The Right to Treatment for Problematic Substance Use in Wales
In Scotland a Right to Treatment Bill has been proposed, to enshrine in law the right for anyone with problematic substance use to have timely access to suitable treatment. I think there are always problems with such approaches but the need to set out a minimum requirement for services in my view is important. That is why we are campaigning for a right to treatment for problematic substance use in Wales.
The challenge for supporting people with drug and alcohol issues is that there needs to be a whole system approach. We need to support people who want to take drugs safely coupled with the need to support people who feel they need a life without a substance which they feel is damaging them. The difficulty for those of us working with people with drug and alcohol issues is the substance is often presented as the problem. In fact, those often struggling with drug use issues are self-medicating to cope with a trauma or a mental health problem, or adverse childhood experiences. They have found the drugs they have come across have helped them deal with such traumas. In some ways, they may have learnt this when as children they were prescribed drugs to deal with where there was a multitude of problems (Antidepressants for children and teenagers: what works? nihr.ac.uk). What is needed with young people is more genuine investment in mental health support, youth services and trauma assistance programmes. If we do this, we may not need adult drug services in anything like the same way we do today. The sad truth, however, is that successive governments have believed that ‘medicating a problem’ is politically easier to sell to voters and potentially cheaper in the short term than investing in transforming society. One cannot then be surprised if children who are medicated or who see their peers medicated turn to substances that work to alleviate symptoms of their trauma.
Drug use is learnt behaviour and often a form of self-medication. It is dangerous to perceive it as deviant behaviour given how society utilises medical interventions from an early life. Problematic drug use is often a consequence of a societal failure to address adverse childhood experiences and therefore any response should be based on showing the same compassion to the struggling adult as we should have done to the afflicted child. In many instances the anti-social behaviour associated with problematic drug use is the symptom of a societal failure. The idea that imprisonment is the right response, which further brutalises a person’s life experience, makes no sense. Thus, the argument for a treatment bill is rooted in compassion as it fundamentally seeks to enshrine in law a minimum level of support that people should expect to receive.
Drug and alcohol services across the world have the shared experience that the first response to a drug use crisis is to meet people where they are at. It is listening to the issues, empathising that in most instances the drug is the prop that keeps them going. We cannot simply get rid of the prop, without first addressing what is causing them pain. This is why offering a regulated substitute that will not risk further health problems is critical. In effect the substitute creates breathing time to reflect and ideally deal with the underlying issues. Some problems can be resolve by listening, by creating community and development of self-worth. Providing training, access to work and developing independence is often key. A person who can be supported in such a way may not need further treatment and a substitution reduction programme may be sufficient for them to live the life they choose. What is critical to such a person is that they have access to rapid treatment as soon as the need is recognised, so their personal situation is not damaged by being caught up with risky behaviour and exposure to further trauma in terms of sourcing street drugs, which can cause serious trauma and potentially exposure to the criminal justice system, which will further complicate their needs.
There are those who have more complex issues, but who still aspire to be free of the illicit drugs they are taking. The trauma, the long-term addiction plus current challenging circumstances such as housing or health conditions means that community services can only help some of those with complex needs to a limited extent. The need for residential support therefore is essential. The sad reality though is that the options for this are very limited unless the individual concerned has very deep pockets. The cost of a detox service is very high and therefore only a very small minority can access it. It is cruel when society makes it clear it wants and expects people to become drug free, but for too many that can only happen in a prison cell or a psychiatric unit. The failure to provide the financial resources needed to invest in making people well is simply unacceptable. Of course, a detox is only the medical care needed to cease a physical dependence on a substance, and there needs rehabilitation centres which support people over a longer period when they are in a supportive environment to tackle the issues that have led them to self-medicate in the first place.
The concept of a lifestyle free from illicit drugs is not an option for everybody. Some people find the substances they take works for them. It could be that they continue to want or need to use these drugs because it is the only positive experience they have and they cannot see a bright future for themselves. It may be that this is a form of escapism for dealing with trauma or this may be because they know they do not have the skills for a suitable job, or they do not see the other positive prospects life may offer. It is vital for us to think differently if we want to make a difference.
In an example of thinking differently, in the case of long-term substance users who are homeless, we cannot give them a needle syringe and expect them to inject anywhere other than a public space. By definition such individuals are homeless, and at present society does not provide safe spaces for them to inject. In having licenced premises for this very small cohort of people who use drugs would have a number of benefits. It would reduce drug litter, which creates anxiety in communities and contributes to a very negative image of substance users in general and toward this group of vulnerable and challenged individuals in particular. Having a premises licenced for homeless people to use their drugs also brings some of the most complex and vulnerable individuals into direct and sustained contact with drug services and gives us the opportunity to provide the additional help.
Beyond services such as rapid prescribing and limited licensed spaces for homeless substance users, we need to work collaboratively to look at the best options for an individual in reducing their need for illicit drugs. Society must have a focus on life; that a life is worth saving, and that people who use drugs can have a worthy and happy life – a life worth living. To do this we need to ensure that the global first here in Wales of a nationwide peer naloxone service is sustained. We also need to explore creative housing options where support can be given to those with complex needs whilst providing some levels of independence. In cases where people are struggling, we need more respite detox services, backed by rehabilitation services. By having a complete approach to support all those with substance use challenges, and by enshrining their right to treatment in law, we can enable all those who currently have problematic substance use to at least get back with a steady relationship with their drug taking with the acceptance that abstinence is for many not a realistic goal for everyone.
Martin Blakebrough, CEO