Why Drug Stigma Still Matters

More sinned against than sinning?

 “Psychological theories of illness are a powerful means of placing the blame on the ill. Patients who are instructed that they have, unwittingly, caused their disease are also being made to feel that they have deserved it.”

--Susan Sontag, Illness as Metaphor

Addiction is always a hot topic, in its way, if only because of an endless supply of fallible starlets. More seriously, valuable research is taking place in myriad directions—the psychology of addiction, the disease of addiction, the neurobiology of addiction, the neuropsychopharmacology of addiction, etc. What sometimes goes missing is any serious analysis of the stigmatization of drug addiction.

The UK Drug Policy Commission (UKDPC) is an independent research group comprised of 12 “expert commissioners” charged with providing objective analysis on drug policy matters. The group recently issued a paper authored by Charlie Lloyd of the University of York. In “Sinning and Sinned Against: The Stigmatisation of Problem Drug Users,” (PDF) Lloyd set out to pull together the evidence-based research on the effects of stigmatizing  “problem drug users.” The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) defines problem drug use as “injecting drug use or long-duration/regular use of opioids, cocaine and/or amphetamines.”

According to Lloyd’s analysis of the research literature, the groups most frequently referred to as stigmatized are the disabled, the mentally ill, minority ethnic groups—and drug addicts. To make matters worse, multiple problems often attach to addicts: “Problem drug users frequently report suffering from other stigmas: being black, female, Hepatitis C or HIV positive, disabled, or suffering from a mental disorder. However, research shows that problem drug user status is the most stigmatising.” The stigma is continuously cemented in place by rhetoric about the “war on drugs.” There is no comparable public war on disability, or mental illness, or ethnicity—at least not overtly.

I cannot vouch for Lloyd’s analysis, but a good deal of it smacks of common sense at the street level. Others have suggested it is logical to assume that the stigma attached to hard drug addiction serves, by example, to deter others. “However,” Lloyd writes, “attempts to scare young people away from drug use have not proved effective. The evidence reviewed here suggests that stigma keeps users away from treatment.”

So this is not a theoretical concern. Stigmatization “may be a major stumbling block to successful rehabilitation.” Health professionals and hospital staff “can be distrustful and judgmental in dealing with problem drug users but drug users can themselves be aggressive and manipulative. In the United States staff who choose to work in hospitals serving the most deprived, inner-city populations appear to be more compassionate and patient.”

The prevailing public view, Lloyd writes, is that problem drug users tend to be “dangerous, deceitful, unreliable, unpredictable, hard to talk with and to blame for their predicament. Young people may have more negative views in this respect than adults.”

Of course, drug addicts can be all those things at one time or another. Drug abusers often stigmatize themselves. For the user, these conflicted feelings lead some of them to feel that “the very act of seeking treatment serves to cement an ‘addict’ or ‘junkie’ identity, which can lead to further rejection from family and friends.” This is most commonly experienced by users on methadone maintenance treatment, “who feel particularly stigmatised, in comparison to other treatment types.” Lloyd notes that a lifetime stigma sometimes attaches to heroin and cocaine addiction, continuing “to haunt such ex-users, preventing access to good housing and employment.” As he trenchantly observes, there is plenty of room “to stigmatise users less, without rendering heroin or crack-cocaine significantly more attractive.”

Lloyd concludes that the primary culprit, the complicating factor, is “blame.” Compared to “blameless groups” such as the disabled and the mentally ill, problem drug users, he writes, “are blamed for taking drugs in the first place and are also perceived to have a choice whether or not to take drugs in the future.”

If public and professional stigma has the power to prevent addicts from entering treatment (as it formerly held a similar power over the mentally ill, and before that, the disabled), what can be done about it? Lloyd makes several concrete suggestions, most of which center, predictably, on education:

--Drug education in schools should focus on the causes and the consequences of active addiction, rather than relying on scare stories.

--It’s time to teach health care and pharmacy staff about the medical, social, and psychological aspects of drug addiction.

--Treatment agencies need to focus on the whole person, “and not see problem drug users as solely problem drug users. Some drug addicts are also bird-watchers.”

--Users themselves, as well as their families, often benefit from a greater understanding of the mechanisms of addiction. This can have the effect of reducing “the self-blame felt by many drug user’s parents.”

--Finally, “police need to reflect on their practice in policing problem drug users at street level.” ‘Nuff said on that.

DrugScope, a leading U.K. charity with a membership drawn in part from the ranks of drug treatment and education workers, praised the report as “timely and insightful.” Martin Barnes, chief executive of DrugScope, said that the report effectively “evidences stigma as a barrier to recovery and reintegration.”

Photo Credit: http://www.zazzle.com/

Addicts, Alcoholics Overwhelm Prison System

1 out of 100 Americans now in jail.

For the first time in American history, according to a study released by the Pew Center on the States, more than one in every 99.1 adult men and women are now in prison or in jail. States spent a total of $49 billion on prisons in 2007, compared to $11 billion 20 years ago. The United States incarcerates a larger percentage of its population than any other country. China ranks second.

“For all the money spent on corrections today, there hasn’t been a clear and convincing return for public safety,” according to Adam Gelb, director of the Pew Center’s Public Safety Performance Project. The report says that higher incarcerations rates have not been caused by increased crime or a corresponding surge in population numbers. Rather, stricter sentencing policies, such as “three-strikes” laws, as well as longer sentences, are behind the surge. A PDF version of the full report is available here.

A Newsweek article by Claudia Kalb notes that the number of drug offenders in the federal prison system leaped by 26 per cent between 2000 and 2006. In addition, more than one out of every three women in prison are serving time for drug-related crimes.

In 2000, fed-up California voters passed Proposition 36, designed to steer nonviolent drug offenders into treatment and job training programs--but funding has been precarious. Other states, including Texas, have resorted to specialized drug courts and greater drug treatment efforts to cope with the overflow of drug addicts in the legal system. As John Whitmire, a Texas State Senator, told the New York Times (Reg. required), “we weren’t smart about nonviolent offenders. The [Texas] Legislature finally caught up with the public.”

The Pew study reveals that addiction is as firmly criminalized as ever. The compressed essence of the war on drugs is simply to put as many people in jail as possible. Obviously, long prison terms will not cure addicts of their condition, any more than long prison terms for diabetics would cure that condition.

As a forced cold turkey treatment for addiction, perhaps some would view prison as harsh but necessary. Yet drugs are known to be widely available within the nation’s federal prison system. As an inmate in an Oklahoma federal prison wrote in a letter to Time magazine: “If the Government cannot stop people from using drugs in a few fenced-off acres over which it has total control, why should Americans forfeit any of their traditional civil rights in the hope of reducing the drug problem?”

The Sentencing Project, a Washington-based group that promotes alternatives to jail time, said recently that as of 2002, 45 per cent of all drug arrests were for marijuana. Simple possession is the rule--only one-sixth of the imprisonments involved charges of marijuana trafficking.

According to Reuters, the latest drug czar, George W. Bush’s man John Walters, alluded to new research showing that “marijuana use, particularly during the teen years, can lead to depression, thoughts of suicide and schizophrenia.” Even assuming this dubious statement to be true, it would seem to argue against prison and in favor of treatment.

The American criminal justice system cannot support the burden of a continual flood of minor drug possession cases. Plea-bargaining—the accommodation that keeps the legal edifice afloat—becomes the rule of the day. The legal system would break down in gridlock if every drug defendant insisted on his constitutional right to a jury trial. Prison sentences are bartered and sold like pork futures, and the jury trial has become an unaffordable luxury. For those accused of drug possession, pleading innocent sometimes looks like a risk they cannot afford to take.

Drug prohibition itself is a major part of the reason why the more potent and problematic refinements of plant drugs keep taking center stage. Since crack cocaine is more potent, more profitable, and more difficult to detect in transit, it replaces powdered cocaine, which, in its turn, replaced the chewing of cocoa leaves. Just as bootleggers switched from beer to hard liquor, so international drug dealers switch from cannabis to cocaine whenever the U.S. enforcement engine lumbers off in the direction of marijuana interdiction and eradication.

If addicted crack dealers sometimes receive stiffer sentences than wanton murderers (and they do), then it is a double irony, since people convicted of drug offenses are often good candidates for rehabilitation. However, public treatment programs are overbooked, and private programs are out of reach for those with little or no health insurance.

Photo Credit: California Dept. of Corrections and Rehabilitation