Sunday, August 24, 2008

where do we put the emphasis?

I've been doing a lot of thinking about addiction and substance use treatment and prevention. In particular, where we place the emphasis and what our priorities are. It's a very difficult issue, with good arguments on all sides. And the thing is, I agree with all of them, unfortunately, there doesn't seem to be enough money to focus on all of them and do them well.

We can look at things in terms of treatment. In this approach, the emphasis would be put on providing really awesome treatment programs. Once people get to the point in their journey where they are ready to come to a treatment program they would get awesome care. There would be long term programs with flexible approaches taking into account people cultures, religions and learning styles. There'd be high staff to client ratios, and people would have a high "success" rate (I won't even begin to discuss what success is).

Then there's harm reduction. In this approach we look at the fact that people are going to use drugs, so how can we help them do less harm, and maybe eventually get to the point where they want to seek treatment. This is the approach that provides clean needle kits, condoms, supervised injection sites and detox programs where you can give your body a break without having to want to leave the life style (we do this with varying results). Harm reduction takes into account people's self determination and right to determine their own life path. Harm reduction can begin to build those connections which lead to further connections such as detox and treatment. However, if all the emphasis is placed here, what happens when they get to treatment and discover it sucks.

Then of course there's enforcement. This says that substance use is wrong, and we need to stop it. It's a legalistic approach, therefore most often enforced by law enforcement. This can include jail time and mandated detox and treatment. A non police example of this is Child and Family Services requiring a woman to go to detox and treatment to regain custody of her children (I'm not asserting this is bad, just explaining). A great deal of time and money goes into jail time for people convicted of drug offences, and many police are assigned to drug related tasks.

And then, there's prevention, a place where an unfortunately small amount of money goes. In this approach the target is children and families. If we can keep someone from starting drug or alcohol use in the first place, the cost of treatment, harm reduction and enforcement completely disappear. The problem of course is, that if we were to funnel all our money to prevention, what would we do with all the existing users who need help?

And so there is is. Various ways of looking at and dealing with substance use. Thanks for the comments on my post about supervised injection sites. It's something interesting to consider!


antiSWer said...

One of the issues of enforcement that I'd like to see addressed is how the drug users and the small time drug dealers are the ones targeted while the main dealers are mostly ignored. I've read reports of BMWs and Mercedes stopping at run down SRO buildings for a little while and the police not even batting an eye. Hello? What exactly do you think they're doing there?

No, it's easier to go after the small time dealer who is just trying to earn enough to supply his habit. That's where enforcement goes wrong, IMO.

I think we need to look at the resources we have available and balance it out. If you think of the four pillars as a table, each leg has to be strong to support the community in a stable fashion. It shouldn't be all or nothing with a focus on one of the legs.

bluejeansocialwork said...

First, thanks to Still Dreaming & AntiSWer for breaking this down in such a nice organized way. In general, I support research-based methods and best practices, so AntiSWer's comments about supervised sites made them more compelling to me.

I like the idea of the four pillars, too, though I'm not sure I agree they should be exactly perfectly balanced. I would put about half the money into prevention, and about 5% of the money into enforcement (basically only for child welfare cases), the rest could go for treatment (30%) and harm reduction (15%). I think it's fair to look at not only what works, but what areas are the most efficient to invest in. This leads me to believe in a special push for prevention and supportive, well-executed treatment.

Still Dreaming said...

I know exactly what you mean antiswer! It drives me crazy the way they go after the small stuff. Although I have to admit they do try and tackle some organized crime stuff, but still...

I like what you said about the percentages too, bluejean. It's something I think about a lot, and not just in terms of addictions, but also in terms of homelessness...