From Abstinence to Risk Reduction (part two)
Following on from part one Núria Calzada continues her conversation with retired Professor Julian Buchanan in New Zealand, they explore the move away from abstinence to risk reduction and the creation of one of the largest multidisciplinary community drugs teams in the country. This interview was originally published in the Cañamo Magazine.
Q. Could we say that this [your realisation that pushing abstinence was not working and that you were part of the problem not the solution] was your revelation period for the change in your perception about drugs?
Undoubtedly, yes, because I realised that none of the basic person centred counselling principles I’d been taught in my social work qualification were being applied. I was trained to be non-judgmental, actively listen, treat people with respect, have no hidden agendas, show unconditional positive regard and have empathy. I realised when working with people who had a drug problem — these important principles did not feature at all. Quite the opposite. I judged them, I had my own agenda, I pressed them in my space, I told them what they had to do or not do and I didn’t really listen to what they really wanted. That’s when I became aware.
Initially, chasing heroin was the preferred method of administration on Merseyside, but eventually injecting became popular across the UK, and that’s when the government became fearful about a new virus — HIV/AIDS — being spread by injecting drug users into the wider population. The Thatcher government was prepared spent a lot of money to contain the drug problem. Partly because they believed that it would be a temporary problem, and they were desperately worried about the threat of AIDS. The government invested ‘pump-prime’ money into Merseyside social services, health, the probation service and education to find a quick solution to the drug epidemic. A group of drug specialist were appointed at various departments around Liverpool which included myself, Russell Newcombe, a health promotions officer and Pat O’Hare, at that time school coordinator for drug education for Sefton in Merseyside.
The Probation Service appointed me as one of four specialist drug workers on Merseyside to develop a strategy and policy to address the drug problem. With my colleague Geoff Wyke we visited a range of people, clinics and services. However, my insight and understanding grew considerably when I sat down with people struggling with drugs and began to genuinely listen to their story, their journey, to understand their situation, and gave them freedom and respect to explore what they wanted to do, and what they were ready or capable of doing. When we sat down to listen to them, without judging and giving them permission to speak freely, including being able to say “I enjoy drugs and I want to continue”, many of the people we interviewed become overwhelmed and tearful, often telling us we were the first people who really listened or understood them. It was moving but sad that nobody had really listened before.
Q. You also worked with the legendary Dr John Marks, a psychiatrist who led a controversial “experiment” with heroin prescription in the North West of England between 1982 and 1995 and with whom you developed what is known as the Merseyside model. How was that experience and what does the model consist of?
With the government money to ‘solve’ the drug problem, Geoff Wyke and I as drug specialists spent three months to meet and interview people far and wide to develop an appropriate response in Sefton. At that time Dr John Marks, was working at the Liverpool Drug Dependency Clinic and when I met with him he suggested I join him at his clinic every Thursday to interview his ‘customers’ from the area where I worked (Bootle) that he had been prescribing oral or injectable methadone or heroin to, on a maintenance basis.
So after a number of months Dr John Marks and I ran the Bootle Clinic together at Hope Street Liverpool Drug Dependency Clinic. Compared to many psychiatrists and clinicians John was very accessible, open and keen to work in partnership. John always said it was his intention to give people clean heroin or methadone, in ampoule form if they are a regular injector, and at a sufficient level he’d say ‘to stop the need for them to buy drugs off the mafia’, so that we can keep them alive until they’ve ‘got bored of drugs’.
Mersey Regional Health Service reorganisation meant that drug services for Bootle ‘customers’ needed to be delivered by the South Sefton authority (Bootle & Waterloo) and not Liverpool. I had been working closely with other drug specialists in Sefton and Dr John Marks was supportive to help us established a new multi-agency community drug team for South Sefton consisting of a new psychiatrist (Dr Tim Garvey), two community psychiatric nurses, an HIV expert, two social service counsellors, and two probation officers where we continued to deliver the same service John provided in South Sefton.
To iron out the philosophy, terminology, approach and policies of our new Community Drugs Team we hired a Youth Hostel in Yorkshire (Aysgarth Falls) and all of us spent two days away deciding how we would work together. We agreed, among other things, that unlike the Liverpool Clinic we would not do any urine tests, we would offer low threshold maintenance prescribing of injectables and linctus methadone and or heroin, and that all our work would be based on person centred values adopting a risk reduction approach. Assistance towards abstinence would be available for those who wanted it. We wanted to offer much more than substitute drugs. We developed contacts to educate and inform other relevant agencies (schools, hospitals, GPs, social workers, probation officers, parent groups etc). We went to into local prisons (Walton, Styal and Risley) to talk to those people who were about to be released — we’d talk about triggers, tolerance and relapse. We went to the maternity units to work with the health professionals and attended child protection case conferences to try and make sure that women on heroin or methadone did not have their children taken from them. We spoke to family doctors and advised them on how and why to prescribe methadone to pregnant women.
So in 1986 the South Sefton Community Drugs Team was formed. We moved into a recently refurbished three storey building where we all shared an open plan office. We also provided a user friendly needle exchange and ensured condoms were available in the toilets throughout the building. It was an amazing multidisciplinary environment that Dr John Marks was instrumental in helping establish. As a team we became hugely influential because we spoke as one voice, so the various agencies couldn’t easily reject the risk reduction policy that we’d put in place.
We secured an agreement to implement the risk reduction philosophy throughout the Merseyside Probation Service that was enshrined within their drug policy document. We operated a prescribing service from some of the local probation buildings where people on probation or parole had to report. When they reported we’d chat and issue them their prescription (script).
Q. It strikes me that already by 1988 you used the term ‘risk reduction’ not harm reduction.
By the mid-1980s, all concern for drug users was driven by the fear of HIV/AIDS and it was a medical profession led approach concerned with disease, curing people, preventing infections and public health. And here I am, a social worker confronted with a medical model that I think is far too narrow, obsessed with curing the disease of addiction by forcing abstinence. The medical approach to drugs fails to take into account social, psychological, cultural and structural factors — glaring issue that I could see at the heart of the heroin outbreak.
The Maryland Centre funded by public health, situated just behind the Liverpool Drug Dependency Clinic and led by Allan Parry, a former user, pioneered and promoter of harm reduction. They offered one of the first needle exchange programs in the country and would show people who injected how to inject more safely, thereby reducing harm to health. This was particularly important for people who injected in their groin — often women who had to hide their drug use.
However, as a multi-agency team when we thought about drugs and problematic drug use, we saw people damaged by poverty, homelessness, discrimination and social deprivation, for whom drug use was not the problem, but rather a solution. At this stage harm reduction was wrapped up in reducing medical harms and failed to conceptualise the social and economic issues at the heart of a lot of the drug issues we saw. We wanted to go beyond public health harm concerns and look at the less medicalised notion of risks. In a report we did in 1986 for the probation service we talked about the need to adopt a ‘risk reduction’ approach, which we thought was more all encompassing and this was later published in the Probation Journal in 1987. However, over time we dropped the term and adopted harm reduction became as that became the more universally understood terminology.
In Part Three we explore prescribing heroin, working with the UNODC, the NZ Psychoactive Substances Act and the failed NZ Cannabis Referendum (continues here).
Follow him: @julianbuchanan / https://julianbuchanan.wordpress.com
