs from being effective or successful. The War on Drugs in the United States, officially declared in the early 1980s, has reshaped the way America thinks about and responds to crime, and has created an era of instability to crime or to drug use? and mistrust in many communities. By the mid-1990s, the climate regarding drug policy in the United States had shifted somewhat toward supporting a treatment model of combating drug abuse. The result was the proliferation of drug courts and other alternative sentencing strategies that sought to divert lowlevel drug offenders from prison into community-based treatment programs. Despite the expansion of these options, the punitive sentencing provisions of the 1980s remain in effect across the United States, and the prohibitionist perspective prevails (Mauer and King 2007:1). For example, the United States maintained a ban on federal funding to support needle exchange programs from 1988 until July 24, 2009, when the House of Representatives voted in support of the 2010 Labor-Health and Human Services-Education appropriations bill, which included language to lift the ban on federal funding for needle exchange programs (Marlatt and Witkiewitz 2012:596). Additionally, as early as the 1950s,

8 numerous medical and criminal justice organizations voiced support for heroin maintenance, but the 8 government rejected all maintenance proposals (Barbour 2000:98). Because of the negative moral attitude towards drug users, opioid substitution therapies are still considered controversial, and government regulation of opioid substitution programs greatly limits the accessibility of these effective treatments for opioid dependency (Marlatt and Witkiewitz 2012:597). The prohibitionist approach to the drugs problem, which began with the 1800s temperance movements, still shapes our paradigmatic views on drugs in the United States and reinforces stigmas and the deviant status of drug users. Because our constructed understanding of drugs is wrapped up with moral arguments and a criminalization policy model, it has been difficult to transition into another drug policy paradigm stage, as Germany already as. In this regard, the United States lacks the progressive, humanistic approach to drug policy and social programs. It seems the analysis call for a return to the theoretical framework here. Harm reduction programs have been found to be effective for those who are serviced. Based on various country case studies, drug policy should aim to promote the public good by improving individual and public health, neighborhood safety, and community and family cohesion by reducing crime. Health and social services for drug users covering a range of treatments, including needle exchange programs and trauma centers, improve drug users health and benefit the broader community by reducing transmission of and mortality due to infectious disease. In order for these programs to be implemented, the society must first switch paradigmatic views on drugs from a prohibitionist, punitive, or moral stance to a humanistic and utilitarian view. A human rights-based approach provides the potential for a unifying foundation of harm reduction services. Once the society transitions views, and decriminalizes or legalizes drugs, then harm reduction programs can be put into place and begin to positively affect the society in a newly constructed paradigmatic reality.

9 Annotated Bibliography 9 Berger, Peter L. and Thomas Luckmann The Social Construction of Reality. New York: Anchor Press. In their book, Berger and Luckmann introduce the theoretical foundation for the sociology of knowledge and the social construction of reality. By addressing such factors as institutionalization and internalization, they articulately and logically theorize that people's conceptions of reality are dependent on social context and symbolic universes. Their theory is important for the purposes of this research project because it lays the theoretical foundation that drugs are not inherently one thing or another, but rather people's definitions and perceptions of drugs are shaped by societal conditions. Bollinger, Lorenz Drug Law and Policy in Germany and the European Community: Recent Developments. Journal of Drug Issues. 34(3): In this article, Lorenz Bollinger outlines the current German drug control system and how it is viewed as an interdisciplinary byproduct of sociology, political science, and social psychology. The most important aspect of his article which helps inform the research paper is his idea of the evolution of drug laws and paradigm shifts between levels of drug policy and drug care. Cheung, Yuet W Substance abuse and developments in harm reduction. Canadian Medical Association Journal 162:12. Sociologist Yuet Cheung defines drug, drug abuse, and the various contexts which correlate with levels of drug use. In addition to analyzing social reactions to drug abuse, he discusses three phases of harm reduction development and how this model can serve as a beneficial way to deal with the drug controversy in the 21 st century. This essay helps inform the research paper because it not only provides definitions of the terms to be addressed, but also discusses how harm reduction historically evolved, and why it is a relevant model to be discussed in the ongoing debate on drugs. Csete, Joanne and Peter J. Grob Switzerland, HIV, and the power of pragmatism: Lessons for drug policy development. International Journal of Drug Policy 23(1): Joanne Csete and Peter J. Grob effectively explore the history of Switzerland s drug policy and paradigmatic shifts from the 1970s through the present. They not only discuss the historical material development of the policy and program changes, but also discuss its limitations. It is extremely relevant for my research paper to discuss Switzerland as a case study with regards to harm reduction, policy, programs, and drug paradigms. Drug treatment overview for Portugal. European Monitoring Centre for Drugs and Drug Addiction < The European Monitoring Centre for Drugs and Drug Addiction article which discusses current drug treatment in Portugal provides statistics and a summary of various drug treatment methods. It is important to provide relevant facts and statistics in this research paper to provide evidence that the

10 harm reduction programs are servicing more people under a humanistic, harm reduction regime of decriminalization in Portgual. 10 Greenwald, Glenn Drug Decriminalization in Portugal: Lessons for Creating Fair and Successful Drug Policies. CATO Institute: Washington D.C. In his report on the current state of Portuguese drug policy and the consequences of decriminalization, Greenwald articulates the successes of decriminalization and how harm reduction strategies complement the policy reform. He uses pertinent statistics to display that drug use hasn t increased as a result of decriminalization, though the number of harms related to drug use, including mortality, have decreased. It is relevant for the research paper because Portugal serves as a prime example of how decriminalization and a shift in theoretical views on drugs can create a society in which harm reduction programs can be more successful. Levine, Harry Gene The Alcohol Problem in America: From Temperance to Alcoholism. British Journal of Addiction 79(4): Harry Gene Levine, in his article, addresses the paradigmatic shifts in how alcohol use and abuse have been viewed in America. From the temperance movement to prohibition to the medicalization of alcohol use, he effectively proves that views on drug use, in particular alcohol consumption, need to be understood in the context of economic and political conditions. This is relevant for the research paper because it provides support to Berger and Luckmann s theory of the social construction of reality. I intend to use Levine s insight to provide a framework in which drug use is viewed in various societies and how policy then reflects these views. MacMaster, Samuel A Harm Reduction: A New Perspective on Substance Abuse Services. Social Work 49:3. Samuel MacMaster's article introduces harm reduction as a complementary or alternative perspective for social workers who work with individuals for whom abstinence may not be immediately appropriate or useful. He believes that both harm reduction and abstinence-based interventions can be useful in social work depending on the client's needs. This article is relevant for the research paper because the author argues that no ethical dilemma seems to be created by using a harm reduction model. It also approaches the topic from a social work perspective, which adds to the interdisciplinary nature of the debate. Marlatt, G. Alan and Katie Witkiewitz Update on Harm-Reduction Policy and Intervention Research. Annual Review of Clinical Psychology 6: From The Addictive Behaviors Research Center at the University of Washington Seattle, Alan Marlatt and Katie Witkiewitz highlight policies and programs that have been effective at reducing the harms associated with alcohol and drug use. They address harm-reduction programs such as needle syringe programs, safe injection facilities, and opioid substitution, but also touch upon interventions at the point of need including housing and trauma centers. This article is important to the research paper because it addresses the most recent developments with respect to harm-reduction policy, prevention,

11 and treatment bringing a more contemporary and relevant perspective. 11 Mauer, Marc and Ryan S. King A 25-Year Quagmire: The War on Drugs and Its Impact on American Society, The Sentencing Project: Research and Advocacy for Reform: Washington D.C. Mauer and King s report highlight statistics and findings which reflect consequences (and injustices) of the War on Drugs. They offer alternative, more cost-effective strategies of drug treatment rather than sentencing. What is most relevant to the research project is that they overview the developments of drug policy and the punitive model which still prevails in the United States.