Society has always taken a different view of middle class and working class drug use, says Mark Gilman – and the results are plain to see.
In the 1990s I wrote a lot about drugs, class and culture. The basic premise of most of my writing back then was that it was OK for middle class people to use drugs, but the use of mind-altering chemicals by the working class was a major cause of societal concern.
If a middle class person were to develop some concerning issues with their consumption they had a ‘drug problem’, but when a working class person developed a similar issue they became a ‘drug problem’. Middle class drug problems were to be medically treated in expensive private clinics. Working class drug problems were to be policed and controlled, as they were perceived as a threat to public health and safety. The goal of middle class drug treatment was detoxification and abstinence. The goal of working class treatment was social control.
The rationale of government investment in the expansion of drug treatment since the 1980s has always been clear – reduce drug-related crime and prevent the spread of infectious diseases from the working class to wider society. Since the advent of public health in terms of drug treatment investment, a further goal has been added – the reduction of drug-related premature death. This latter goal has seen a more empathetic response to working class drug treatment.
The message to working class drug users is now threefold – don’t commit crime, don’t spread diseases and don’t die too early. The method of controlling working class drug use by way of drug treatment had three elements – get them in, keep them in, get them out. Providers of drug treatment were monitored and rewarded or penalised by their ability to juggle these three elements. Some third sector providers grew to dominate the drug treatment sector by their adeptness at juggling these balls. The NHS, as a slow and lumbering bureaucracy, wasn’t that good at juggling and lost many of its historic contracts.
There is now in the UK a drug treatment industrial complex. Have things changed for the better? Have we managed to control working class drug use to the satisfaction of government and middle England? Are the prospects for a working class person with a drug problem better now that they were in 1985? If you’d been in a coma since 1985 and woke up in 2024, would you see substantive change for the better?
There have been improvements as a result of continued government investment. People with an opioid use disorder now have more choice in medication. Methadone is still available and various preparations of buprenorphine are around. Heroin-assisted treatment has been made available to some.
Working class people now have greater access to detoxification and residential rehabilitation, often in the form of ‘recovery housing’ provided by people with ‘lived experience’. There is much greater access to various forms of ‘mutual aid’. There are ‘LEROs’ – lived experience recovery organisations. However, if you came out of your coma in Piccadilly Gardens in Manchester (a place I’ve been familiar with for over sixty years) you might be forgiven for failing to appreciate these improvements. You might feel that you’d emerged into a dystopian other world. Drug ‘addicts’ in wheelchairs with limbs missing (as result of infected femoral vein injection sites) slumber in public under the influence of Lady Morphia or wheel around in crack cocaine induced confusion. Homeless people lie in shop doorways or on the pavement.
The inner city of Manchester today makes the Piccadilly Gardens of 1985 look like the lawns of Downton Abbey. How has this happened, and what role has drug treatment had in such a spectacular and depressing downturn? Are the actors in the Piccadilly Gardens dance of despair in drug treatment? If not, why not? If yes, why are they in such a sad state of disrepair? Can we not get them into, or keep them in, treatment? What part of our offer is not sufficient to improve their lives?
Every town and city in the UK has its own version of Piccadilly Gardens, and some places are worse. There are some explanations for this decline. In 1985, few heroin users were also dependent drinkers. Crack cocaine wasn’t widely available. ‘Spice’ still meant chilli powder. Illicit benzodiazepines weren’t available at pocket money prices. Heroin wasn’t available 24/7, 365 days of the year. Dealers didn’t make their daily heroin and crack offers available via mobile phone.
I’m all too aware that all this can sound like your grandad saying ‘In my day… blah, blah, blah’. For the record, I happen to be a person with ‘lived experience’. For many years, I was a staunch advocate for ‘recovery’ in general and 12-step mutual aid in particular. To an extent I still am, but as a result of my lived experience I have many critiques and criticisms of all that. I’ve made many bad decisions in my life but the worst mistakes I’ve made have been while ‘clean and sober’ and engaged in 12-step mutual aid. As a direct result of those mistakes I now find myself, at the tender age of 68, living near Blackpool with regular visits to Manchester and Bradford. When I came into the drug treatment world I was a fundamental ‘harm reductionist’, and I’m back there again.
It seems to me that the primary response to the challenges that face us today is good old fashioned harm reduction. At the time of writing the working class are once again being demonised by polite middle class society. Who would have thought that John Major’s ‘condemn more, understand less’ would be repeated by progressive middle class liberals? It’s a funny old world.
Mark Gilman is a freelance consultant in substance use and is expressing his personal opinion in this article