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Drug-related Harms in Homeless Populations: Response to Call For Evidence and Dialogue

What follows is a submission for Scottish Parliament of perspectives relevant to drug related harms in homeless populations plus correspondence on the submission. There was a call for evidence and participation from people with lived or living experience of drug use. As a part of this initiative, which is feeding into the redevelopment of national policy for the next ten years, I have become a participant in a number of roles and groups; one of them being a contributor to the steering committee of the Drugs Research Network based at Stirling University.

Drugs Research Network Scotland
Drugs Research Network Scotland

Following the submission to the call for evidence are the notes generated in correspondance with Dr Iain Mcphee Senior Lecturer at the University of the West of Scotland who focuses in quantitative and qualitative research methods, with a focus on drug use, drug policy, and hidden and marginalised populations.

This is a part of being involved in the Drug Research Network where people with lived or living experience can help shape the considerations around how drug and alcohol use and recovery is approached in terms of understandings.  This is an area of life that holds many problems which are threaded through other problems; no single perspective can represent the whole ‘truth’.

This is why there is a open consultation.  If you are keen to get involved, and find out what is happening you can join the Drugs Research Network and become a member without cost:

 


Scottish Parliament
Scottish Parliament

Submission to Scottish Parliament

My background is what is labelled ‘multiple needs’ and at the age of 40 now I can look back to various life circumstances which have given definition to my present; things I have no choice but to live with as I still contend with the effects of an anomic society and the social traumas which live with me as successions of this anomie compounded by my own failures and strategies to survive.

 

Structural Exclusion

Bureaucratic systems of administration, outcomes and measures procedures, automated and online processes, outsourced ‘help lines’, lack of legal representation, lack of critical feedback procedures, credit and identity administrations, and decimation of person on person support services have all proved the most tenacious, active barriers for me to do the most simple of ordinary day to day tasks let alone ‘recover’. Structural exclusion from culture comes in various forms that break the spirit through making the day-to-day contested and arduous (and sometimes plain impossible).

Once at the bottom of the ‘triage system’ it is next to impossible to extricate oneself from such poverties without some professional support worker with the agency, willingness and time/resource to mitigate the structural failures of an ad hoc, cobbled together series of information/decision systems which overwhelmingly determine one’s life chances and opportunities. This is the life saving juncture; without a professionally employed person beside you in these processes, you are arbitrarily not heard and/or represented.

 

Failure demand

Extending from the structural exclusion is the growing Failure Demand of an administrative culture which favours activities which feed into targets and key performance indicators. As social scientist Donald T. Campbell put it: “The more any quantitative social indicator is used for social decision-making, the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor.”

 

Assessing the Impact of Planned Social Change Donald Campbell
Click to Download a Copy of ‘Assessing the Impact of Planned Social Change by Donald T. Campbell’

 

The way social support processes are resourced and administrated is short term, onerous, fractured, boom and bust, resulting in the effectiveness of frontline staff and their efforts being undermined regularly. Prof John Seddon coined the term Failure Demand to describe “demand caused by a failure to do something or do something right for the customer”.

 

Click to Download 'Better Thinking About Demand' by Prof John Seddon
Click to Download ‘Better Thinking About Demand’ by Prof John Seddon

 

People in almost every sector are being crippled from achieving their job by the imposition of inappropriate metrics on sociological and complex life circumstances due to the necessity for organisational survival to chase what become ‘Perverse Incentives’; the effects of these metrics are borne out on the least advantaged.

 

Criminalisation

When homeless, a significant proportion of the population views you through processes of dehumanisation (See Prof Susan T. Fiske). Losing social footing to be important to survive in an urban landscape is a critical moment for orienting towards drug cultures precisely because such black market’ economies/cultures do not hold the same sociological or technocratic exclusionary principles which amount to ostracism (think credit record, proofs of address and identity, curriculum vitae, etc).

 

 

Criminalisation of the possession of drugs has been a significant factor in destabilising my life because at times the most menial work was withdrawn because of my ‘spent’ convictions. Lord Dyson has since ruled on blanket background checks which preclude an estimated 75% of people with any type of conviction from getting to the interview stage of job application processes. When orthodox society and its systems turn their back, there is nowhere else to go but to the cultures which will sustain you in the face of impoverished circumstances.

 

Pathologisation of Trauma and OTC Toxicology

A great deal of the issues with homelessness and drug use are tightly bound up with the way that sociological stresses are being pathologised as biochemical imbalances rather than understandable reactions to extreme traumas. The Psychiatric Overshadowing which takes place in the homeless and drugs population is problematic along with the culture of prescription drugs which are addictive, psychoactive and which often carry side effects which get mistaken for medical conditions in themselves.

A toxicological mapping of all drugs in people’s lives needs to be done to understand what the significant physiological factors are which intersect with the sociological. Prescription drugs such as antipsychotics are opioids and have cumulative effects with anxiolytics (i.e. Benzodiazepines) and alcohol (via formation of Tetrahydroisoquinoline), all of which aggregate to poisonous levels through their actions as opioids.

In toxicological mapping the Over-The-Counter drug culture needs to be factored to identify additional toxicological loads such as paracetamol which is often is taken to attenuate or prevent pain and symptoms of ‘hangovers’. A series of ‘street knowledge’ contraindications needs to become common currency.

 

Loss of Habitat

As there were no places I could connect with which I could take part in, largely defined by the fact that there are hidden financial costs to participating in a culture and social activities, I felt outside of that world. The more I was moved on, the more my sleep was broken, the more alone I encountered the world, the more my emotional and mental health suffered.

 

Clinical Nutrition

A critical improvement in my health and wellbeing came with nutrition (use of whole foods rather than refined), in particular the application of clinical nutrition which was used for recovery in orthodox medicine. Specifically use of n-acetyl cysteine (used to treat overdoses) to reconstitute liver function and stabilise nervous system; glutamine (used to treat multiple trauma and infection) to attend to brain and tissue damage; baby milk to reconstitute tissues generally; thiamine formula (used to treat alcoholism) to attend to alcohol related brain damage; and opiate blockers to attenuate addictive cravings.

 

N Acetyl cysteine as treatment for addiction
Click to Download ‘N-acetyl cysteine as a treatment for addiction’

 

All clinical nutrition had the effects of improving my physiological capabilities and thus psychological abilities thereby equipping me for engaging with the vital support and guidance of Edinburgh Cyrenians – in my opinion, a gold standard for the experience and insight necessary for giving appropriate, progressive support in navigating multiple needs.


Iain McPhee
Iain McPhee

Reply to Alex Dunedin from Dr Iain Mcphee Senior Lecturer

Drug related harms in homeless populations

I am struck by this as a topic, still in 2018! My own postgraduate dissertation for the alcohol and drugs studies course I undertook in 1995 was all about homeless populations in Glasgow in the 1990’s, as I worked at the time for Blue Triangle Housing, which funded my way through university from 1990.

What struck me then, in undertaking this research was the understanding of how homelessness is defined from rooflessness and rough sleeping to the other end of the spectrum of living in unsafe or unsuitable or hazardous accommodation.

The links between alcohol misuse, family and job loss, or chronic unemployment and its impact on depositary hopelessness and stigma and discrimination (note that discrimination occurs when a power dimension is added to stigma, i.e. those individuals and agencies that lean on bureaucracy to deny access to housing, education, health and welfare (now called in a discursive sleight of hand ‘benefits).

I found that homelessness was complex, and that there were very strong links between lack of stable accommodation and mental and physical ill health. That many people became homeless for a variety of reasons, but a lack or shortage (intentional) of affordable accommodation was then as now a significant factor. I do believe though that the current benefits system will only increase ill health due to landlord led evictions caused by universal credit. As this is a devolved mater, it will significantly increase the rates of drugs related deaths in Scotland.

I note that you refer to Durkheim and his coining of the term anomie, which he states occurs when there is a lack of rules, or norms or better still ‘values’ in his magnum opus ‘Suicide’, though he does refer to this term in his earlier works on the division of labour.

 

Click to Download 'Excerpts from Suicide by Emile Durkheim'
Click to Download ‘Excerpts from Suicide by Emile Durkheim’

 

Values are necessarily hierarchical, and it does seem that they could be perhaps unfairly linked to the growth in bureaucracy. In my opinion excessive reregulation occurs when government grow, make agencies meet targets, which are managed by a regulatory system which is the bureaucracy and as Weber termed it follows the rule of the ‘iron cage of rationalisation’, and warned us of the consequences of increased power being given to state officials and workers of the state in denying others access to rights.

As state funded ‘helping’ agencies strive to meet expectations upon which their funding depends, they must focus solely on meeting the needs of this managerial culture, and targets and outcomes and outputs, naturally this means that there is no time or value placed on being human, being nice, and being non-judgemental and bending or breaking the rules for one person.

If what our society values is not spending monies on people who can’t help themselves (the very essence of neo liberalism and free markets built on the private sector – responsible only to shareholders, and regulated by ineffective quangos), then what we allow to be created in our name is a value system based on meeting targets and meeting performance needs, and what is allowed to be devalued or undervalued is meeting the needs of our fellow human beings.

I understand that your own input into this call for evidence is of course from lived experience.

Your section called structural exclusion refers to bureaucracies and administration systems. This occurs due to a change in values, on cost being valued of more (of more benefit) than service. What also made this occur, at least in alcohol and drugs services, are complex, but are underpinned by what our culture seems to value, sobriety, control, and being productive. See Warner & Riviere (2007) ‘Why abstinence matters to Americans’, Addiction, Volume 102, Issue 4, pages 502–505.

 

Why abstinence matters to Americans
Click to Download a copy of ‘Why abstinence matters to Americans’

 

If you accept that in the natural world hierarchies exist (packs of wolves, pride of lions and herds of elephants), then by definition there are winners and losers in the act of living and being human, and we are in many ways socialised and even genetically predisposed to live in social communities. In a free market if it operates with little government interference, or corporate lobbying of politicians to have their interests at the forefront, then there will be winners and losers if viewed and considered objectively.

I am not saying I support this thesis, I am saying that in essence we do not live in such an economic system, we actually have socialism for the very wealthy (bank bailouts and tax breaks) and capitalism for everyone not in this 1%. Class interests, underpinned by the needs and wants of individuals, tend to have value.

One of the main reasons for the vast inequality (in relative terms) is that the working class fought for and won the rights to free health care, and welfare in times of economic hardship (now known as benefits) after world war two. This has been systematically devalued and underinvested to the point that we now spend more on regulating the benefits system than on paying out monies and giving to the poor. We still have health care at the point of contact, but a value on performance and meeting targets has eroded the care and compassion threshold of the workers to deliver a service to their fellow human being.

Considerable amounts of money is spent on propaganda that demonises the poor, the benefits scrounger, the single mothers and those who appear to ‘screw the system’. I am thinking of what is printed in free newspapers given out on trains and buses, and of course televised programmes such as cops with cameras and programmes that offer the viewer the opportunity to watch the degradation of their fellow humans in working class estates – the ‘scrounger, the workshy, and the criminal, non-tax paying ‘other’. And yet rationally we know that corporations often pay less tax than individual earners on very high salaries in business and commerce, and certainly way more than the poor as a percentage of their wage.

What is my point here? In a neo liberal (I do not like the term but it is useful as a short hand) ‘system’ the individual has rights and responsibilities, and a value is placed on how able or productive one appears to be. This is exemplified in Scotland’s drug policy.

At the launch of the Scottish government drugs strategy in 2008 – 2018 they defined recovery as:

‘…a process through which an individual is enabled to move on from their problem drug use, towards a drug-free life as an active and contributing member of society’ (Scottish Government, 2008 chapter 3:81, page 24) .

 

Click to Download: 'Research for Recovery A Review of the Drugs Evidence Base'
Click to Download: ‘Research for Recovery A Review of the Drugs Evidence Base’

 

In this statement they make it clear that drug and by deduction alcohol users who cannot take part in civil society are unproductive and contribute little if anything, unless they are using only approved of drugs. See Thomas Szasz’s book called Ceremonial Chemistry and his descriptions of sacred versus profane drugs.

 

Click to Read: 'Ceremonial Chemistry The Ritual Persecution of Drugs, Addicts and Pushers by Thomas Szasz'
Click to Read: ‘Ceremonial Chemistry The Ritual Persecution of Drugs, Addicts and Pushers by Thomas Szasz’

 

As for your description of your experience of seeking help, this is in fact part of the punishment for being non-productive. That of being subject to humiliation rituals to programme you to become part of the productive collective.

These vast bureaucracies require a steady stream of university educated drones to make it function and manage these systems. They themselves quickly become disillusioned at being unable to actually help anyone. In addition they are often themselves subjected to constant propaganda called training to help the agency meet targets, and not necessarily help individuals in crisis or need.

A dedicated and trained workforce of advocacy workers (such as those trained by REACH Advocacy in south Lanarkshire) are required in every community to help the poor and uneducated (almost everyone) navigate the DWP and state bureaucratic systems, legal jargon, and procedural policy, and to understand that everyone has basic rights to health and social security. Indeed as most agencies are set up to deal with only one or two issues, by default those in crisis are required to spend vast amounts of their time being frustrated by those systems that are supposed to help.

 

In your section ‘failure demand’ you point out rightly that focus on performance i.e. targets do corrupt.

 

The section on criminalisation highlights what occurs when possession of a certain commodity becomes a criminal act. It creates groups of individuals that we label criminal, with its attendant stigmatising processes that occur and when linked to power, become opportunities for discrimination due to rules being broken. You do tend to describe what is known in sociology of deviance as ‘drift theory’, that is that deviance becomes almost inevitable as individuals drift into groups where their deviance is unrecognised, or at least in part, accepted. See David Matza 1964 who further developed neutralization theory by incorporating it into the concept of drift, which is the idea that adolescents become delinquent because the weakening of controls allows them to drift between delinquent and conventional behaviours.

 

Deliquency and Drift by David Matza
Click to Read: Deliquency and Drift by David Matza

 

The section on pathologisation of trauma and OTC toxicology is well done. As science requires empirical data upon which to define reality, then certain theoretical constructs become useful. The hijacked brain theory emerging from the National Institute on Drug Abuse (NIDA) Alan Leshner built a career on persuading the American public that chemical imbalances in the brain of ‘addicts’ were responsible for individuals being unable to stay ‘in control’, and this is in part also supported the further criminalisation of drugs as commodities, to protect the health of the public. This began when the UN in 1972 updated the 1961 UN Convention, to include those drugs they labelled ‘psychotropic’, and made links globally between drug use and mental illness.

On your paragraph on the mixing of drugs in a problematic manner, this was best stated by the Advisory Council on the Misuse of Drugs (ACMD) 1998 report called ‘Drugs misuse and the environment’, and again in 2000 when they published their report on drugs related death, which noted that three drugs in combination were responsible for the majority (80%) of all drug related deaths. A fatal combination that depresses the central nervous system that naloxone in unable to reverse. A fatal combination which we have known about for decades, but appear unable to provide even basic information, without propagandising this harm reduction information into a demonization of drug taking.

 

Drug Misuse and the Environment
Click to Download: ‘Drug Misuse and the Environment’

 

As for levels of knowledge regard drugs, yes there are very uninformed problematic drugs, alcohol and OTC users out in the world, but there are also very well informed drug takers whose knowledge tends to be unknown, and if known, undervalued, due to our pre occupation with being ‘clean and sober’ a legacy of the temperance ideologies of the 19th century, and the AA in the 20th and 21st centuries, and the success of medicine in owning the addition discourses, as their ‘turf’. Non-professional knowledge is undervalued in this sense.

Your section on loss of habitat, while very short, is very well articulated in my opinion.

Your section on clinical nutrition, well you have used the term clinical which has in itself a certain currency, and lends authority to any discourse so labelled. This is of course paying homage to the status and fiscal needs of the medical profession appropriating the term ‘clinical’ to mean ‘valid’ using their discourses and gaze. Your prescription for how you obtained optimal health is interesting though. Most doctors are uninformed about nutrition, as this does not help them prescribe that which they are trained for, the dispensing of pharmaceutical products.

Finally your shout out to the Cyrenians is noted.

 

The intentionally unseen exploring the illicit drug use of non treament seeking drug users in Scotland by Iain McPhee PhD
Click to Download: ‘The Intentionally Unseen Exploring the Illicit Drug Use of Non Treament Seeking Drug Users in Scotland by Iain McPhee PhD’

 

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