This is an important study from the LEAP UK secretary to the board, Beccy Gardham
Heroin Addiction in the United Kingdom: Epidemiology, Aetiology and Relevant Models of Health
Heroin addiction is a chronic, relapsing condition as urges to take the drug can interfere with normal life leading to problems with work, relationships and family (National Institute on Drug Abuse (NIDA), 2005). Nutt (2011) argues that addiction is characterised by habitual behaviour which leads to routine use and an increase in tolerance. Clark (2013; p1) states that “…before long your first thought is always heroin and your first act to smoke, snort or inject the amount needed to get straight, often without getting out of bed if you can manage it…” in many respects this is understandable as withdrawal symptoms from heroin include muscle and bone pain, diarrhoea and vomiting. However after taking heroin, users report feelings of drowsiness after an initial ‘rush’ (NIDA, 2005). The most challenging consequences of heroin use include unemployment as approximately 80% of problematic drug users are long term recipients of welfare benefits and criminal prosecution; as there are high levels of heroin induced acquisitive crime- with heroin injectors committing approximately 200 – 260 crimes per year on average (Geraghty,2011; Clark et al 2001; Bryan, Del Bono and Pudney, 2013; HM Govt, 2010). For example Clark (2013; p5) argues that crime such as shoplifting can become a routine habit for heroin users stating that “[shoplifting becomes]…a full time job… it was nine in the morning ‘til five at night, seven days a week.”
Heroin addiction is also a highly stigmatised condition with users referred to as ‘junkie scum,’ which leaves family members of heroin users feeling unable to disclose their situation to friends and colleagues for fear of a stigmatising response (United Kingdom Drug Policy Commission (UKDPC), 2010). However stigmatising responses to heroin use cause low levels of self-esteem in an already vulnerable population, with experiences of stigma leading to reticence in terms of heroin addicts feeling safe to admit they have a problem and to access treatment services (UKDPC, 2010; Nutt, 2012; Buchanan, 2004). Although despite this the National Treatment Agency for Substance Misuse (NTA) (2013) argue that drug treatment services are more accessible than ever with a 5 day waiting time for treatment; and in 2008/9 approximately 210,815 people accessed services in comparison to 100,000 in 2001.
In terms of epidemiology, heroin use first emerged as a problem in the mid 1980’s with 60 – 80,000 users reported to the home office. However by the beginning of the 1990’s this had risen to 300,000, although rates of heroin use in those aged under 25 began to fall from 1998 (Morgan, 2014). NTA (2013), argue that this decrease in the younger population of heroin users resulted from an increase in public health warnings, as well as young people witnessing the long term consequences of heroin use, both of which acted as deterrents. Arguably this is correct as by 2011/12 rates of heroin use had declined to 256,163 (Burton et al, 2014), of which 87,302 individuals were injecting drug users, although this is a relatively small decrease in terms of the length of time it has taken to achieve it (Hay, Rael Dos Santos & Worsley, 2013; Buchanan, 2004). However the main risk of heroin use – especially after periods of abstinence is that of overdose (Jones et al, 2011) and the Office for National Statistics (ONS, 2015), reported that despite falling levels of heroin use overdoses had increased from 596 in 2011 to 952 in 2014.With the median age of death from drug misuse rising from 35 to 42 between 1999 and 2011. This corroborates the assertions of NTA (2013) as there has been a statistically significant increase in the numbers of heroin users aged 35 – 64 years, and significant decreases in heroin users aged 15 – 24 years of age, indicating that heroin users are now an ageing cohort (Burton et al, 2014).
Despite the epidemiological shifts seen over the years, the aetiology of heroin addiction is multi-factorial (Galea, Nandi and Vlahov, 2004). Leshner (no date) argues that addiction is a brain disease which is caused by repeated drug use altering the structure and function of the brain, impacting on mood, perception and emotional state. However this purely biomedical standpoint is reductionist, as it fails to account for psychological and social factors which can influence the behaviour of heroin addicts, as well as connoting that heroin users are solely to blame for their drug use (Engel, 1977; Levy, 2013). One determinant of heroin addiction in later life is childhood trauma, as in comparison with other individuals those with a history of trauma may prefer the use of opiates due to their analgesic properties (Heffernan et al, 2000). Dube et al (2003) further this by arguing that up to 2/3 of intravenous drug use can be attributed to abusive or traumatic childhood experiences. This is corroborated by ‘Kylie’ (in Spencer and Popovich, 2014;p1) who states with regard to addiction “…it’s a symptom of unresolved underlying issues….my addiction was born out of an intense lack of self -esteem and severe childhood trauma.” This can be seen to corroborate the assertions of Heffernan et al (2000) who argue that opiates offer relief from emotional pain in those who have experienced abuse, as the endogenous opiate system can undergo significant impairment after traumatic and stressful events. Arguably the changes in the structure of the brain described by Leshner (no date) precede addiction and are not caused by it. However, addiction is also correlated with low socioeconomic status (Levy, 2013). Murali and Oyebode (2004) argue that unemployment quadruples the likelihood of an individual developing a substance use disorder. Wilkinson and Marmot (2003) state that the most deprived sections of society are nine times more likely to use drugs than their more affluent counterparts; as individuals use substances to numb the pain of poverty. Arguably the analgesic properties of heroin are utilised by people who experience high levels of pain from trauma, poverty or both (Murali and Oyebode, 2004). Whilst trauma and poverty lead to high levels of addiction (Dube et al 2013; Wilkinson and Marmot, 2003), Foster (2000) argues that deindustrialisation had a causal effect on rates of heroin use. In the North of England where the employment market was characterised by manual labour, rates of heroin use are still disproportionately higher than in other areas of the country as it can be seen to mirror increases in poverty and unemployment (Witton, Keaney and Strang, 2005; La Guilla, 2013). For example these effects are still visible in Yorkshire and the Humber which has the highest estimated prevalence rate of opiate use per 1000 population at 9.32, compared with 4.99 in the South East (Hay, Rael Dos Santos and Worsley, 2013). This is furthered by Buchanan (2004) who argues that social disadvantage and exclusion precede problematic drug use. However, Morgan (2014) argues that social networks also play a role in rates of heroin use via processes of ‘micro – diffusion,’ after heroin users enter a community and spread heroin use among friends. Arguably this can be seen to be correct as Williams and Latkin (2007) argue that family and peer networks with a history of drug involvement support the initiation of drug use. In many respects addiction can be seen to be a complex phenomenon with many determinants which can be seen to interact with each other in creating an environment in which heroin use can flourish (Galea, Nandi and Vlahov, 2004). However, Roy and Buchanan (2015) argue that the structural factors which underpin problematic drug use must be recognised alongside social inequalities in the United Kingdom (UK).
In 2010 the Conservative and Liberal Democrat coalition government, released their drug strategy ‘Reducing Demand, Restricting Supply, Building Recovery’, whereby they argue that a whole systems approach is required to enable recovery from addiction. This included (amongst others) employment and the need to ensure that people in receipt of opioid substitution therapy such as methadone, are encouraged towards abstinence in locally funded services which are paid by results. Public Health England (PHE) will also provide support to local government with advice, practical support and data as part of this strategy (HM Govt, 2010; HM Govt, 2013). However the Centre for Social Justice (CSJ, 2013), argue that since 2010 the numbers of people in receipt of methadone for over ten years has increased by 40%. This is furthered by Duke et al (2013) who state that the government failed to define ‘recovery’ in their policy document, leaving room for negotiation into how substitution treatment could be implemented in recovery focused practice. Although in many respects this is necessary as funding for the National Health Service (NHS) pooled treatment budget which supports prescribed interventions has been ring fenced. Although local authorities are judged on specific drugs and alcohol criteria which form only 3 of 66 PHE outcomes, despite 1/3 of the PHE budget coming from former drugs and alcohol funding (CSJ, 2013). However, Abramsohn et al (2009) argue that methadone can cushion heroin addicts against the large scale changes they have to make in terms of lifestyle and the stress this can cause in the early stages of recovery. This is furthered by Mackenzie (2006), who states that models of public health focus on harm reduction, treatment programmes and providing replacement drugs. However, payment by results has raised concerns about the quality of provision offered to recovering addicts, with Roy and Buchanan (2015) arguing that it encourages service providers to focus on measurable outcomes rather than deliverable targets, leading to small effective providers being prevented from bidding for services as financial capability to take a risk on a project is more important than best practice. For example Woods (2015) states that Crime Reduction Initiatives (CRI), in Nottingham which took over from NHS recovery provision in 2014, ignored dual diagnosis of comorbidity with mental health issues and only treated substance misuse, leading to many doctors leaving the service. Despite this HM Govt (2013) state that their payment by results strategy has been a success with local authorities more able to tailor treatment to individual and local needs (HM Govt, 2010). However as opiates are used to blunt emotions created by trauma, recovery from substance misuse could cause a re-emergence of trauma related symptomatology and an increased risk of relapse (Heffernan et al, 2000).
Abramsohn et al (2009) state that the manner in which an individual copes with stress is dependent upon past experience which can influence the way they perceive the world, which can in the correct circumstances facilitate successful coping with a range of complex stressors (Antonovsky, 1993). Arguably, the Salutogenic model of health is appropriate in the treatment of addiction as it focuses on interrelated factors of health which can then be utilised to build resilience, with the main focus being the production of health (Lundman et al, 2010). This can only be achieved by the development of a ‘sense of coherence’, which enables individuals to perceive problems as comprehensible, manageable and meaningful (Antonovsky, 1993), which in turn can be seen to be a component of recovery capital which views social capital in the form of networked resources to be an important indicator of success in recovery (Best and Laudet, 2010). However, as seen above with the failure of CRI to adopt a multidisciplinary approach (Woods, 2015), heroin addicts may be hindered in their ability to develop resilience and in turn a sense of coherence as one element of Salutogenesis and recovery capital is confidence in support networks when problems arise (Chen, 2008; Best and Laudet, 2010). Although Fishbeyn (2015) argues that ideologically based policies with a focus on eradicating drug use often misapply arbitrary health policies which can lead to addicts being held responsible for the problems they face. In many respects this can be seen to be correct as government strategy can be seen to have focused on payment by results (CSJ, 2013), which not only negatively impacts on the experience of heroin addicts (Woods, 2015); it has also led to a reduction in funding with drug services having to compete among other health and social needs for limited resources (Roy and Buchanan, 2015).
As part of their policy on recovery HM Govt (2010) have also emphasised employment as a key component in ending the social exclusion faced by heroin addicts, with those in drug treatment having job search conditions relaxed for six months to give them time to focus on their recovery. However, dedicated Job Centre Plus advisors no longer receive national funding and their roles have been absorbed into wider service provision (NTA, 2012). Also since funding provision was transferred over to local authorities, 55% have cut funding to residential rehabilitation services, leading to smaller numbers of heroin addicts being able to engage with effective drug treatment (CSJ, 2013). However, since 2008 welfare policy has begun to question the worthiness of problem drug users in terms of accessing welfare benefits, with George Osbourne (Chancellor of the Exchequer) claiming that those with underlying drug problems will have to undergo mandatory intensive regimes (Roy and Buchanan, 2015). This can be seen to impact on the stability of heroin addicts at a time when they require resilience and a sense of coherence (Lundman et al, 2010). This is furthered by Dahlgren and Whitehead (1991), who argue that positive outcomes for health at one policy level can be offset by another, which can be seen in the difficulties faced by heroin addicts to access welfare benefits; which in turn rely upon the individual being in structured drug rehabilitation despite a significant lessening of provision at the local level (HM Govt, 2013 CSJ; 2013). Sexauer (2014), states that austerity measures saw £23bn in spending cuts from May 2010 to May 2015, leading to service cuts in areas which provide social integration and employment opportunities which impact on vulnerable populations such as substance misusers. However in terms of recovery capital – which are the resources required by heroin addicts to begin and sustain recovery, social integration is a key component of this (Best and Laudet, 2010). HM Govt (2010), argue that their strategy actively promotes the model of recovery capital stating that employment is a core element of this model, which can also be seen to support the Salutogenic approach as it views access to resources such as economic security as improving the socioeconomic position of an individual, which in turn improves levels of health (Charlton & White, 1995). However UKDPC (2008) state that many employers have an arbitrary ‘two years drug free’ rule with regard to hiring those with addiction issues even if they have the correct competencies for the job. This coupled with a reduction in provision at Job Centre Plus (NTA, 2012) can be seen to have impacted harshly on the chances of current and ex heroin users being able to access employment (CSJ, 2013). This is furthered by Acheson et al (1998) who argue that all policies with a direct or indirect effect on health, should be evaluated in how they impact on health inequalities and should be formulated with a reduction of inequality in mind.
Arguably the government’s strategy with regard to assisting heroin addicts into recovery has not taken into account the true extent of the barriers faced by current and ex heroin users (CSJ, 2013). It can be seen to be an ideological policy based upon cost cutting, responsibilisation and abstinence rather than social reintegration, rehabilitation and full citizenship (Roy and Buchanan, 2015). Despite addiction having a multifactorial aetiology (Galea, Nandi and Vlahov, 2004), service provision which reflects this in terms of addressing comorbid mental health issues and difficulties in accessing full employment, are no longer a priority in a climate of payment by results (Woods, 2015; Roy and Buchanan, 2015; UKDPC, 2008). However this in itself can be seen to impact on the ability of heroin addicts to develop components of salutogenesis such as resilience and a sense of coherence, which are core elements of the concept of recovery capital which is championed by the Conservative government (Abramsohn et al, 2009; Antonovsky, 1993; Best and Laudet, 2010; HM Govt, 2010). In many respects until a policy is developed which encompasses all the determinants which can lead to individuals using heroin, we will likely continue to see slow epidemiological shifts in terms of numbers of users, with the consequences being further social exclusion and a continuing increase in rates of death by overdose.
Word Count 2,748 including citations.
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