"I'm Going to Stop Myself Before Someone Stops Me": Complicating Narratives of Volitional Substance Use Treatment.

David Frank,Suzan M Walters

doi:10.3389/fsoc.2021.619677

Abstract

Background: Often people assume that entry into drug treatment is a voluntary action for persons who use drugs (PWUD). This narrative informs the organizational and regulatory structure of most treatment programs and consequently affects patients’ ability to exert agency over their own treatment. Yet, this view ignores the complex interplay between individual and structural factors in peoples’ decision-making processes, particularly among people who use drugs who are stigmatized and criminalized. Treatment programs that assume voluntary entry may lack appropriate services for the populations of treatment seekers that they serve. Methods: This paper uses semi-structured interviews with 42 participants in Opioid Substitution Treatment (OST) (including patients, clinic doctors and staff, and advocates) informed by one of the author’s own lived experience in OST, to examine patients’ treatment decisions, and in particular, if and how, the structural context of drugs’ illegality/criminalization affected their willingness to pursue treatment. A Critical Discourse Analysis was used to identify key themes. Results: Interview data demonstrates that most people who use drugs enter treatment under constrained conditions related to drugs’ illegality. Themes that emerged included: 1. A feeling of limited choices due to drugs’ illegality; 2. Peer and family pressure; 3. Fear of losing children; and 4. Internalized stigma (i.e. feeling they are dirty or bad for using). Conclusion: Narratives that frame PWUD’s treatment decisions as volitional provide political cover to policies that criminalize PWUD by obscuring their effect on PWUD’s treatment decisions. Treatment models, particularly those that serve highly criminalized populations, should be re-conceptualized outside of normative narratives of individual choice, and be broadened to understand how larger structures constrain choices. By looking at macro-level factors, including the interplay of criminalization and drug treatment, programs can begin to understand the complexity of PWUD motivations to enter drug treatment. Recognizing the role of the War on Drugs as a force of oppression for people who use drugs, and that their treatment decisions are made within that setting, may enable people in treatment, and providers, to develop more productive ways of interacting with one another. Additionally, this may lead to better retention in treatment programs.

Highlights

Entry into drug treatment is usually conceptualized as a voluntary, unconstrained action taken by people who use drugs (PWUD) and intended to rectify the problem of “addiction.” This is evident through clinic descriptions that state that their services are voluntary (University Hospitals, 2020), and through the Substance Abuse and Mental Health Services (SAMHSA)’s Federal Guidelines for Opioid Treatment Programs which states that clinic physicians must receive “voluntary, written, program-specific informed consent to treatment” before patients can be medicated (SAMHSA, 2015: 24)
Research demonstrates that many people become involved with methadone maintenance treatment (MMT) as a way of avoiding harm associated with illegal substance use, rather than substance use itself, this view is rarely part of how treatment is institutionally conceptualized or organized (Frank 2018; Frank, 2020)
We argue that by acknowledging such macro-level factors and how they interact with treatment decisions, programs can better organize their services to meet the complex set of issues their patients are facing

Summary

Introduction

Entry into drug treatment is usually conceptualized as a voluntary, unconstrained action taken by people who use drugs (PWUD) and intended to rectify (i.e., treat) the problem of “addiction.” This is evident through clinic descriptions that state that their services are voluntary (University Hospitals, 2020), and through the Substance Abuse and Mental Health Services (SAMHSA)’s Federal Guidelines for Opioid Treatment Programs which states that clinic physicians must receive “voluntary, written, program-specific informed consent to treatment” before patients can be medicated (SAMHSA, 2015: 24). The Recovery Oriented Systems of Care model adopted by SAMHSA in particular relies on presenting MMT as a “voluntary, self-directed, ongoing process” (2015: 39) This view may ignore the role of larger structural forces such as criminalization and the War on Drugs, in the lives, and treatment decisions, of PWUD. Often people assume that entry into drug treatment is a voluntary action for persons who use drugs (PWUD) This narrative informs the organizational and regulatory structure of most treatment programs and affects patients’ ability to exert agency over their own treatment. This view ignores the complex interplay between individual and structural factors in peoples’ decision-making processes, among people who use drugs who are stigmatized and criminalized. Conceptualizing problematic substance use through the lens of “addiction” has been criticized by many scholars (Hart, 2017; Fraser et al, 2014; Keane, 2002; Reinarman, 2005), this narrative is dominant culturally, and informs the organizational and regulatory structure of most treatment programs in the United States (SAMHSA, 2016; White and Mojer-Torres, 2010)

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Discussion

Conclusion