Substance misuse: the implications of research, policy and practice

Edited by Joy Barlow, Reviewed by Dr Adrian Bonner

This edited book contains approximately two hundred pages of useful insights into the problems of tackling alcohol and drug abuse and dependency. The majority of the contributors either work or have strong links with problematic substance use in Scotland, the editor having been instrumental in establishing STRADA (Scottish Training on Drugs and Alcohol). This Scottish perspective is quite pertinent to a comparative view of attitudes, policies and treatment approaches across the UK. Other cultural dimensions are provided by researchers and policy experts from New Zealand and Italy.

The first part of the book provides a helpful summary of the development of alcohol and drug trends which provoke different government policies and responses. The commodity alcohol, “… has the most impact on the way we live, over the longest period, and which has caused the most damage, public concern and legislative responses…..” in contrast to drugs, the market of which is largely uncontrolled and “… is hidden and rarely disturbed by government or criminal justice agency intervention..” This review highlights the problems of managing alcohol problems in the community which is subjected to highly sophisticated marketing and lobbying activities of the drinks industry, which confounds the issues of control of a visible market by, until recently, undue influence of the industry on government policy. A useful comparison is made between the Welsh Assembly’s inclusion of alcohol and drugs in the same strategy, suggesting the common underlying motivation mechanisms for both alcohol and other drugs and includes service users in the planning of services; the “reintegration” approach to the rehabilitation of drug users as promoted by the UK government, with incentives linked to the welfare support; and the “recovery” perspective of the Scottish Government which seeks to bring about a change in culture and its main aim being to bring about drug-free lives. The debate concerning a “harm reduction“ approach as opposed to abstinence goals leans towards the latter in Scottish policy.

This introduction to the cultural and political backdrop to alcohol and drug issues lead to a consideration of the global price–related alcohol harm and overwhelming evidence of alcohol and poor health. The role of partnerships in responding to this set of socioeconomic circumstances is leading to modern regulatory systems as that emerging in New Zealand. Support for this community-development approach is provided by the example of the apparent success of smoking cessation in various regions.

The second section of the book focuses on treatment and recovery. Data from the DORIS (Drug Outcome Research in Scotland) study indicates that despite a signifi cant use of engagement approaches such as needle and exchange schemes, more than fifty percent of DORIS respondents are still using heroin and fewer are in employment compared to those at the outset of their treatment. Furthermore, high levels of unsafe drinking continue and acquisitive crime continues to be a signifi cant problem. One explanation for this is the under capacity of the substance misuse services to provide adequate intensive support for service users. The long term support needed to change someone into a non-drug user appears to be a very distant aspiration when such a large number of people are in need of support. The authors suggest the importance of differentiating between those who are likely to achieve abstinence and those for whom harm reduction is the most pragmatic way forward.

The importance of employment opportunities is highlighted but combining aspiration with reality is needed. The large number of barriers to employment result in many people failing to meet the demands of the world of work. A staged (re-) introduction is suggested as a way forward to prevent failure and negative motivational factors associated with relapse into dependency. A number of case studies are presented which illuminate the opportunities for developing this approach.

The final sections of the book focus on children affected by parental drug and alcohol misuse, the role of the family, prevention, and the impact of social exclusion. These sections are followed by a brief review of integrated working and workforce development.

In summary, the book provides a wide ranging commentary of the issues leading to substance misuse and society’s varying responses, which appear to be culturally influenced. It is easy to read and should prove useful for practitioners and those studying on social work and related courses. In view of the Scottish orientation of the contributors, and nutritionally associated alcoholic brain (ABD) damage which is at a high frequency in Scotland, it is surprising that no mention was made of Wernicke- Korsakoff syndrome (WKS). WKS is found in chronic alcohol abusers, and ABD at less apparent pre-clinical stages of cognitive dysfunction. ABD, even at subclinical levels, mitigates against the development of individual potential and life chances and impacts on personal relationships in the family and in employment. A section on nutritional dimensions of alcohol and drug misuse would add another often ignored aspect of these biopsychosocial problems.