THE RISE, FALL, AND REVIVAL OF RECOVERY IN DRUG POLICY

The British Government's recent drug strategy, Reducing Demand,
Restricting Supply, Building Recovery: Supporting People to Live a
Drug-Free Life (2010), focuses on recovery from addiction. The
strategy claims that it has recovery at its heart. Long-term extended
treatment using methadone or other substitute prescribing, without a
definite endpoint, is now out of favour. Many addicts say that they
want to come off drugs and so the Government aims to facilitate that
desire. This so-called new abstentionism has been a controversial
change in the drug field. Some commentators have feared that the
focus on abstinence will end the era of harm reduction in drug
policy. One prominent debate in the UK last year, "The Future of Harm
Reduction and Drug Prevention in the UK", pitched Neil McKeganey, a
sociologist and prominent advocate of abstinence, against Stanton
Peele, a psychologist and analyst of the "meaning of addiction", thus
epitomising the divergent positions.

Recovery is by no means a new idea in the treatment of addiction,
although the language used to categorise it has varied much over the
years. Why has recovery gained and lost support, and why has it been
spoken about in different ways? The history of treatment for people
who use illicit drugs, and the language that is used to describe
them, tells us about a wider context, about the operation of
interests within politics and within the discipline of addiction.

Recovery is a term redolent of 19th-century temperance, with the
pledge as creed and reformed drunkards as the saved. In the late 19th
century, the concept was framed through a different, medical lens.
The idea of treatment for a condition called "inebriety", which
encompassed both alcohol and drugs, began to form the basis of a new
form of specialist practice. Up until then, "treating" people who
drank alcohol or took drugs had not been much discussed; such people
were not seen as diseased or in need of a doctor's attention. The
British professional society, established in 1884, was originally the
Society for the Study and Cure of Inebriety (nowadays it is the
Society for the Study of Addiction). Initially, optimism about
recovery was to the fore. But just a few years after its foundation,
"cure" of the presumed disease disappeared from the strap line, as
some of that early optimism waned.

Cure did not go away, however, and became bound up in institutional
solutions during the late 19th and early 20th century. Doctors wanted
to establish a state-funded system of treatment aimed primarily at
the alcoholic caught up in the revolving door of the criminal justice
system. Addicts sent to prison would instead be referred to
"inebriate asylums" rather like so-called lunatic asylums, where they
would undergo long-term treatment aimed at ultimate abstinence. The
treatment described at that time was most often a combination of
food, work, and religion, the rebuilding of "moral" qualities seen as
lacking in the addict, and removing him or her from polluting
environments. There were experiments, too, with new drug
treatments-cannabis perhaps, coca, or chloral. There were debates
about whether abrupt, gradual, or long-term withdrawal was most
appropriate. Abstinence, as for temperance, was the ultimate aim. The
proposed system never fully took root and had died away in most
European countries and in the USA by World War 1. Recovery was not to
come through institutional confinement.

Just after that war, during the 1920s, recovery underwent an
important redefinition. This reconfiguration of policy lasted for
some 40 years, into the 1960s. Treatment again assumed prominence in
drug policy discussions. The exception was alcohol, which went its
own way as temperance waned as a policy issue. The postwar peace
settlement in 1918 established an international system of drug
control, still in operation today, and national systems for the
regulation of "dangerous" drugs.

Britain and the USA took different paths in drug treatment. In the
USA, there was no option but abstinence-or the black market. The
prohibition of prescription to addicts dated back to the 1914
Harrison Narcotics Act. Doctors were prosecuted thereafter if they
prescribed. In the UK it was different. The continuance of heroin and
other opiate-based prescribing there in the 1920s owed much to the
power of the British medical profession and the particular focus on
mainly middle-class addicts. Attempts by the Home Office, newly in
charge of drug policy, to impose a state-authorised policy of abrupt
withdrawal, foundered in the face of medical opposition. The language
at the time pitted the British Home Office's preference for "stamping
out addiction", which was inspired by US policy, against the medical
emphasis on minimum doses of drugs for addicts who could not
otherwise lead "useful and fairly normal" lives. By the late 1920s, a
medical modus vivendi with the Home Office had been established on
that basis-sometimes known as the British system-which set the tone
of policy and treatment for the next 40 years. But abrupt withdrawal
was still the norm for addicts who came from low socioeconomic
groups, who self-medicated, or who ended up in prison. Who controlled
the drug and what sort of person took it was important in defining
whether the endpoint was abstinence or continued prescription.

Contextual issues like these also affected the change towards
methadone prescribing during the 1960s and 1970s. In the USA, a
switch from abstinence as the only legal option to methadone as a
substitute prescription took
place under the influence of doctors Vincent Dole and Marie Nyswander
in New York, but also through the broader dynamic of the changes in
the USA drug-treatment system in the wake of the Vietnam war and the
return of addicted conscripts. Methadone had the status of a
"medical" drug, whereas heroin in the US did not.

In Britain, the change that took place was from prescribing heroin on
a long-term basis to prescribing methadone in the short term with the
aim of achieving abstinence. The specialist drug dependence units
established in the late 1960s had silted up with long-term heroin
users. Evidence produced at the time provided a rationale for a focus
on addicts' ultimate recovery, an approach promoted by clinic staff
who longed for a therapeutic function. Abstinence was tied to what
was called rehabilitation, a social "disability" model transferred
across from similar developments in the alcohol field, and used most
significantly by the UK's Advisory Council on the Misuse of Drugs in
their report Treatment and Rehabilitation of 1982.

The focus on abstinence had its critics in the drug field and
elsewhere. During the 1980s, the expanding drug voluntary sector in
the UK was wedded to reducing harm from drugs, but this remained a
largely unspoken objective in the context of the public "war on
drugs". The advent of HIV/AIDS provided the opportunity for
pre-existing ideas to be put into practice. The threat of the spread
of HIV/AIDS into the general population through the conduit of drug
users came to be seen as greater than the threat of the spread of
drug misuse itself. The language changed again. What was called a
"hierarchy of objectives" in drug treatment replaced the previous
focus on short-term treatment leading to abstinence. That new
hierarchy could include substitute prescribing. Both needle exchange
and long-term maintenance with methadone became permissible,
redefined as essential prevention strategies to tackle HIV/AIDS.

Even in those days, British Conservative politicians were unconvinced
about treatment. But research commissioned for the Treatment
Effectiveness Review initiated by the then Minister of Health Brian
Mawhinney in the mid-1990s was subsequently interpreted as showing
that "treatment works". In particular it seemed to work in ensuring
that addicts stayed out of prison, an idea which harked back to the
late 19th century. So maintenance and methadone revived as part of
the incoming Labour Government's criminal justice agenda. The
influence of the "user movement" ensured that prescribing continued
as a central strategy.

In the USA, different issues prevailed and needle exchange as a harm
reduction tactic (rather than methadone) proved to be particularly
controversial. For example, in some African-American communities
community leaders questioned the provision of needle exchanges and
raised objections. Treatment has been legitimised in a different way.
In the USA the "brain disease" model, which has now assumed purchase
on both sides of the Atlantic, had its origin in the assertion from
the US National Institute on Drug Abuse that addiction was a "chronic
relapsing brain disorder", and so would be amenable to drug
treatment-a portfolio of developing pharmaceutical interventions.

Now the post-AIDS consensus in the UK around harm reduction is
questioned and recovery is the definition of the moment. Some
commentary has identified a political strategy. Conservative
politicians, notably Iain Duncan Smith, had questioned continuing
drug prescription and advocated abstinence well before the Coalition
Government came to power. Mental health had adopted the term and the
language of "recovery" seems to have percolated through to the drugs
field. The influence of the significant American focus on abstinence
can also be detected. Professional interests are involved. Some
workers in the drug field had grown tired of the focus on what one
called "methadone, wine and welfare" and, as in the 1970s, longed for
change. The purpose of treatment and the meaning-and history-of
"recovery" is being negotiated. The UK Drug Policy Commission has
defined recovery as a process, which may involve support from
medication. Economics, payment by results, is also on the new agenda.
How "recovery" differs from "cure", "rehabilitation", or a "hierarchy
of objectives" will depend on the changing context within which the
new language operates, and the political and professional interests
who negotiate to establish its meaning in policy and in practice.