Substance Misuse

The Implications of Research, Policy and Practice

Joy Barlow

• Publisher: Jessica Kingsley Publishers
• Year: 2009
• ISBN:
  9780857002198
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

Substance misuse and its pervasive problems is a constant challenge for social work, health and related professionals today. With heightened political and policy emphasis on all aspects of substance misuse, it is paramount that professionals remain up-to-date on current issues and their responsibilities. Based on research and evidence, this book provides a sound basis for grounded and innovative practice.

Leading international contributors outline holistic and specialist approaches to policy and practice, and highlight the shift in emphasis from immediate risk minimisation to long-term recovery, the importance of prevention and the pivotal role of workforce development. Issues surrounding work with children and families affected by substance misuse are explored, and ways of implementing new approaches revealed. The book also looks at the impact of the smoking ban in Scotland, and suggests ways to support tobacco use cessation.

This book is essential reading for all front-line practitioners working with substance misusers, including social work, health professionals and counsellors.

Part I

The History of Drug and Alcohol Policy

CHAPTER 1

How We Got to Where We Are Now

Charlie Lloyd

In considering where we are now in terms of current drug and alcohol policy, it is useful to look back at the pathways that have taken us here. Laws, policies and strategies are, and always have been, primarily driven by actual or perceived trends in drinking and drug use (and associated problems). So in considering how and why particular laws have been passed or particular policies forged, it is also necessary to look at the problems that have led to them.

This chapter therefore provides a brief history of how we got to where we are now – in terms of the history of drug and alcohol consumption and legislative and policy responses to this consumption – before turning to a consideration of where we are now – in terms of current drug and alcohol strategies in the UK.

Viewed historically, the drug that has had the most impact on the way we live, over the longest period, and which has caused the most damage, public concern and legislative responses to it, is alcohol. Public fears concerning other drugs have a much more recent history, with legislative control not occurring before the late 19th century. Given the very different and largely separate histories of drinking and drug use, and policy responses to them, alcohol and drugs are here dealt with separately.

Alcohol

A short history of drinking and legislative responses to drinking

It is impossible to find out when alcohol was first intentionally consumed but as Edwards (2000) points out, alcohol must have been around ‘as soon as it was possible to gather fruit, add water and wait a few days for enzymatic action to do its work’ (pp.3–4). Throughout recorded history, alcohol has played an important role in the large majority of civilisations. Wine was consumed in Ancient Egypt, Greece and Rome.

A key event in the history of alcohol was the development of distillation, which became widespread over the 16th and 17th centuries. While, initially, distilled alcohol was primarily used for medical purposes, gin came to be consumed in large amounts in 18th-century London (the ‘Gin Craze’). Between 1700 and 1735 gin consumption rose from 500,000 gallons to five million gallons (Thom 2001). The causes of this drink epidemic were political and economic: the government had acted to help farmers find a market for excess grain by encouraging the fermentation and distillation of the grain to produce gin, and thereby also to prevent the reliance on foreign spirits. The tax on distilling was abolished and gin was allowed to be sold without a licence. This led to the rapid escalation in gin drinking and the attendant social consequences famously portrayed in Hogarth’s etching Gin Lane.

Up until the 20th century, legislative controls were primarily ‘linked to economics, politics and social order rather than to individual and public health concerns’ (Thom 2001, p.18). For example, in the Middle Ages, local licensing control grew out of concerns that public houses had become ‘unruly hotbeds of political dissent’ (Thom 2001, p.19). This led to an Act in 1495 which allowed alehouses to be closed on the agreement of two justices of the peace. Then the disease model of alcohol addiction, which saw addiction to alcohol as a disease of the brain, became increasingly influential. Seeing problem drinkers as suffering from an illness rather than a moral weakness led to more sympathetic responses: treatment and rehabilitation rather than disapproval and punishment. The Temperance Movement also drew on this new understanding of alcoholism. Temperance had its roots in the US but soon spread to Europe, where large numbers of people ‘took the pledge’ and refrained from drinking. Despite being a widespread social movement, the Temperance Movement had very limited success in bringing about any legislative control in the UK – this in contrast with the US, where the Temperance Movement was influential in bringing about prohibition, which lasted from 1920 to 1933. It was rather the need to keep the population fit and able to work during World War I that brought about increased legislative control on drinking. The Defence of the Realm Act 1914 brought in controls over pub opening hours and the strength of beer; and it increased taxation. Similar motivations lay behind the State Management Scheme (1916) which led to the nationalisation of breweries and pubs in three areas where large armaments factories existed.

Alcohol use declined after the turn of the century and remained at a low level between the wars. However, from 1960 onwards there has been a quite dramatic increase in alcohol use up until the present day (British Medical Association 2008). While the disease concept had been influential over the course of the 19th century, its influence waned over the first half of the 20th but was rediscovered under the new term ‘alcoholism’ in the 1940s. This was particularly influential in the expansion of specialist provision for alcoholics in the 1950s and 60s (Edwards 2000). The 1970s witnessed a move towards focusing on alcohol misuse and problem drinking (rather than alcoholism) at a population level (Kneale and French 2008; Thom 2001). This new public health paradigm led to an increasing focus on ‘universal’ approaches, such as substance-use education, public awareness campaigns, and lower-level interventions, such as community-based detoxification and brief interventions. The adoption of ‘units’ as the standard measure of alcohol in the 1980s rendered problem drinking more quantifiable and, therefore, more visible. This public health approach has continued to gain in influence over the intervening years and is now increasingly reflected in recent policy documents emanating from the Department of Health.

In the 21st century, public concern about drinking has grown exponentially. Disorderly drinking in town and city centres has caused a growing level of public disquiet, as has drinking among young women. The public health lobby has proved increasingly effective in getting its voice heard, with frequent opportunities provided by growing figures on alcohol consumption and on alcohol-related illness and death. Alcohol has therefore become a major policy issue – increasingly eclipsing illicit drugs as the substance abuse issue of the day.

Current alcohol policy

The first overarching UK drug strategy was introduced in 1995, and this led to increasing pressure from the voluntary sector for a similar overarching strategy for alcohol. In 2004 this finally arrived in the shape of the Alcohol Harm Reduction Strategy for England (Cabinet Office 2004). Since then, there has been a flurry of policies reflecting the political salience of the alcohol issue. The Licensing Act 2003 came into effect in 2005, and a new English policy document, Safe. Sensible. Social. (Department of Health et al. 2007) came out in 2007. In Scotland, a quite radical consultation document came out in 2008: Changing Scotland’s Relationship with Alcohol: A Discussion Paper on Our Strategic Approach (Scottish Government 2008a: henceforth the Discussion Paper); and the Welsh drug and alcohol strategy Working Together to Reduce Harm (Welsh Assembly Government 2008) included a range of measures focusing on alcohol.

The main elements of these policies were:

1. Public health and the need for culture change

2. Education and information

3. Treatment

4. Crime, disorder and licensing

5. Taxation.

1. Public health and the need for culture change

The increasing dominance of the public health paradigm in alcohol policy has been accompanied by a growing realisation that, if any difference was to be made to alcohol-related health problems, policy had to make an impact on the large numbers of people who drink over the recommended levels, not just the problem drinkers or alcoholics. This has led to strong calls for culture change in Safe. Sensible. Social. (SSS), the Discussion Paper and in the Welsh strategy. It has also led to an emphasis on all groups who drink too much, rather than just the familiar target of young people.

Two means of realising such culture change are proposed: public campaigns and influencing the price and availability of alcohol. The UK strategy in particular promises sustained national campaigns that will ‘challenge public tolerance of drunkenness’ and raise public knowledge of alcohol units, so that people can more readily estimate the amount they are drinking. However, the main means proposed of reducing drinking levels at the population level, particularly in the Scottish document, is through attempting to influence how alcohol is priced, made available and sold. There is a tacit recognition that, in order to encourage people to drink less, governments will have to address the considerable force of the alcohol industry pushing people in the opposite direction. SSS promised a review of the effectiveness of the industry’s Social Responsibility Standards for the Production and Sale of Alcoholic drinks in the UK. This was subsequently undertaken and showed that these voluntary standards ‘are currently having negligible impact in either reducing bad practice or promoting good practice on the ground’ (KPMG 2008). In 2009, the UK government (Home Office 2009) published a consultation document on a new, mandatory code of practice for alcohol retailers in England and Wales, which includes a ban on ‘irresponsible promotions’ (such as ‘Women drink free’ and ‘All you can drink for £x’).

The Scottish Discussion Paper also included a ban on reduced-price and loss-leading promotions. However, it went much further by proposing a minimum retail price, preventing promotion of alcohol in stores, and introducing separate check-outs for people buying alcohol. By such measures, the Scottish Government aimed to ‘denormalise’ alcohol and reduce consumption. Since the publication of the discussion document, the Scottish Government has decided to go ahead with these measures. However, initial attempts to introduce a minimum price through licensing powers were foiled by opposition parties and the change will therefore have to be made through legislation.

2. Education and information

One potentially important source of information on drinking is the bottle or can in which it is bought. The UK government has been putting increasing pressure on the producers to include unit information and health messages on alcohol containers. While initially it was hoped that this would be done voluntarily, there have been increasing threats of coercion.

It is noticeable that there is very little focus in any of the alcohol strategy documents on school-based alcohol education, presumably reflecting scepticism about the potential for such approaches to have an impact on drinking.

3. Treatment

There is good evidence that brief alcohol interventions delivered by GPs in a primary healthcare setting can have an impact on drink problems (e.g. Kaner et al. 2007). The main focus in all three strategy documents is on early identification of alcohol problems and early, brief interventions.

4. Crime, disorder and licensing

Over the past decade, there has been growing public and media disquiet about alcohol-related disorder in town and city centres. In England and Wales the Licensing Act 2003 came into effect in November 2005 and was introduced amid a furore in the media about the potential for extended licensing to aggravate the problems already being experienced. The introduction of flexible opening hours was well-publicised. The Act also expanded court and police powers to close licensed premises temporarily due to disorder problems, and included provision for licences to be reviewed prior to their expiry. Evaluation of the Act has shown little impact on public order and crime (Department of Culture, Media and Sport 2008).

Relevant sections of the Violent Crime Reduction Act 2006 came into effect in England and Wales in June 2008. They introduced Drinking Banning Orders, whereby individuals could be banned from drinking in particular premises; and Alcohol Disorder Zones, which allow local authorities to impose charges on licence holders in designated ADZs, to recoup the...

Table of contents

• Cover
• Title
• Contents
• Acknowledgements
• Introduction
• Part I The History of Drug and Alcohol Policy
• Part II Alcohol and Tobacco
• PART III Treatment and Recovery, and the Wider Impacts of Substance Misuse
• Part IV Prevention
• Part V Integrated Services and Workforce Development