Thesis Proposal: ‘Pathways to recovery from heroin addiction: An oral history account of addicted heroin users in recovery.’

Part 5 References

Abrams, L. 2010. Introduction: Turning practice into theory. In: Abrams, L. ed. Oral History Theory. New York: Routledge, 1-17.

Alexander, B. 2000. The globalisation of addiction. Addiction Research, 8 (6): 501-526.

Alexander, B. 2012. Addiction; The urgent need of aparadigm shift. Substance Use and Misuse,  (47): 1475-1482.

Alexander, B., Beyerstein, B., Hadaway, P. and Coambs, R. 1980. Effect of early and later colony housing on oral ingestion of morphine in rats. Pharmacology  Biochemistry & Behaviour, 15: 571-576.

Alexander, B. and Schweighofer, A. 1988. Defining "addiction". Canadian Psychology, 29 (2): 151-162.

Bamber, S. 2010. Rethinking community: Addiction, recovery and globalisation. In: Recovery Writing: Volume 1, 2009-2010. Manchester: The Art of Life Itself.

Batty, E. 2009. Reflections on the use of oral history techniques in social research. People, Places and Policy, 3 (2): 109-121.

Bobo, L. D. and Thompson, V. 2006. Unfair by design: The War on Drugs, race, and the legitimacy of the criminal justice system. Social Research, 73 (2): 445-472.

Borkman, T. 1998. Is recovery planning any different to treatment planning? Journal of Substance Abuse Treatment., 15 (1): 37-42.

Bourgois, P. 2003. Crack and the political economy of social suffering. Addiction Research and Theory, 11 (1): 31-37.

Chetty, R. 2015. Social complexity of drug abuse, gangsterism and crime in Cape Flats' schools, Western Cape. Acta Criminologica: South African Journal of Criminology.,  (Special edition no 3.): 54-65.

Dahl, I. and Malin, T. 2009 Oral history, constructions and deconstructions of narratives: Interdections of class, gender, locality, nation and religion in narratives from a Jewish women in Sweden. Enqiure, 3: 1-24.

Di Chiara, G. 1999. Drug addiction as a dopamine-dependent associative learning disorder. European Journal of Pharmacology, 375: 13-30.

Dos Santos, M. 2012. Healing the dragon: Heroin use disorder intervention and recommendations for policy advancement. New Voices in Psychology, 8 (1): 44-63.

Dos Santos, M., Rataemane, S. and Rataemane, L. 2013. Substance abuse and mental health in Africa. In: Sorel, E. ed. 21st Century Global Mental Health. Burlingon: Jones and Bartlett, 253-280.

Dos Santos, M., Rataemane, S., Russel, M., Pluddemann, A., Sinisi, V. and Benn, M. 2009. Heroin use disorder intervention  within the South African context. New Voices in Psychology, 5 (1): 3-28.

Du Pont , R. and Humphreys, K. 2011. A new Paradigm for long term recovery. Substance Abuse, 32 (1): 1-6.

Evans, A., Lamb, R. and White, W. 2013. The community as patient: Recovery- focused community mobilisation in Philadelphia, PA (USA), 2005-2012. Alcohol Treatment Quarterly 31 (450-465)

Evans, A., White, W. and Lamb, R. 2013. The role of harm reduction in recovery oriented systems of care: The Philadelphia experience. 

Fontana, A. and James, F. 1994. The Art of Science In: Denzin, N., Lincoln, Y., Daniels, A. and Silverman, D. eds. The Handbook of Qualitative Research Thousand Oaks: Sage Publications.

GCOD. 2011. War on drugs: report of the global commission on drugs.  Available: http://www.globalcommissionondrugs.org/ (Accessed 25/06/2016).

Geyer, S. and Lombard, A. 2014. A content analysis of the South African national drug master plan: lessons for aligning policy with social development. Social Work, 50 (3): 329-349.

Gray, J. P. 2001. Why our drug laws have failed and what we can do about it: a judicial indictment of the War on Drugs. Philadelphia: Temple University Press.

Green, A. 2004. Individual remembering and 'collective memory': Theoretical presuppositions and contemporary debates. Oral History, 32 (2): 35-44.

Hoffmann, J. 1990. The historical shift in perception of opiates: From medicine to social menace. Journalof Psychoactive Drugs 22 (1): 53-62.

Holloway, W. and Jefferson, T. 2000. Doing Qualitative Research Differently. London: Sage.

Howell, S. and Couzyn, K. 2015 The South African National Drug Master Plan 2013-2017: A critical review. South African Journal of Criminal Justice          Vol 28  (1): 1-23.

Humphreys, K. 2015. Addiction Treatment Professionals are not the gate-keepers of recovery. Substance Use and Misuse, 50 (8-9): 1024-1027.

Jagganath, G. 2015. The Anti-Drug Forum: a case for community -based substance abuse education and rehabilitationin post-apartheid South Africa. Acta Criminologica: Southern African Journal of Criminology, Special Edition no 3: 222-235.

Jeewa, A. and Kasiram, M. 2008. Treatment for substance abuse in the 21st century: A South African perspective. South African Family Practice, 50 (6): 44-44d.

Keen, H., Sathiparsad, R. and Taylor, M. 2015. Prevalence of multiple addictions and current treatment by drug treatment centres in Durban, south Africa. Social Worker/ Maatskaplike Werker, 50 no2 (6): 244-261.

Kerr, D. 2003. "We know what the problem is": Using oral history to develop a collaborative analysis from the ground up. Oral History Review, 30 (1): 27-45.

Levy, N. 2013. Addiction is not a brain disease (and it matters) Frontiers in Psychiatry, 4: 1-7.

Matto, H. 2008. Applying an ecological framework to understanding drug addiction and recovert Journal of Social Work practice in the Addictions, 4 (3): 5-22.

McIntosh, J. and McKeganey, N. 2000. Addicts' narratives of recovery from drug use: constructing a non-addict identity. Social Science & Medicine,  (50): 1501-1510.

Miller-Rosser, K., Suzanne, R.-M., Chapman, Y. and Francis, K. 2009. Analysing oral history: A new approach when linking method to methodology International Journal of Nursing Practice, 15: 475-480.

Mudavanhu, N. and Schenck, R. 2014. Substance abuse among the youth in Grabouw Western Cape: Voices from the community. Social Work/ Maatskaplike Werk, 50 (3): 370-392.

Myers, B. and Parry, C. D. 2005. Access to substance abuse treatment services for black South Africans: findings from audits of specialised treatment facilities in Cape Town and Gauteng. South African Psychiatry Review,  (8): 15-19.

Neale, J., Nettleton, S. and Pickering, L. 2012. The everyday lives of recovering addicts. London: RSA.

Panel, B. F. C. 2007. What is recovery? A working definition from the Betty Ford Institute. Journal of Substance Abuse Treatment,  (33): 221-228.

Prinsloo, J. and Ovens, M. 2015. An exploration of lifestyle theory as pertaining to the use of illegal drugs by young persons at risk in informal settlements in South Africa. Acta Criminologica: South African Journal of Criminology,  (Special Edition no 3): 42-53.

Roberts, M. 2009. Drug treatment at the crossroads: What it's for, where it's at and how to make it even better. London: DrugScope.

Rolles, S., Murkin, G., Powell, M., Danny, K. and Slater, J. 2012. The Alternative World Drug Report: Counting the Cost of the War on Drugs. Counting the Costs.

Sangster, J. 1994. Telling our stories: feminist debates and the use of oral history. Women's History Review, 3 (1): 5-28.

South Africa, R. o. Development, D. o. S. 2012. National Drug Master Plan 2013-2017.  Available: http://www.dsd.gov.za/ (Accessed 26/03/2016).

UKDPC. 2012. A Fresh Approach to Drugs; The final report of the UK drug policy commission.  Available: www.ukdpc.org.uk (Accessed 26/06/2016).

White, W. 2007a. Addiction recovery: Its definition and conceptual boundaries. Journal of Substance Abuse Treatment, 33: 229-241.

White, W. 2007b. The new recovery advocacy movement in America. Addiction, 102: 693- 715.

White, W. and Evans, A. 2014. The recovery agenda: The shared role of peers and professionals. Public Health Reviews, 35 (2): 1-15.

White, W. and Mojer-Torres, L. 2010. Recovery-oriented methadone maintenance. Illinois: University of Chicago.

Thesis Proposal:‘Pathways to recovery from heroin addiction: An oral history account of addicted heroin users in recovery.’

Part 4 Research Methodology   This study will employ qualitative techniques of data collection and analysis.  Sampling will be purposive. I have done extensive work with addicted users at a community level.  I am a member of a 12-step fellowship support group in my local area and play a role as a peer support person for other addicts who are in recovery or who are aiming for recovery. Being a recovering addicted user myself will help with locating subjects and with the bonding required to gain their trust.   Many, like myself, attend 12-step fellowship groups.  I will make use of my own membership with these groups, and my active participation in them as a gateway to recruiting participants in this study. However I will not limited my respondents to 12 step group members in my locality.  I am also eager to hear the stories of recovery as told by those who are not, and have not been, members of 12 step fellowship groups. This will be facilitated my colleagues at the Urban Futures Centre who are doing a large scale research and intervention project entitled ‘Pathways into and out of street level drug use’. Subjects will be chosen according to severity of their addiction and all will have spent time on the streets, in institutions or jail as a result of their addiction to heroin. The number of interviewees will be determined by data saturation, with a tentative figure of 15, bearing in mind that the interviews will be extensive, covering the life story of the subject in detail. Trials interviews conducted in preparation for this work have lasted between 90 and 150 minutes. According to Polkinghorne, quoted here in Holloway and Jefferson, narrative is the “primary form by which human experience is made meaningful”  (2000: 32). Through the narrative the researcher can gain understanding of events and processes in the life of the subject, and the meaning attached to them. Oral histories allow the subject to construct the narrative of their life story in a free-flowing way according to the themes that are important to them, and at the same time make their experience accessible to the interviewer. Oral history originated in the humanities as a means of introducing the voice of ordinary people into the study of history,  as well as giving voice to marginalized and oppressed groups. (Fontana and James 1994; Dahl and Malin 2009 ). Thus it is suited to the task of telling the stories of drug users, who fall within this category. It is also useful for locating individual experience within broader cultural and historical contexts (Sangster 1994; Green 2004; Batty 2009), and for revealing processes and agency (Abrams 2010)). Thus it is an appropriate approach for uncovering the causes and effects of addiction, and recovery, which may play out in unsuspecting ways. Oral histories have more recently been  widely used in the social and health sciences (Kerr 2003; Miller-Rosser et al. 2009) . Thematic analysis will be conducted using the NVIVO program to reveal the common elements within the subject’s histories. Focus will be on the subjects personal understanding of life events in relation to their subsequent addiction and recovery, and on relations with family and community. The emerging themes will then be analysed in relation to the literature around existing treatment models and theories of addiction with the aim of identifying the strengths and addressing the limitations of these.

Thesis Proposal: ‘Pathways to recovery from heroin addiction: An oral history account of addicted heroin users in recovery.’

Part 3 Literature Review

The traditional discourse on the subject focuses on two models: the judicial and the medical. The first has led to the War on Drugs and conceptualises the addicted user as a criminal who needs to be punished and removed from society. Addiction is viewed as a moral failing, or a lack of willpower (Gray 2001). This approach is largely recognised as having failed, but it still the dominant model for dealing with addiction at a societal level. The second conceptualises the addicted user as a patient in need of medical intervention and has led to the rise of the treatment industry. There is a growing awareness of the limitations of current approaches to treatment (Borkman 1998; White 2007a; Keen,  Sathiparsad and Taylor 2015) . In South Africa Jeewa and Kasiram (2008: 44) found “there is no “best treatment option” and “there are too many variations and complexities in reaching the goal of freedom from dependence”. He also found that the approach to treatment was founded on a “unidimensional philosophy”  and that there was a need for more comprehensive and creative approaches.  Dos Santos found that successful treatment programs needed to be holistic, long term and focus on all aspects of life (Dos Santos et al. 2009).  At present, however, treatment usually involves a short intervention during which the addicted user is the passive recipient of a bio-medical or psycho-social treatment program, after which the individual is sent on their way, with little follow up. Further the treatment is still largely based on expensive, in-patient, rehabilitation models, inaccessible to the majority. The “expert hierarchical model” is applied, relying on doctors, psychiatrists, nurses and other professional who are assumed to have expert knowledge (Borkman 1998: 41).  Newer methods of dealing with addiction are coming to the fore. Predominant among these is the social model which places addiction firmly in a community context and conceptualises the addict as a vulnerable and alienated member of society in need of re-integration into their community. The two main approaches using this model are the harm reduction and recovery schools of thought. These approaches are often portrayed as being in conflict, but in reality have much common ground and can complement one another (Roberts 2009; Evans,  White and Lamb 2013). Both are geared towards the normalization of life for the addicted user. In the harm reduction model abstention is not the necessary outcome, whereas for the recovery model abstinence is central. Opioid-substitution treatment, one of the key options of harm reduction approaches, is controversial within the recovery movement. Recovery supporters are concerned about the addictive nature of opiate substitutes and speak of “methadone madness” (Neale,  Nettleton and Pickering 2012: 33). Opiate substitution therapy has, however, been endorsed by William White, a leading figure in the recovery movement, among others. (White and Mojer-Torres 2010). Both the harm reduction and recovery approaches view recovery as a long term, active process of re-connection and learning, rather than as an event  (Du Pont  and Humphreys 2011). The social model, both in the form or harm reduction and recovery,  is prevalent in Europe and the Americas, but is practically unknown in South Africa.  A search on the Sabinet SA e publications website revealed no one single article that used the term “social model recovery” or any combination of these words in relation to recovery from drug addiction, as opposed to a search of international journals which turned up over a hundred. There is however a growing body of literature on harm reduction, with the National Drug Master Plan making reference to it  (South Africa 2012). Writers within the growing social model discourse place the causes of both addiction and recovery firmly in the community (Bamber 2010; Alexander 2012; Evans,  Lamb and White 2013). Alexander attributes addiction to what he calls “inadequate social integration” or “dislocation”. Those suffering from dislocation construct “substitute lifestyles” which may focus on dangerous and excessive drug use. (Alexander 2000: 502). The famous Rat Park experiment (Alexander et al. 1980) is a powerful demonstration of this. They conceptualizes addiction as a learning or developmental disorder, rather than a medical condition (Di Chiara 1999; Matto 2008; Levy 2013) and argue that it should be treated as a community health issue, (Mudavanhu and Schenck 2014; Jagganath 2015) rather than a criminal or medical one. Addiction is viewed as a disorder of society rather than the individual, rooted in the alienation and dislocation so prevalent in the modern world (Alexander 2000; Bourgois 2003; White 2007b).  The solution then to problematic drug use is re-connection. The Betty Ford Clinic, one of the oldest and most respected treatment centers in the USA holds up personal health and citizenship along with sobriety (abstention) as measures of recovery  (Panel 2007: 222). Also important is the emphasis the center places on peer based support in the recovery process. This is another element the recovery and harm reduction movements have in common.  White and Evans, among others have emphasized the significant role that non-professional recovering addicted users can play (White and Evans 2014). For them, community based support is often an overlooked resource with a massive potential for assisting in the process of recovery.  The “gatekeeper myth” keeps us believing that professionals have a better understanding of the workings of addiction than those who have been addicts, when in reality treatment by professionals is no more (or less) successful than programs run by recovering addicted users (Humphreys 2015). Many too recover without any intervention (McIntosh and McKeganey 2000). The rationale of the social model in terms of the underlying causes of problematic drug use (and how to deal with it) is of great relevance in the South African context where individual and community trauma and disconnection, both current and historical, is deeply embedded. Evans et al use the term “historical trauma” to describe a unique form of distress brought about by sustained assault on a community’s values, through colonisation  and dispossession, which could result in increased vulnerability to drug related problems (Evans,  Lamb and White 2013). White and Evans write that  “clinical and social interventions can be substantially enriched by drawing lessons from the lived solutions to these problems at personal, family, neighbourhood, and community levels.” (2014: 2). If we wish to begin to utilize this resource,  the experience of addicted drug users in various stages of recovery, through the telling of their own stories, may be the most appropriate place to begin in making sense of best practice models for promoting recovery and the reduction of harms that addiction creates to individuals, their families their community and society at large. This dissertation draws on the recovery approach in analysing the oral histories and in engaging with existing and future policy and treatment models.

Thesis Proposal:‘Pathways to recovery from heroin addiction: An oral history account of addicted heroin users in recovery.’

Part 2: Research Problems and Aims The use of drugs is as old as humankind. For the most part drugs have been used for healing, spiritual purposes and recreation with very little negative consequences (Hoffmann 1990). However there has always a small minority of people who have become problematic drug users.  Drug use becomes problematic when it becomes the sole focus of one’s life and when their use harms the user, their family and the community they live in. This small percentage of problematic drug users from within the drug use community could best be described as “addicts” ((Alexander and Schweighofer 1988). This thesis will attempt to understand how and why certain people, at certain points in their lives, turn to drugs for relief, become addicted, and how and why they recover [1].  It will do this by exploring the oral histories of previously addicted heroin users, now in recovery.  Both ‘addiction’ and ‘recovery’ are contested terms. The meaning we give to these terms has  profound implications for our approach to policy and treatment. Different models have different measures and diverse underlying concepts and normative outcomes. It could be said, however, that all treatment models aim towards what can be broadly called ‘recovery’. [2] An essential part of this study is to explore what these terms mean to the recovering addicted user, to begin to understand these from lived experiences. The aim of the study is to allow the subject free rein to tell their life stories in their own words, to construct it in ways that are meaningful to them. Through analyzing these stories the aim of this dissertation is to gain a greater understanding into the pathways of addiction and recovery.  This information can then be used to inform debates around the nature and the lived realities of addiction, but also the effectiveness of different treatment and policy models. The objectives are as follows: 1                  to record the oral histories of a group of addicted heroin users in recovery. 2                 to analyse the narratives to extract common themes relating to pathways in and out of addiction. 3                 to assess the emergent themes in relation to the various theoretical and evidential debates about addiction and recovery in the existing literature, particularly relating to current treatment models. 4                 to use the insight gained to begin to address the limitations in the current treatment models by engaging with current policy and the various agents involved in treatment of drug addiction.  The primary question that will be asked is: What insight can we gain from the oral histories of recovering addicted heroin users that might assist in identifying the strengths and addressing the limitations of present treatment models in South Africa?

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[1]          I have elected to use the term “addicted user” since it does not hold the stigma of the term addict, yet still manages to convey the level of obsession inherent in what we refer to as addiction.

[2]              The meaning of these terms is explored in the literature section below.

Read pt 3: Literature review here:  http://davidonymous.blogspot.co.za/2017/02/thesis-proposal-pathways-to-recovery.html 

Proposal for Research Thesis: Provisional Title: ‘Pathways to recovery from heroin addiction: An oral history account of addicted heroin users in recovery.’

PT I Context of the Research

The United Nations recently convened a special assembly recently in response to the growing criticism of present international drug policy. In particular the so-called “War on Drugs”  is coming under increasing attack as, at its best,  a costly and futile exercise, (Gray 2001; Rolles et al. 2012) and, at its worst, a sinister machination of bio-political control (Bobo and Thompson 2006). Internationally and locally experts are baffled by the growth of what is perceived as a “drug problem”. An increasing number of countries, institutions and individuals are exploring and debating   a range of alternatives in reducing the harm that drugs cause,  from legalization to policies that are aimed at harm reduction rather than punishment (GCOD 2011; UKDPC 2012).   In South Africa the National Drug Master Plan commits to a multi-disciplinary and community-based oriented in what it refers to as a “bio-psycho-social” model (South Africa 2012: 30). However according to Howell and Couzyn (2015 : 1) the plan is “riddled with internal inconsistencies and impractical resolutions” and will be extremely difficult to implement due to lack of government resources and co-ordination on one hand, and the lack of non-government facilities on the other. Furthermore content analysis by Geyer and Lombard (2014: 342) reveal that the master plan is still stuck in using the language of criminalisation and individual pathology, which, they conclude, has the result of absolving the government of any responsibility. There is a growing perception that present treatment and policy models in regard to drug addiction are inadequate to deal with the multitude of psycho-social, family and community issues emanating from, and leading to, the ever-increasing abuse of drugs. They tend to pathologise the individual and overlook the structural and social aspects of the problem (Chetty 2015; Prinsloo and Ovens 2015) . Further there is little agreement as to what the outcome of the recovery process should be. Dos Santos claims too that “that the pathways to recovery tend to be complicated and the variety of possible outcomes is extremely great”  (Dos Santos 2012: 54) .   Practically treatment is inaccessible to the majority of addicted user (Myers and Parry 2005; Dos Santos,  Rataemane and Rataemane 2013). This is available either through private residential treatment centres, which are prohibitively expensive and inaccessible to the majority of addicted users, or available, largely as out-patient treatment centres through non-profit state or NGO organisations. Access to these centres is limited, due to lack of funding and resources, and there is usually a three to six month waiting list. In both private institutions and the NGO/state sector there is a poor record in achieving sustained recovery. (Jeewa and Kasiram 2008) . Largely missing from this debate is the voice of addicted user themselves. As a recovering addicted heroin user myself, I have come to I have come to believe that it is critical to have such voices heard if a decent model for dealing with drug use disorders is to be developed and implemented. Drug users are a highly stigmatised and marginalised community. Their voices are seldom heard when it comes to policy making and practice models that are directed at them. Yet their own experiences and journeys into and out of problematic drug use could provide invaluable insights into the development of more effective treatment models. Read pt 2; Research Problems and Aims here:  http://davidonymous.blogspot.co.za/2017/02/pathways-to-recovery-from-heroin.html

The story of Small--Latest

My heart is sore today.I often pass through Umzinto on the way home from Scottburgh to Pennington, as there is no direct taxi to Pennington. On Saturday I attended a meeting in Umzinto and then headed for the taxi rank. This is where all the whoonga addicts hang out. Many of them know me. I always stop and talk to them, sometimes buy them something to eat.
This Saturday I saw someone I had not seen in about six months. It was Mike (read Mikes story here http://davidonymous.blogspot.co.za/2016/05/mikes-story.html ). He had at one stage been a regular attendee of meetings and we had tried to help him. We had raised money to send him to rehab and on another occasion bought him suboxone. He continued to use and eventually stopped coming to meeting, and I lost contact with him.Mike was always small and thin, but he had been full of life energy. I remember him as someone who no matter how desperate his circumstances, always had a laugh and a smile. This could very quickly turn to tears, as Mike was an addict, and a child. Incredibly manipulative, he was always ready with a tall tale that would tug at your heartstrings. I never knew Mike to steal. He never had to. People gave him money. Most people who knew him would never have guessed he was a whoonga addict. He always walked around with a bucket, ready to work, clean cars, push trolleys ...whatever it took. I once saw someone give him a hundred rand..When I asked him about it he said.'Oh that guy..he gives me every week.." And he had a round of regulars like that. . Another time i saw him on the beach collecting sand in a packet. He had literally convinced some tourist to buy some beach sand to take home.This was not the Mike I knew. The smile was still there, but it seemed like the life had been sucked out of him. He was all skin and bone. Hugging him i felt I had to take care not to break him. For all his seventeen something years he looked like an old man with not much time left in this world. I took him to a shop and offered to buy him something but all he would have was some milk....he could not hold down anything solid he said.  The doctors said it was TB. I asked about treatment. He said he had been to the hospital and been given medication, but some guys on the street had stolen it, no doubt thinking it was something they could get high on. He had been meaning to go back, but never got around to it. Sitting in queues at hospitals is not something you want to do when you have a rosta. I extracted a promise to return to the hospital as soon as possible but I doubt this will be kept.
This is a boy who has been on the streets and using whoonga since he was 10. He has never known anything else and never really stood a chance. The sad thing is that Mikes story is all to common. I know there is very little I can do … I can share my story… carry a message of hope…try and bring him into the fellowship of recovering addicts… but is this enough? Surely there is more we could be doing ? I have seen time and again the miracle of the 12 step program…I know it works….But what about those like Mike who don’t get it? There is no help for them. Society turns a blind eye to these people. We like to pass the buck…the government….the family…. And nobody does anything. The 12 step program  has taught me that I cannot change the world and I need to focus on the things I can change. But does that mean I must accept the way things are? I do not believe so… I believe it is still possible to work for a better society where all  are valued. Ultimately the fact that there are people like Mike in the world is an indictment of us all. We are all responsible. We all need to be involved in finding a solution.