I work in a service where the power we exert frequently occurs at the overlap between ‘risk management’ and ‘medication control’.
We prescribe people with ‘opiate substitution’ treatments, providing buprenorphine or methadone to reduce their physical need for heroin or other opiates. However, if a service user is not engaging with support and regular risk reviews, I will be asked to put their script ‘on hold’ in the pharmacy, requiring that they attend an appointment prior to accessing their medication. For service users who are living in chaotic circumstances, I’m doing this regularly.
This is considered an important part of risk management, as if I were unable to properly assess a service user it would limit the support I could offer. If a service user never engaged with the service, we could not continue to prescribe opiates for them as it could pose risks to themselves and others in the community.
However, feedback from service users has been clear that this feels like a coercive imposition on their lives. While some have thanked me for putting their scripts on hold – forcing them to come into the service to ask for help – and others simply recognise it as a ‘normal’ part of how services operate, I’ve had service users arrive in tears because I’ve put their scripts on hold. Sometimes service users have shared that they missed appointments due to crippling anxiety, and by putting their script on hold I’ve made them the centre of attention in the pharmacy and forced them to attend the service on a ‘bad mental health day’.
Service users have shared similar feedback around being forced to collect daily supervised medication, rather than being provided with a week’s medication at once. These decisions do not fall under my power – they’re clinical decisions – however as the keyworker I’m the face of the organisation. One service user in particular spoke about our control over collections as a method of social control, utilised to reward or punish people.
Incorporating this feedback into risk management has triggered the question of whose risks are we managing. There’s a tension between managing and mitigating risks for the service user, and mitigating and managing risks for us as an organisation.
One example – we were concerned that one service user was using heroin on top of her prescription. We followed normal procedure and changed her collections to daily supervised in the pharmacy. Her feedback was that because of her severe anxiety – for which she was on long waiting lists for secondary mental health support – she began missing doses and buying more heroin, because, as she put it, heroin from her dealer is ‘home delivery’. We had effectively mitigated our own organisational risks, as the medication we prescribed was now less likely to be misused – however, had we really mitigated the risks to the service user, who was now saying plausibly that as a result of our decision she was using street heroin more regularly than before?
This dilemma of risk management has an enormous impact on service users’ lives on a regular basis. By providing a high-strength opiate to someone physically and psychologically dependant on that drug – and who could be placed in severe distress by its withdrawal – and then imposing conditions on continuing to prescribe it, we must recognise the power of coercive impact, and threat of real harm, that we hold over service users. I’m not a clinician and I make no final clinical decisions, but as a recovery worker (and in particular as a qualified social worker trained in safeguarding) my assessment of the risks present carries weight. That creates a power imbalance and an implicit threat between myself and the service user.
Questions of power imbalance and coercion become even more relevant when service users are also engaging with other state agencies that are more openly coercive than drug/alcohol addiction services. There are countless examples of service users trapped in cycles of coercive control by the criminal justice system, often for drug-related offences. This raises for me the dichotomy of multi-agency working between different agencies (criminal justice and addiction/social work) that have a different relationship with service users, and which treat drugs in such a different way.
Service users imprisoned for drug-related offences or missed probation appointments have told me the criminal justice system makes them feel their personal circumstances were rendered irrelevant, their essential recovery connections cut short and their lives reduced to a box-ticking exercise. Service users from migrant backgrounds face additional barriers, such as fears of services sharing information with the Home Office and the ‘hostile environment’, making many reluctant to seek help.
Addiction support, medication control (under the Misuse of Drugs Act 1973), and multi-agency working must be placed in the context of the ongoing ‘war on drugs’, which many people argue has had the impact of exacerbating structural inequalities, traumas and the health and social damage of drug use.
Working in drug and alcohol services has made me more aware as a practitioner of the power contained in my professional role. While in practice my job role involves exercising power, as part of safeguarding, risk management, medication control and multi-agency working, what I’ve tried to do is have more open conversations with service users about the nature of the systems they’re engaging with.
My aim is to position myself not as a ‘gatekeeper opposite’ but rather an ‘advocate alongside’, who will explain every process and seek to help them navigate systems and legal frameworks which may in many circumstances be unjust.
Tom Zagoria is a recovery worker and social worker at Change Grow Live
There’s a consensus in many treatment services that coercion to require compliance with treatment is necessary in the long run. There are arguments that even in circumstances where a mental capacity assessment would judge an individual to have capacity, their independent agency is impaired over the long term through the impact of addiction on their brain. Many in recovery have emphasised that they found being pushed into engaging with services beneficial at certain points.
The impact of addiction on the brain is agreed both from biological neuroscience-focused perspectives on addiction, and alternative perspectives such as Gabor Maté’s ‘biopsychosocial’ paradigm of addiction. Maté argues that a continuum of addiction runs throughout our society, with more extreme forms of addiction developing in the early childhood environment when the ‘neurobiology of the brain’s reward pathways’ develop. Continuing and ongoing stress – which can be related both to ongoing traumas, as well as service failures – continues to create and renew predispositions to addiction over the course of life.
Nevertheless the service user remains the person with the most expertise regarding their own life, and it’s the responsibility of the practitioner to respect this and support the service user to make their own choices as safely as possible. This can be done using tools of motivational interviewing and other social work techniques.