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Discussion

Would decriminalising drugs improve care?

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Substance misusers often experience stigma. Would changing the laws on illegal drugs change nurses’ attitudes and result in the delivery of effective care?

Abstract

The decriminalisation of illegal drugs is controversial. This article examines the debate in the UK, and argues that a change in the laws would help to remove stigma and consequently change health professionals’ attitudes towards drug users and improve services.

Citation: Riddell S (2012) Would decriminalising drugs improve care? Nursing Times [online]; 108: 9, 16-18. 

Author: Stephen Riddell is a community staff nurse, Dumfries and Galloway Health Board.

Introduction

In recent years, the use and misuse of both legal and illegal drugs has increased. The UK, in particular, continues to have one of the highest rates of recorded illegal drug use in the western world, double that of most other European countries (Department of Health et al, 2007). This is despite a rapid expansion of treatment programmes for drug misusers in the past 10 years.
The misuse of drugs remains a crime in the UK and this has been the subject of heated debate for some time. Over 20 years ago, the Royal College of Psychiatrists (1987) said:
“Drug problems will not be beaten out of society by yet harsher laws, lectured out of society by yet more hours of health education or treated out of society by yet more drug experts.”

Would a change in the law to decriminalise drug use be beneficial for both patients receiving care and nurses providing it? This question comes at a time when interested eyes - government, health specialist, medical and journalistic - are looking at Portugal, where drug use has been decriminalised for the past decade with dramatic results.
Decriminalisation is not the same as legalisation. The production and distribution of drugs in Portugal is still illegal; decriminalisation simply means that possession is considered a health and social problem rather than a criminal one. It is accepted that it is unrealistic to expect people to give up addiction as a result of legal sanction or coercion, and resources are put instead towards mitigating risk for the individual and the population by harm reduction, treatment and reintegration.
Contrary to some conservative expectations, decriminalisation has not resulted in higher rates of drug use or turned Portugal into a magnet for drug tourists. Instead, there have been recorded reductions in HIV diagnoses, overdose deaths, petty crime and drug experimentation among young people (Hughes and Stevens, 2010). The strategy appears to be working and to have benefited the criminal justice system and wider society.
In the light of this evidence, it would seem a reasonable proposition that reclassifying drug use to encourage it to be viewed as a health problem rather than a crime could also benefit the nursing profession and its patients.

The current UK position

Recently opponents of the status quo have been voicing concerns. The UK government’s position that decriminalisation “sends out the wrong message” has been under attack, most notably from the former chair of the Advisory Council on the Misuse of Drugs, Professor David Nutt. He lost his job for publicising scientific evidence on the relative harms of illegal drug use and legal pursuits (Nutt, 2009; Tran, 2009).
The suggestion by the Royal College of Nursing’s general secretary that addicts be given free heroin at clinics as a method of driving down crime and helping people to come off the drug also attracted criticism (Ramesh, 2010).
Pilot projects allowing users to inject heroin under medical supervision in London, Brighton and Darlington have resulted in lower levels of street drug use and crime (Strang et al, 2010). However, dissenting nurse voices have expressed fears of a creeping extension of the scheme to other drugs, raising costs to the NHS.
At the end of his presidency of the Royal College of Physicians in 2010, Sir Ian Gilmore called for a review of the law on misuse of drugs and the adoption of a more regulatory approach. This was considered controversial by some media commentators (BBC News, 2010).

Conflicts in the legislation

These questioning voices show debate opening at all levels within government and among the healthcare professions.
The law on drug misuse is a confusing and divisive issue. There is an inherent illogicality at the heart of drug legislation whereby the drugs that have the greatest potential to harm are not necessarily the ones controlled by law (Nutt, 2009).
Use of alcohol, tobacco and tranquillisers (if prescribed) are not prohibited, although tens of thousands die prematurely each year from their adverse effects (Working Party of the Royal College of Psychiatrists and the Royal College of Physicians, 2000).
Use of these drugs carry no stigma or threat of criminalisation, unlike the prohibited drugs described in the Misuse of Drugs Act (Room, 2005; Misuse of Drugs Act 1971). This seems confusing when - as Dr Nutt did - we look at the proportionality of harm. Famously, Dr Nutt pointed out that ecstasy use can be compared with horse-riding in terms of risk; deaths from smoking and alcohol abuse eclipse both.

Nurses’ attitudes to drug users

In cultural terms, many would agree that the notion of freedom of choice is one of the defining characteristics of UK society. We prize individual autonomy, have a strong sense of democratic rights and no great love for paternalism.
Philosophically speaking, such a society would not be expected to seek to restrict the individual’s freedom to experiment with drugs. Yet, paradoxically, we accept restrictions on liberty as a method of ensuring “the greater good” and protecting the interests of society. Choice over drug experimentation, therefore, with its moral and legal facets, produces philosophical conflict, which, of course, has implications for the nursing profession (Giddens, 2008).
Nurses, as people raised with the same values and biases as the rest of society, undoubtedly have a range of personal views on the reform of drug legislation. For some, there is a conflict between their personal views on drug use and their professional responsibilities towards drug users.
Historically, negative and ill-informed beliefs about drugs produce negative and ill-judged reactions to those who use them - that is, people will subscribe to common stereotypes (Eliason and Gerken, 1999).
In the past, some nurses have regarded drug users as weak rather than ill, and culpable rather than victims (Rasool, 1993). Even more judgemental terms have been documented, including “immature”, “neurotically impulsive”, “crime prone”, “psychopathic” and “inadequate” (McLaughlin and Long, 1996).
Judgemental and punitive attitudes to drug users from nurses have included notions that: drugs corrupt the young; drug users represent a threat to society and should be treated in specialised units; and drug users should be compulsorily tested for HIV infection (Carroll, 1995).
More recent research indicates these attitudes are still prevalent in both nursing (Bate, 2005) and medicine (Landy et al, 2005), and that stigmatisation of this group is hampering effective care and rehabilitation (Lloyd, 2010).
Links have also been found between these attitudes and drug users’ reluctance to enter treatment, and premature discharge rates for those in treatment (Rassool, 2006).
The UK Drug Policy Commission (2010) revealed that widespread stigma still exists in society and is a barrier to substance user recovery. In this report, Professor Colin Blakemore said:
“If the government’s drug strategy is to succeed, it must first address this very real barrier of stigma. Our research shows that the public agree that recovering drug users need help and support to help rebuild their lives. But they are also seen as blameworthy and to be feared. These public attitudes spill over into public services, so we see time and again former drug users stigmatised and discriminated against when they try to access services” (UKDPC, 2010).

However, the culture of care for addiction is changing, with many nurses perceiving substance misuse as more of an illness than a moral weakness (Grafham et al, 2004). Improvements in attitude have also been reported in those of younger age or most senior in grade, as well as among undergraduates (Rassool, 2006).
New titles such as “substance misuse nurse” or “addiction nurse” have entered both the lexicon and job market, which is surely a sign of acceptance and recognition that addiction is not just a crime and that treating it requires a particular skill set.
Nevertheless, many nurses still dislike and fear substance misusers, describing giving care to them as the most negative, unrewarding and unpleasant experiences of their careers (Peckover and Chidlaw, 2007).

Suboptimal care

Despite an improving picture, continuing personal discrimination and societal criminalisation means that substance users receive care that is inappropriate, standardised, judgmental and ineffective.
Opportunities for change are hampered by negative attitudes that compromise learning opportunities and result in nurses lacking the will to improve their understanding of drug use and their skills to care for users (McClelland, 2006). Poor training via nursing education programmes and in-service training compounds the problem - and not only in general hospitals. Criticisms have been noted in primary healthcare, mental healthcare and, particularly, with adolescents (Green, 2000).
Judgmental approaches have been shown to severely hamper health professionals’ ability to deliver primary healthcare and health promotion messages with the sincerity they deserve and require for success (McLaughlin et al, 2000).
The Nursing and Midwifery Council’s (2008) code of conduct states that nurses must not discriminate in any way against those in their care, and must act as an advocate for them. Attitudinal difficulties related to drug use, personal or peer influenced, will lead to nurses being unable to follow their own code of professional conduct (McClelland, 2006).

Service provision

What kind of care do drug users need? The range is vast and the role diverse. Some care relates to the effects of the drug itself, such as overdoses, obstetric problems, unsupervised withdrawal and psychiatric complications including psychosis and suicide.
However, more often, care needs relate to self-neglect or risk-taking as a result of the drug’s effect on behaviour. Common problems include life-threatening infections, physical injury and accidental injuries such as burns, head injuries and road traffic accidents. Infections and ulceration associated with long-term needle use are also common.
Many practical problems associated with nursing substance misusers are exacerbated by the client group being classed as criminals.
Lack of training may mean health professionals could confuse symptoms of drug-taking with other conditions. For example, cannabis may make someone appear confused, disoriented or frightened, all of which may cause ill-informed practitioners to suspect some form of head injury (Jones and Owens, 1996).
Another area where problems can occur is in nursing patients with coexisting pain and substance misuse, where pain control can be inadequate because health professionals fear patients are faking pain to obtain drugs (Finney, 2010).
Care can also be compromised if nurses fear criminal charges for not giving police the names of drug users, or if families are fearful of disclosing important information about patients’ drug habits (Duffin and McMillan, 2000).
Some of the most demanding nursing work in this field takes place in the community; specialist nurses working in primary healthcare teams are at the forefront of service provision for this client group (Matheson et al, 2004).
Positive attitudes based on cooperation and acceptance, where nursing care is non-judgemental, non-confrontational and accepting of drug users’ autonomy, would enable nurses to fulfil a crucial role in preventing, recognising, screening and managing substance misuse (Gold, 2009).

Conclusion

Nurses could - and indeed should - be care providers, educators, counsellors, therapists, health promoters, researchers, supervisors and consultants for those in their care who misuse substances of any kind (Rassool and Marshall, 2001).
If this laudable aim is to be achieved, a reform of drugs legislation would remove some of the barriers to change. Criminalisation is a powerful stigma and cannot fail to result in discrimination; the current system has an enormous financial and human cost and simply does not work.
Far more productive would be to view drug addiction as a public health issue rather than a criminal justice issue. A good relationship between nurse and client is a high indicator of a positive outcome for clients (McClelland, 2006).
Until legislation changes, nurses will struggle to provide truly appropriate and compassionate care to those whom society considers to be criminals.

Key points

  • The UK has one of the highest rates of recorded illegal drug use, double that of most other European countries
  • Decriminalising drugs in Portugal has led to reductions in HIV diagnoses, overdose deaths and petty crime
  • Some nurses find their personal views on drug use conflict with their professional responsibilities towards drug users
  • Stigmatisation of drug misusers hampers effective care and rehabilitation
  • Positive nurse attitudes based on cooperation and acceptance would enable nurses to play a crucial role in managing substance misuse
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