Drugs in Society The Epidemiologically Based Needs

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 Foreword v

drug scene. Under the umbrella term 'drug use' we are talking about a
complex set of behaviours - different drugs and different patterns of use,
different motivations and different consequences, all influenced by time
and place and the prevailing cultural and political context. It may be
useful for many reasons to be able to describe general patterns of drug use
in Europe but we forget at our peril the underlying reality of our subject
matter.
The task of elaborating this reality, or perhaps even realities, has been
one of the ongoing achievements of the European Society for Social Drug
Research (ESSD), and this book owes it parentage to this group and its
annual meetings. ESSD events are unlike many conferences as they
demand, with threats if necessary, that you should not only attend but
also participate. This, together with an emphasis on qualitative research
and the regular presence of some of the more interesting and thought-
provoking researchers working in Europe at the moment, has resulted in
a series of conferences that stand apart for both their originality and
vitality. In short, if you are feeling jaded and uninspired, and have
forgotten why this topic ever interested you in the first place; if you
simply want to read something provocative and different that reminds
you of why the use of drugs is not only an important policy issue but also
a fascinating area for social research - this book is for you - and these
seem to me pretty good reasons for recommending a text.

Paul Griffiths
Scientific Co-ordinator, Situation Analysis
European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)
Lisbon, Portugal
January 2007
About the editors

Professor Jane Fountain, PhD, has been working in the drug research field
since 1988, and became a Professor of Substance Use Research in 2005.
She is currently the lead on research at the Centre for Ethnicity and
Health, University of Central Lancashire, UK. She previously worked as
a researcher at the National Addiction Centre at the Institute of Psychi-
atry/Maudsley Hospital in London. She is a research consultant for
several international organisations, her work has been widely published
in academic journals, and she has edited several books.
Jane uses mainly qualitative research methods, most often to conduct
research on drug use, drug treatment and other drug-related issues,
particularly among so-called 'hidden' or 'hard-to-reach' populations and
those vulnerable to problematic drug use.

Dirk J Korf, PhD, is associate professor in criminology at the Universities

of Amsterdam and Utrecht. His main fields of research are patterns and
trends in drug use and drug trafficking, drug policy, crime and crime
prevention, and ethnic minorities. He has published many papers,
reports and books on these issues. He is chair of the European Society
for Social Drug Research (ESSD).
List of contributors

Sundari Anitha, PhD

Senior Lecturer (Research)
Centre for Ethnicity and Health, Faculty of Health
University of Central Lancashire
Preston
UK
Vibeke Asmussen, PhD
Associate Professor and Researcher
Centre for Alcohol and Drug Research
University of Aarhus
Aarhus
Denmark

Cas Barendregt, MA
Researcher
Instituut voor Onderzoek naar Leefwijzen and Verslaving
Rotterdam
The Netherlands

Brigitte Boon, PhD

Research Manager
Instituut voor Onderzoek naar Leefwijzen and Verslaving
Rotterdam
The Netherlands

Helle Vibeke Dahl, MA

Anthropologist
Centre for Alcohol and Drug Research
University of Aarhus
Aarhus
Denmark
viii Drugs in society

T om Decorte, PhD
Director of the Institute for Social Drug Research
Department of Penal Law and Criminology
Ghent University
Ghent
Belgium

Maria do Carmo Gomes, MSc

Researcher
Centro de Investigacao e Estudos de Sociologia/Centre for Research and
Studies in Sociology (CIES-ISCTE)
Lisbon
Portugal

Axel Klein, PhD

Lecturer
Addictive Behaviour Group
Kent Institute of Medicine and Health Sciences
University of Kent
Canterbury
UK

Marjolein Muys, MA
Researcher
Institute for Social Drug Research (ISD)
University of Ghent
Ghent
Belgium

Alfred Springer, MD
University Professor
Ludwig-Boltzmann Institute for Addiction Research (LBISucht)
Vienna
Austria

Alfred Uhl, PhD

Senior Scientist
Ludwig-Boltzmann Institute for Addiction Research (LBISucht)
and Director
Alcohol Co-ordination and Information Centre (AKIS)
Federal Ministry of Health and Women
Anton Proksch Institute (API)
Vienna
Austria
Acknowledgements

This book's editors and contributors are all members of the European
Society for Social Drug Research (ESSD), which was established in 1990.
The principal aim of the ESSD is to promote social science approaches
to drug research, with special reference to the situation in Europe.
The editors thank Sundari Anitha, Vibeke Asmussen, Cas Barendregt,
Brigitte Boon, Helle Vibeke Dahl, Tom Decorte, Maria do Carmo
Gomes, Axel Klein, Marjolein Muys, Alfred Springer and Alfred Uhl
for their diverse and interesting contributions to this aim, their painstak-
ing responses to the editors' and peer reviewers' queries and comments,
and their adherence to tight deadlines.
We gratefully thank the following individuals, who peer reviewed the
authors' contributions, for their time and insightful comments: Nicole
Crompton, Hermann Fahrenkrug, Ludwig Kraus, Bob McDonald,
Aileen O'Gorman, Deborah Olszewski, Colm Power, Sharon Rodner,
Alastair Roy, Sandrine Sleiman, Tim Thornton, Hylke Vervaeke and
Marije Wouters.
We also thank the staff at Radcliffe Publishing, especially Gillian
Nineham, for their efficiency and understanding.
Finally, the editors gratefully acknowledge the support of the Council
of Europe Pompidou Group.
Introduction: the social
meanings of drugs
Jane Fountain and Dirk J Kori

Drugs are more than chemical substances that influence individual

human behaviour through their effect on the brain. Drug use is often a
social activity that takes place in an environment with other users. In
addition to a drug's pharmacological properties, the drug user's per-
sonality, attitudes, expectations and motivating factors, and especially
the setting in which drug use occurs, have a great influence on both the
user and their drug-using patterns. 1 Drugs may be used as a means of
forgetting daily problems, such as poverty, unemployment, homelessness
and mental ill health, but for other users they symbolise the 'sunny' side
of life while partying and clubbing. The same substance can be used by
different people for different reasons, and with different effects being
experienced. Cocaine is a typical example. It is used as a 'street drug' by
deviant and socially excluded groups, but is also popular among those
who are socially well integrated. As in North America, the use of cocaine
(in its powder or crack form) has become part of the drug-using
repertoire of heroin addicts in many European countries, and among
socially excluded groups its use is more prevalent than that of heroin."
However, the snorting of cocaine powder is also increasingly popular
among young people in trendy urban nightlife settings. In these settings,
cocaine has become a serious competitor with ecstasy," the most popular
party drug of the last decade in many European countries, including the
new European Union (EU) member states."
Drugs also have social meanings for non-users, and not only can the
same drug - for example, cocaine - have different meanings at the same
time, but also the social meaning of a particular drug can change
drastically over time. Cannabis is probably the best example of this.
Initially strongly stigmatised, the use of this drug was associated with
individual pathology (such as cannabis psychosis and amotivational
syndrome) in the early 1960s. However, it became redefined as a
symbol of the youth protest subculture in the late 1960s and early
 Introduction: the social meanings of drugs xi

1970s. As cannabis use has increased further among the whole popula-
tion in subsequent decades, sociologists today define it as 'normalised.'
This term may imply that the use of cannabis has become normal
behaviour among the general population, in particular amongst the
younger generation, but this is not a crucial element of the concept. At
the core of normalisation is the notion that the use of drugs - particularly
cannabis - has lost its exceptional status and has entered the realm of the
familiar and habitual.? Drug use among socially non-excluded people
(e.g. smoking cannabis or using cocaine powder or ecstasy on the club
scene) is now commonly described as 'recreational drug use.' Thus drug
use is no longer the exclusive preserve of a specific population, and is only
one of the many symbols of social distinction among young people,
together with a specific style of music, clothing, and so on.

Different ways of perceiving drugs

From general population data on social perceptions of drugs, drug users
and consequences of drug use in Portugal, Maria do Carmo Gomes
constructs a tripartite typology in Chapter 1. Almost half of the
Portuguese population perceives drugs as a health problem, and addic-
tion as a curable illness. Members of this group are typically in their mid-
thirties to mid-forties, employed, oriented towards social stability in the
community, and have little experience of drugs and drug users. The other
half of the Portuguese population can be divided into two equally sized
subgroups. On the one hand, there are those who perceive drugs in terms
of lifestyle. For them, drug use can be a conscious choice and does not of
itself have negative social consequences. Members of this subgroup tend
to be young, often students or unemployed, more focused on the
individual, and close to (or part of) the social world of drug use. On
the other hand, there is a subgroup that perceives drugs as a social
problem. They identify drug users with specific youth cultures and/or
with social exclusion, criminality and stigmatisation. Members of this
subgroup are mostly older people, educated to a lower level, housewives
or retired, and with no experience of drugs or drug users. It is likely that
the distribution of the three types will not be identical across Europe, but
it appears that the typology itself is applicable to other countries, as there
are striking similarities with the results of an earlier study conducted in
urban areas in 11 European countries."
At first sight, the chapter by do Carmo Gomes might seem to be in
conflict with the normalisation thesis. Only a quarter of the Portuguese
population aged 15 years or older perceive drugs as an expression of
lifestyle, but this was the dominant definition among young people - that
is, those who are most likely to be drug users or to be in contact with drug
users. Individuals in their late thirties and early forties tend to define drug
xii Drugs in society

users as people with a health problem, and the older generation tends to
define them in terms of deviance and crime. Indirectly, the Portuguese
study has clearly illustrated the development of society's moral judge-
ments of drug use, ranging from deviance (as perceived by today's senior
citizens) to a health problem (as perceived by middle-aged adults), to an
expression of lifestyle (as perceived by adolescents and young adults).

Dynamics of the cannabis market

Cannabis (known in its solid form as resin or hashish and in its herbal
form as marijuana) is the most commonly used illegal drug across
Europe. Within the EU around 62 million people have used cannabis
at least once in their life, and approximately 20 million have used it
during the past 12 months." In a survey conducted among 15- to 16-year-
old students in 35 European countries, a total of 21 % reported that they
had used the drug at least once in their life, with around 40% of
respondents in the Czech Republic, France, Ireland and Switzerland
having used it? In the EU, between 11 % and 44% of young people aged
15-34 years have tried cannabis at least once, with the highest rates in
France (40%), the UK (43%) and Denmark (45%). Use within the last 12
months within the same age category ranges from 3% to 22%, and is
highest in the UK and France (both 20%) and the Czech Republic (22%).
Figures are higher in urban than in rural areas, but the difference has
tended to decrease in recent years.
Cannabis appears to be relatively easily available. Although the
prevalence of use peaks in late adolescence and early adulthood, over a
third of 15- to 16-year-old students in Europe (and close to two-thirds of
those in the UK and Ireland) report that hashish or marijuana is fairly or
very easy to obtain." Over 50% of students of this age say that they know
of places where cannabis can easily be bought, such as discotheques and
bars (27%), public places such as streets or parks (23 %), a dealer's home
(21 %) or in and around school (16%). However, apart from coffee shops
in the Netherlands, where the sale of small amounts of cannabis to
consumers aged 18 years or over is tolerated under certain conditions,
little is known about the structure of the cannabis market in Europe.
Until the late 1980s, the European cannabis market was largely
supplied with imported hashish, in particular from Morocco. More
recently, both commercial and non-commercial domestic cultivation of
marijuana has increased with the advent of new growing techniques and
crossbred varieties. Domestic cultivation of marijuana is now becoming
increasingly professional, and criminal organisations have become in-
volved. In Chapter 3, Tom Decorte describes and analyses this evolu-
tionary process in Belgium and the Netherlands in terms of drug policy
initiatives, arguing that it represents a process of 'import substitution',
 Introduction: the social meanings of drugs xiii

that it has also occurred in other European countries and in North

America, and that it appears to be irreversible. Decorte believes that it is
likely that the domestic production of hashish will be the next step in this
market development.
The focus of the retail supply of cannabis has been for many years and
still is on the Netherlands, but other European countries have an implicit
history of tolerating the sale of hashish and marijuana to consumers. It is
common for the police not to actively enforce laws against cannabis
retail sales, particularly in urban areas (Switzerland is the only European
country that intends to legalise the retail cannabis market). For example,
for many years the sale of cannabis was tolerated in Denmark, including
its sale in so-called 'hash clubs' (similar to the coffee shops in the
Netherlands) in some cities, and on 'Pusher Street' in the Free City of
Christiana in Copenhagen - probably the most well-known open
cannabis market in Europe. However, since a change in government in
2001, Danish drug policy has taken a more repressive turn. In Chapter 2,
Vibeke Asmussen discusses how this change was implemented in practice
with regard to cannabis dealing. She describes the political agenda and
the role of mass media with regard to the closing of Pusher Street, and her
analysis clearly illustrates a classic problem that in criminology has
become known as 'displacement.' The cannabis retail market in the
Danish capital did not disappear when Pusher Street was closed, but
merely resurfaced in other parts of the city.

Old drugs, new meanings

Many substances that are sold today on the illicit drugs market in Europe
have been used for centuries. Typical examples include cannabis, opium
and psilocybin (magic mushrooms). Some are relatively new, such as
heroin, which was discovered in 1898 and was first used as a cough
medicine and as a cure for morphine addiction. Ecstasy (methylenedioxy-
methamphetamine (MDMA)) was patented in 1912, but medical
experiments with the drug in the US army did not meet initial expecta-
tions, and it was not until the 1970s that psychotherapists experimented
with the drug in order to revive memories and bring suppressed emotions
to the surface.V' Following these experiments, MDMA was perceived as
an ideal way to relieve daily stress and to relate to personal and others'
feelings. 10 From the mid-1980s onward, ecstasy and its 'loved-up' effects
became a popular dance drug among clubbers and ravers.
Ephedra is a generic term for a number of extracts from ephedra-
containing herbs that are known under their Chinese name, Ma huang.
This drug contains ephedrine and pseudo-ephedrine, which act as
stimulants in the same way as adrenaline. In the late 1990s, ephedra
was introduced to the recreational drug market as a 'natural drug' or
xiv Drugs in society

'natural ecstasy.' In Chapter 4, Cas Barendregt and Brigitte Boon report a

variety of reasons for using the drug according to a survey of ephedra
users in the Netherlands, but these were largely gender-specific.
Women's main reason for using ephedra was to lose weight, whereas
men used it so that they could dance for longer. Barendregt and Boon also
shed some light on the dynamics of the drug market. After ephedra was
banned in the Netherlands in 2004, some of its users cut down their
consumption, while others used alternative legal or illegal substances.
Khat is another 'old' drug that has been introduced to Europe in recent
decades, predominantly within immigrant communities, especially
Somalis. Today this stimulant is illegal in most European countries,
the UK and the Netherlands being the exceptions. Although it is often
maintained that khat is a part of Somali culture and tradition that should
be allowed to continue in exile, Axel Klein argues in Chapter 5 that it was
not widely used in Somalia until the 1970s, and he defines the rationale
for khat-chewing among Somali immigrants in Europe as an 'invented
tradition.' This has serious consequences for the social meaning of khat
use. Not only are regulation mechanisms affected by migration, but also
there is no cultural memory of socially acceptable use and harm reduc-
tion strategies. This locks a significant minority of persistent users into
problematic khat-using patterns.

Minority ethnic groups and drug use

Immigrant communities may introduce new traditions in substance use
to their host country, whether 'invented' (as in the case of khat, described
above) or 'real' (as in the case of the anti-alcohol culture among many
Muslims). Some immigrants may become important bridgeheads in the
international drug trade because they have social and commercial ties to
countries that produce drugs (e.g. heroin in Asia, cocaine in Latin
America, hashish in Morocco). However, in the host country, immi-
grants may also begin to use drugs that, in their country of origin, were
not available or were not part of their social world.
The opening of the borders between member states of the EU has
strongly stimulated the mobility of its citizens, both for studying and for
work. In contrast, access to Europe for immigrants from non-western
countries has become much more difficult, and is largely restricted to
political and war refugees. In Chapter 6, Marjolein Muys shows how
drug use among asylum seekers and refugees can be understood as self-
medication. Using a literature review, she argues that despite the exist-
ence of some protective factors, these groups are likely to self-medicate
problems that originate from stress due to pre- and post-immigration
resource loss (e.g. loss of cultural resources, family, social status and
future perspectives). Muys builds a theoretical model around three
 Introduction: the social meanings of drugs xv

issues. First, refugees lack sufficient coping resources to offset resource

loss. Secondly, they have no control over their situation. Thirdly, their
low self-esteem makes it likely that they will respond to stress in a
passive-avoidant way.
In Chapter 7, taking a more sociological perspective, Sundari Anitha
describes low self-esteem (along with shame, blame and secrecy) as one
of the feelings that are captured by the concept of stigma - a negative
attribute, trait or disorder that marks out or labels its bearer as different
from 'normal' people and attracts social sanctions. Anitha argues that
what is defined as normal behaviour varies according to the society in
which it occurs. A fear of stigma may prevent problematic drug users
from seeking help or hinder those in treatment from deriving lasting
benefit from it. This chapter's focus is on the manifestations of stigma
related to problematic drug use in prisons in England and Wales.
Drawing on data collected from multiple sources, Anitha describes,
analyses and interprets the experience of stigma in a prison culture.
This is linked, for example, to the drugs used. Minority ethnic prisoners
were found to be more likely to disclose crack cocaine use than the use of
heroin, especially if they injected the latter. In the context of a male
prison, any attempt to shed the stigma of drug use by accessing drug
treatment services may also be fraught with the danger of losing social
status, as it could be seen as flouting the dominant discourse of
masculinity and invulnerability. This chapter is a strong plea for a
culturally sensitive approach to drug service provision, both theoretically
and practically. For example, Anitha reports that, for minority ethnic
prisoners, the predominantly white composition of prison drug service
teams is a major barrier to accessing their services (as it is for minority
ethnic drug users in the communityll). As an alternative, Anitha suggests
the creation of ethnically diverse teams of culturally competent drug
service providers, who can understand concerns about stigma and take
proactive measures to improve drug service accessibility.

From morphine to methadone

Methadone has become the 'gold standard' in substitution treatment of
heroin addicts, first in the USA and now in most European countries -
over half a million heroin addicts are on methadone maintenance
treatment in Europe. In Chapter 8, Alfred Springer describes how in
Austria there is a diversified system that allows prescription of different
opioid substances for maintenance purposes. Under this system, the drug
used for substitution has shifted from methadone to slow-release mor-
phine, as many clients prefer this medication. However, in 2004 a
campaign that aimed to abolish slow-release morphine preparations in
maintenance treatment stimulated a process that, according to Springer
xvi Drugs in society

in his analysis of the discourse in Austria, will put an end to diversified

medical treatment of opioid dependency. He critically discusses how
morphine has become stigmatised - using the same arguments that were
put forward against methadone in the past - and how this is threatening
the Austrian system, which is in danger of returning to methadone as the
only substitute medication in maintenance treatment.
In Chapter 9, Helle Vibeke Dahl studies the practice of methadone
treatment in Denmark from a different angle. Her focus is on the
perspective of those clients who play the 'methadone game' as a response
to its prescription as a means of controlling and disciplining them. To
these clients, methadone maintenance treatment represents far more
than a medical substitution for heroin, as the aim of the game is to be in
possession and control of the methadone itself.

Ethics in social drug research

Definitions of the drug problem change over time, and drug use is thus an
ideal subject for social drug research. In recent years, the medical study of
drug use has made significant progress, and much more is now known
about how drugs work via the brain. In the field of treatment, the
medically based ideology of evidence-based research results has gained
much influence, and rather than viewing drug addiction as an expression
of a deviant lifestyle or a means of dealing with socio-economic prob-
lems, drug addiction is defined as a brain disease.
Shifting perspectives, even shifts in paradigms, are prerequisites for the
advance of science. However, a mono-dimensional shift in drug research
towards the medical discipline carries serious risks. First, drug use is
largely recreational and can only be fully understood within the social
context of fashions and lifestyles. Treatment, even when primarily
medical, is also a social event. This makes it difficult, if not sometimes
impossible, to evaluate the interventions in the field of drug prevention
and treatment along the classic lines of evidence-based methodologies.
Secondly, drug use is a social problem. Even though some drug use has
normalised among the younger generations, politicians and policy
makers often have a different perspective and a strong impact on the
research agenda. Implicitly or explicitly, these diverging perspectives are
reflected in drug research, not only in the presentation of research
findings, but even in apparently 'neutral' questionnaires administered
in surveys. In the final chapter of this book, Alfred Uhl issues a provoca-
tive challenge to researchers to be more self-critical in order to promote
the advancement of research. He argues that drug policy research is not
value-free, that the role of a researcher is totally incompatible with the
role of an advocate, and that the term 'evidence-based policy' is a
 Introduction: the social meanings of drugs xvii

contradiction in itself, meaning that evidence-based drug policy is a

fallacy.

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