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Sumnall H., Brotherhood A.
European Monitoring Centre for Drugs and Drug Addiction, 2012.
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Report for the EU identifies an urgent need to increase access to social reintegration interventions for problem drug users. Though unable to pin down the best approaches, it stresses that reintegration measures should be embedded into drug treatment at an early stage.
Summary [This account is based on the featured report’s own summary. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) which published the report is a decentralised agency of the European Union (EU) which provides the European Union and its member states with a factual overview of European drug problems and a solid evidence base to support the drugs debate and for drawing up informed drug laws and strategies. The centre also helps practitioners pinpoint best practice and new areas of research.]
In the European Union most treatment activities are predominantly oriented towards the management and cessation of substance use. This has led to concerns that support aimed at the psychosocial and other needs of problem drug users is lacking. This apparent gap recently received increased attention in many member states, where drug policies have focused attention on ‘recovery’ and social reintegration. This report aimed to review recent discussions and developments concerning the social reintegration of problem drug users and to examine the evidence for the effectiveness of interventions that aim to increase their employability. It drew upon a review of scientific papers and grey literature, reports submitted by the national focal points of the EMCDDA’s network, and EMCDDA standard data collection. Although evidence is sparse, it is possible to integrate this information and to present in this report a logic model to assist policymakers and drug practitioners in developing coherent and inclusive strategies to promote social reintegration.
Many problem drug users in Europe have unmet housing, educational, employment and other social needs, often evident before drug use commenced. Across Europe, this group is more likely than the general population to be vulnerably housed, to report fewer years of education and fewer educational qualifications, and to be unemployed. Their social and family networks may be less well developed than in the general population, adding to their exclusion. Ongoing treatment contact and long-term secondary illnesses mean they often have to attend daytime prescribing, support and aftercare services, which can be difficult to reconcile with regular employment. Further challenges await those individuals who successfully complete drug treatment. The stigma associated with being a (former) problem drug user and the increased likelihood of having a criminal record mean that obtaining and maintaining employment is more difficult. These problems are particularly acute for individuals who have recently left prison and who face further difficulties after the loss of rented accommodation while incarcerated. Some employers perceive (former) problem drug users as being ‘problem people’, and because they have disengaged from education and training at an early age many of them do not have the qualifications, personal capital and other life skills needed to succeed in an increasingly competitive and demanding employment market.
‘Social reintegration’ is not used or defined consistently across EU member states, but it is a key aspect of full recovery from drug dependence. Its scope is wider than the traditional treatment focus on pharmacological and psychosocial outcomes. The EMCDDA defines it as: “any social intervention with the aim of integrating former or current problem drug users into the community”. Its three ‘pillars’ are: housing; education; and employment, including vocational training. Other measures, such as counselling and leisure activities, may also be used. More recently the EMCDDA has introduced the concept of ‘employability’ to account for the complexity of an issue affected by factors ranging from the individual’s situation and capabilities to national policies and interactions between these factors. Furthermore, as employment is acknowledged in the member states and beyond as important for social integration, supportive measures to overcome personal and structural-level barriers to obtaining employment and increasing personal employability are seen as a keys to social reintegration.
Simply being employed is not equivalent to being socially integrated, so employment should not be considered as the only goal of social reintegration. Non-work-related spheres of life, such as supportive networks and relationships with significant others, are equally important, including the ability to lead a life free from stigma and discrimination.
Social reintegration is seen as a foundation for drug treatment and as such it also includes all those activities that aim to develop human, social, economic and institutional capital. Activities that promote social reintegration are ethical and should be integral to drug treatment.
The overall aim of the EU drugs action plan (2009–12) is to “significantly reduce the prevalence of drug use among the population and to reduce the social and health damage caused by the use of and trade in illicit drugs”. Social reintegration contributes to achieving this aim and is specifically included in the national drug strategies of 22 member states. In March 2006, the European Council also adopted a framework for social protection and social inclusion that was designed to promote social cohesion and social inclusion policies. The United Nations 1961 Single Convention also makes specific reference to the need for social reintegration measures: “The Parties shall give special attention to and take all practicable measures for the prevention of abuse of drugs and for the early identification, treatment, education, after-care, rehabilitation and social reintegration of the persons involved and shall co-ordinate their efforts to these ends.”
The review conducted for the featured report identified a range of research and discussion papers that either discussed evidence of effectiveness or presented good practice in social reintegration of problem drug users. Strategies included in the review were specific to problem drug users and so must be considered alongside other general population and targeted programmes to promote stability, employability and economic prosperity such as employment services, welfare to work, benefits, and job creation schemes for unemployed populations in general.
Approaches to social reintegration can be broadly categorised as: general vocational rehabilitation; drug treatment; criminal justice interventions; housing support; education and (vocational) training; employment support; general policy on welfare benefits; and advocacy.
Overall, there was little evidence internationally – and almost none from EU member states – to clearly suggest ‘what works’ with regard to social reintegration interventions, although it became clear that contextual factors (eg, social attitudes to drug users, local and national economic prosperity, standards of living in the general population, professional training, stability in problem drug users’ lives, etc) were extremely important moderators of success. The findings from the review can be summarised as follows:
• In general, providing drug treatment alone without additional support or services had only limited and inconsistent effects on employment outcomes.
• Vocational training, which aims to improve job-seeking skills and improve motivation for work, shows promise, but no particular intervention models were identified as producing consistently positive outcomes.
• Contingency management approaches, whereby rewards (eg, monetary vouchers) are contingent on successfully performing a particular activity, such as getting a job or providing a negative urine toxicology sample, showed some promise, but these types of interventions were mainly developed and researched in the USA. Their application might raise particular ethical concerns in the EU, and they have largely been developed to motivate drug abstinence rather than social reintegration.
• Court-mandated treatment is used increasingly in some EU member states, and research has shown that such (quasi-)compulsory treatment produces similar outcomes to ‘voluntary’ drug treatment. Drug courts specialising in drug-related offences and drug-dependent offenders have also shown promising results in well-designed studies in the USA and Australia. Evidence from the former country shows that this may be an effective way of improving employment outcomes.
• Anti-discrimination legislation may be useful to ensure that former problem drug users are not disadvantaged in the workplace. Anti-disability discrimination legislation such as that developed in the USA may be one policy model to consider, but findings from the USA suggest that discrimination against problem drug users still occurs in the workplace. Furthermore, classifying former problem substance users as ‘disabled’ assumes a medical model of dependence, and that substance use dependence is extremely difficult to overcome and that full recovery can never occur. Such an interpretation may be at odds with current EU member state national drugs policies and the views and experiences of treatment professionals and drug users themselves.
There was not enough evidence of effectiveness to be able to make direct recommendations about which specialist types of interventions should be promoted in the EU, although responses to a structured questionnaire indicated that member states reported delivery of most of these already. However, there was little coherence between the approaches described in the literature and the way in which these activities were delivered. Most implementations have not been evaluated and overall coverage appears poor. It was also difficult to identify the best ways the approaches should be delivered alongside traditional drug treatment as part of an individualised care plan.
In the absence of specific recommendations on intervention models, the recommendations below present general considerations on activities promoting social reintegration. These are based on the synthesis of the implications of primary studies, reports from expert groups (including existing good practice guidelines) and wider discussions of social exclusion and associated factors. The lack of a consistent set of research findings and the paucity of EU research into this topic mean these recommendations should be considered only as the first steps in promoting social reintegration activities, and it is essential that this work be expanded in the coming years. Given the crucial role of social reintegration in limiting and overcoming drug-related problems in the long term, a better understanding of these interventions in Europe is greatly needed.
There is an urgent need to increase access to social reintegration interventions for problem drug users in the EU
• The need for social reintegration interventions should be acknowledged in funding provision and national drug policies. Drug treatment alone cannot address the complex needs of problem drug users. Treatment alone is also not sufficient to prevent social exclusion of marginalised individuals, particularly as many problem drug users were already marginalised before they started using drugs. Without social reintegration interventions, there is a serious danger that the gains made during treatment will be undermined.
• There is an urgent need to increase the availability of and access to social reintegration interventions for problem drug users in the EU. The availability and coverage of social reintegration measures in EU member states are overall limited and interventions are often subject to particular conditions that may exclude those most in need of support (eg, drug-free status, stable housing). Additionally, policymakers should encourage the expansion of intermediate labour market interventions and the role of social enterprises, as these have been shown to be profitable for the wider society and to provide a bridge back to the world of work for disadvantaged, long-term unemployed individuals.
• It is important that definitions of social reintegration use a broad understanding of social reintegration that, besides economic integration, should also prioritise components related to human, social, economic and institutional capital. This also allows a better understanding of the level of social reintegration that individuals can achieve. The logic model presented in this report promotes a comprehensive approach to social reintegration that systematically addresses the multiple barriers faced by problem drug users. It is also important to recognise that many individuals were already socially excluded prior to their drug use, and thus the term ‘social (re)integration’ may be more appropriate in some cases.
• Social reintegration measures can, and should, be embedded into drug treatment at an early stage. Depending on individual client needs, the provision of supportive structures, such as stable housing in the short term and vocational training in the medium term, may lead to improved treatment outcomes. Drug use abstinence should not necessarily be a condition of social reintegration support.
• Treatment providers should consider social reintegration outcomes as part of individual care planning and make use of multi-sectoral working to address these. Although stabilising and reducing drug use and associated harms is a primary outcome of drug treatment, outcomes related to social reintegration should also be considered important. Therefore, it is recommended that the monitoring of effectiveness of drug treatment must include data on social reintegration.
• Research funders should provide sufficient resources to allow high-quality outcome evaluations and cost-effectiveness studies of existing interventions in the EU or consider commissioning work that aims to adapt promising models of social reintegration developed elsewhere. Once sufficient evidence is available, evidence-based guidelines should be developed.
• Problem drug users are not a homogeneous population and consist of many different subgroups with different needs. Social reintegration services need to be oriented accordingly. For example, most EU services target opioid users, which means users of other drugs such as stimulants or cannabis may have even less access to social reintegration provision.
commentary For more background and research see the Effectiveness Bank hot topic on promoting recovery through employment.
Last revised 11 October 2016. First uploaded 07 October 2016
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HOT TOPIC 2016 ‘Recovery’: meaning and implications for treatment
HOT TOPIC 2015 Promoting recovery through employment